The Veterans Crisis Line: Relations among immediate call outcomes and treatment contact and utilization following the call

OBJECTIVE

Crisis line callers experience reductions in distress and suicidal ideation and utilize more health care following calls. The purpose of this study was to determine whether changes in distress and suicidal ideation during a call are associated with later healthcare contact and utilization.

METHOD

Veterans Crisis Line calls from 599 veterans were extracted with call dates between 12/1/2018 and 11/30/2019. Calls were coded for changes in distress and suicidal ideation and linked with VA medical records to obtain healthcare data. Generalized Linear Mixed Modeling was used to examine the associations of changes in distress and suicidal ideation with healthcare contact (yes/no) and utilization (days of treatment) in the month (30 days) following the call.

RESULTS

Reductions in distress were associated with behavioral (i.e., mental and substance use) healthcare utilization, F(1, 596) = 4.52, p = 0.03, and reductions in suicidal ideation were associated with any healthcare utilization, F(1, 596) = 6.45, p = 0.01. Changes in distress and suicidal ideation were not associated with healthcare contact.

CONCLUSION

Responders need to help resolve distress and suicidal ideation and link callers with treatment. Unresolved distress and suicidal thoughts may signify later problems with treatment utilization. Research is needed to determine causality.

Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit

STUDY OBJECTIVES

This study sought to investigate perceptions of sleep disruptions among patients and staff in the inpatient neurology setting. The objectives were to explore the differences between these groups regarding factors that impact sleep, identify the most significant sleep disruptions, and examine the barriers and opportunities suggested to improve inpatient sleep.

METHODS

A survey-based observational study was conducted on a 25-bed inpatient neurology unit at an academic medical center. Staff and patients completed the Potential Hospital Sleep Disruptions and Noises Questionnaire, and focus groups were held to gather qualitative data. Patient-reported sleep measures were collected for additional assessment. Responses were dichotomized for comparison. Regression models were used to assess associations between disruptors and patient-reported sleep measures. Qualitative thematic analyses were performed.

RESULTS

Forty-nine inpatient staff and 247 patients completed sleep surveys. Top primary patient diagnoses included stroke, epilepsy, autoimmune diseases, and psychogenic nonepileptic attacks. Medical interventions, environmental factors, patient-related factors, and unit workflows emerged as key themes related to sleep disruptions. Patient-reported sleep efficiency was significantly reduced when pain, anxiety, stress, temperature, and medication administration disrupted sleep. Staff perspectives highlighted medical interventions as most disruptive to sleep, while patients did not find them as disruptive as expected.

CONCLUSIONS

Differing perspectives on sleep disruption exist between staff and patients in the inpatient neurology setting. Medical interventions may be overstated in staff perceptions and inpatient sleep research, as pain, anxiety, and stress had the most significant impact on patient-reported sleep efficiency.

CITATION

Kadura S, Poulakis A, Roberts DE, et al. Sleeping with one cerebrum open: patient and staff perceptions of sleep quality and quantity on an inpatient neurology unit. J Clin Sleep Med. 2024;20(4):619-629.

Veteran Beliefs About the Causes of Gulf War Illness and Expectations for Improvement

BACKGROUND

Individuals' beliefs about the etiology of persistent physical symptoms (PPS) are linked to differences in coping style. However, it is unclear which attributions are related to greater expectations for improvement.

METHOD AND RESULTS

A cross-sectional regression analysis (N = 262) indicated that Veterans with Gulf War Illness (GWI) who attributed their GWI to behavior, (e.g., diet and exercise), had greater expectations for improvement (p = .001) than those who attributed their GWI to deployment, physical, or psychological causes (p values > .05).

CONCLUSIONS

Findings support the possible clinical utility of exploring perceived contributing factors of PPS, which may increase perceptions that improvement of PPS is possible.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02161133.

Relationship of insomnia to sexual function and sexual satisfaction: Findings from the sleep and sex survey II

OBJECTIVE

Research suggests that healthy sleep is a key component of sexual function. When evaluating sexual function, however, poor sleep is often overlooked as a contributing factor. This cross-sectional survey expands prior work by exploring relationships among insomnia severity, sexual satisfaction, and sexual function with an updated battery of measures for the Sleep and Sex Survey.

METHOD

The sample (N = 1266) consisted of 618 men, 648 women recruited via Prolific, an online survey platform. The Sleep and Sex Survey II included measures addressing insomnia, fear of sleep, nightmares, sexual function, sexual satisfaction, sexual activity, depression, anxiety, posttraumatic stress, and alcohol use.

RESULTS

Recent sexual activity was correlated with better sleep, lower anxiety, and lower scores on a posttraumatic stress disorder screener. Insomnia severity was negatively correlated with sexual satisfaction (r = 0.22, p < .001) and the presence of insomnia was associated with higher rates of sexual dysfunction in women (53.8% vs. 31.8%; p < .001) and men (22.7% vs. 12.5%; p = .036). In regression analyses, after accounting for depression and anxiety, insomnia had a statistically significant association with sexual function for women (β = 0.12; p < .01) but not men (β = 0.11; p = .60).

CONCLUSION

Findings support a relationship of insomnia to sexual function and satisfaction with some gender differences. Future work may be enhanced by assessing these relationships in a gender diverse population including objective sleep measures and addressing contributing mechanisms. Clinically, findings support the assessment of sleep when evaluating patients for sexual dysfunction.

Treatment and life goals among veterans with Gulf War illness

Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.

Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares

STUDY OBJECTIVES

This study's objective was to evaluate the effect of nightmares (NMs) on attrition and symptom change following cognitive behavioral therapy for insomnia (CBT-I) treatment using data from a successful CBT-I randomized controlled trial delivered to participants with recent interpersonal violence exposure.

METHODS

The study randomized 110 participants (107 women; mean age: 35.5 years) to CBT-I or to an attention-control group. Participants were assessed at 3 time periods: baseline, post-CBT-I (or attention control), and at time 3 (T3) post-cognitive processing therapy received by all participants. NM reports were extracted from the Fear of Sleep Inventory. Participants with weekly NMs were compared with those with fewer than weekly NMs on outcomes including attrition, insomnia, posttraumatic stress disorder, and depression. Change in NM frequency was examined.

RESULTS

Participants with weekly NMs (55%) were significantly more likely to be lost to follow-up post-CBT-I (37%) compared with participants with infrequent NMs (15.6%) and were less likely to complete T3 (43%) than patients with less frequent NMs (62.5%). NMs were unrelated to differential treatment response in insomnia, depression, or posttraumatic stress disorder. Treatment with CBT-I was not associated with reduced NM frequency; however, change in sleep-onset latency from post-CBT-I to T3 predicted fewer NMs at T3.

CONCLUSIONS

Weekly NMs were associated with attrition but not a reduced change in insomnia symptoms following CBT-I. NM symptoms did not change as a function of CBT-I, but change in sleep-onset latency predicted lower NM frequency. CBT-I trials should screen for NMs and consider augmenting CBT-I to specifically address NMs.

CITATION

Hamilton NA, Russell JA, Youngren WA, et al. Cognitive behavioral therapy for insomnia treatment attrition in patients with weekly nightmares. J Clin Sleep Med. 2023;19(11):1913-1921.

Associations between insomnia medications and risk of death by suicide

PURPOSE

Insomnia is a modifiable risk factor for suicide often treated with medications. However, little is known about the associations between insomnia medications and risk of death by suicide. The purpose of this study is to model the comparative risk of suicide by each insomnia medication compared to zolpidem, a sedative-hypnotic approved for insomnia.

METHODS

First prescription fills of medications commonly used to treat insomnia were identified in electronic medical records. Date and cause of death were identified in death certificates. Cox proportional hazards models were used to analyze time from insomnia prescription to suicide.

RESULTS

More than 2 million patients filled a new insomnia prescription between 2005 and 2015, and 518 of them died by suicide within 12 months. Compared to zolpidem, the tricyclic antidepressants (amitriptyline, doxepin) were associated with a 64% lower risk of suicide (HR 0.36 (95% CI 0.22-0.66) and the sedating antihistamines (hydroxyzine, diphenhydramine) a 40% lower risk of suicide (HR 0.60 (0.41-0.89)). In contrast, the tetracyclic antidepressant (mirtazapine) was associated with a 62% higher risk of suicide (HR 1.62 (95% CI 1.10-2.38) compared to zolpidem.

CONCLUSION

Insomnia is a modifiable risk factor for suicide, yet many medications used to treat insomnia have never been tested for the indication in clinical trials. To define efficacy in the prevention of suicide, trials are warranted.

A two-phase, prescriptive comparative effectiveness study to optimize the treatment of co-occurring insomnia and depression with digital interventions

BACKGROUND

Insomnia and depression frequently co-occur. Significant barriers preclude a majority of patients from receiving first line treatments for both disorders in a sequential treatment episode. Although digital versions of cognitive behavioral therapy for insomnia (CBTI) and for depression (CBTD) hold some promise to meet demand, especially when paired with human support, it is unknown whether heterogeneity of treatment effects exist, such that some patients would be optimally treated with single or sequential interventions.

OBJECTIVE

Describe the protocol for a two-phase, prescriptive comparative effectiveness study to develop and evaluate an individualized intervention rule (IIR) for prescribing the optimal digital treament of co-occurring insomnia and depression.

METHODS

The proposed sample size is 2300 U.S. military veterans with insomnia and depression recruited nationally (Phase 1 = 1500; Phase 2 = 800). In each phase, the primary endpoint will be remission of both depression and insomnia 3 months following a 12-week intervention period. Phase 1 is a 5-arm randomized trial: two single digital interventions (CBT-I or CBT-D); two sequenced interventions (CBT-I + D or CBT-D + I); and a mood monitoring control condition. A cutting-edge ensemble machine learning method will be used to develop the IIR. Phase 2 will evaluate the IIR by randomizing participants with equal allocation to either the IIR predicted optimal intervention for that individual or by randomization to one the four CBT interventions.

RESULTS

Study procedures are ongoing. Results will be reported in future manuscripts.

CONCLUSION

The study will generate evidence on the optimal scalable approach to treat co-occurring insomnia and depression.

Development of a model to predict antidepressant treatment response for depression among Veterans

BACKGROUND

Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.

RESULTS

In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.

CONCLUSIONS

Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.

Development of a model to predict psychotherapy response for depression among Veterans

BACKGROUND

Fewer than half of patients with major depressive disorder (MDD) respond to psychotherapy. Pre-emptively informing patients of their likelihood of responding could be useful as part of a patient-centered treatment decision-support plan.

METHODS

This prospective observational study examined a national sample of 807 patients beginning psychotherapy for MDD at the Veterans Health Administration. Patients completed a self-report survey at baseline and 3-months follow-up (data collected 2018-2020). We developed a machine learning (ML) model to predict psychotherapy response at 3 months using baseline survey, administrative, and geospatial variables in a 70% training sample. Model performance was then evaluated in the 30% test sample.

RESULTS

32.0% of patients responded to treatment after 3 months. The best ML model had an AUC (SE) of 0.652 (0.038) in the test sample. Among the one-third of patients ranked by the model as most likely to respond, 50.0% in the test sample responded to psychotherapy. In comparison, among the remaining two-thirds of patients, <25% responded to psychotherapy. The model selected 43 predictors, of which nearly all were self-report variables.

CONCLUSIONS

Patients with MDD could pre-emptively be informed of their likelihood of responding to psychotherapy using a prediction tool based on self-report data. This tool could meaningfully help patients and providers in shared decision-making, although parallel information about the likelihood of responding to alternative treatments would be needed to inform decision-making across multiple treatments.

Beyond maintaining safety: Examining the benefit of emotion-centered problem solving therapy added to safety planning for reducing late life suicide risk

Few clinical trials have examined brief non-pharmacological treatments for reducing suicide risk in older Veterans, a high-risk group. Problem Solving Therapy (PST) is a promising psychosocial intervention for reducing late life suicide risk by increasing adaptive coping to problems through effective problem solving and related coping skills. The current randomized clinical trial will compare the efficacy of six telephone-delivered sessions of Safety Planning (enhanced usual care; EUC) only or an updated version of PST (emotion-centered PST [EC-PST]) + EUC to determine the added clinical benefit of EC-PST for reducing severity of suicidal ideation and for increasing reasons for living, a critical protective factor. Participants randomized to EC-PST + EUC or EUC only will be 150 Veterans (75 each) with active suicidal ideation who are aged 60 or older; have a current DSM-5 anxiety, depressive, and/or trauma-related disorder; and without significant cognitive impairment. Primary outcomes (Geriatric Suicide Ideation Scale and Reasons for Living-Older Adults scale) will be assessed at 11 timepoints: baseline, after each of 6 treatment sessions, posttreatment, and at follow-up at 1, 3, and 6 months posttreatment, and analyzed using mixed effects modeling. Additionally, moderators and mediators of primary outcomes will be examined-functional disability, executive dysfunction, and problem-solving ability. Qualitative feedback from participants will identify potential Veteran-centric changes to the EC-PST protocol and to EUC. Ultimately, the goal of this study is to inform the evidence-based clinical practice guidelines for treatments to reduce suicide risk in older Veterans and specifically to inform clinical decision-making regarding the merit of adding EC-PST to EUC.

The memory sources of dreams: serial awakenings across sleep stages and time of night

Memories of waking-life events are incorporated into dreams, but their incorporation is not uniform across a night of sleep. This study aimed to elucidate ways in which such memory sources vary by sleep stage and time of night. Twenty healthy participants (11 F; 24.1 ± 5.7 years) spent a night in the laboratory and were awakened for dream collection approximately 12 times spread across early, middle, and late periods of sleep, while covering all stages of sleep (N1, N2, N3, REM). In the morning, participants identified and dated associated memories of waking-life events for each dream report, when possible. The incorporation of recent memory sources in dreams was more frequent in N1 and REM than in other sleep stages. The incorporation of distant memories from over a week ago, semantic memories not traceable to a single event, and anticipated future events remained stable throughout sleep. In contrast, the relative proportions of recent versus distant memory sources changed across the night, independently of sleep stage, with late-night dreams in all stages having relatively less recent and more remote memory sources than dreams earlier in the night. Qualitatively, dreams tended to repeat similar themes across the night and in different sleep stages. The present findings clarify the temporal course of memory incorporations in dreams, highlighting a specific connection between time of night and the temporal remoteness of memories. We discuss how dream content may, at least in part, reflect the mechanisms of sleep-dependent memory consolidation.

Associations between risky alcohol use, disability, and problem-solving impairment among Veterans with Gulf War Illness: Secondary data analysis of a randomized clinical trial

OBJECTIVE

Gulf War Illness (GWI) and alcohol use are both major sources of disability among Gulf War Veterans. The goal of this secondary data analysis was to examine associations between risky alcohol use, problem-solving impairment, and disability among Veterans in a randomized clinical trial of problem-solving treatment (PST) for GWI. We examined cross-sectional associations and conducted longitudinal analyses to test if alcohol use moderated treatment outcome of PST.

METHODS

Participants were 268 United States military Veterans with GWI randomized to PST or a control intervention. Participants were assessed at four timepoints. Measures included the World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0), Problem Solving Inventory (PSI), and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). We conducted multivariate regression (cross-sectional) and mixed model analyses (longitudinal) with separate models for WHO-DAS 2.0 and PSI. All models included AUDIT-C and household income. This analysis was pre-registered on the Open Science Framework.

RESULTS

Cross-sectional analyses revealed a significant negative association with small effect size between AUDIT-C and WHO-DAS 2.0 (p = 0.006; f² = 0.05); worse disability was associated with less risky alcohol use. There was no evidence that risky alcohol use moderated effects of PST on disability or PSI.

CONCLUSION

If replicated, the cross-sectional findings suggest high levels of disability may deter heavy drinking among Veterans with GWI. We did not find evidence that risky alcohol use moderated treatment outcome of PST for GWI. More research is needed to identify moderators of GWI interventions and to understand risky drinking among Veterans with complex health problems.

Characterization of sleep among deaf individuals

OBJECTIVES

Numerous health disparities are documented in deaf population research, but few empirical sleep assessments exist for this under-served population, despite knowledge that sleep contributes to physical and mental health disparities. We sought to document subjective and objective sleep in deaf adults with cross-sectional and prospective measures.

METHODS

Twenty deaf participants completed validated sleep and mental health questionnaires, 2-weeks of nightly sleep diaries and continuous wrist-worn actigraphy monitoring, and 1-week of nightly, reduced-montage EEG recordings.

RESULTS

Questionnaire data suggest high prevalence of insomnia (70%), poor sleep (75%), daytime sleepiness (25%) and nightmares (20%) among participants. Strong correlations were found between depression and sleep quality, fear of sleep, and insomnia severity (p's < .005). Objective sleep assessments suggest elevated wake after sleep onset and low sleep efficiency and sleep duration.

CONCLUSIONS

The prevalence of sleep disturbance recorded from self-report and objective sleep measures provides preliminary evidence of sleep health disparity among deaf adults.

Exploring the acceptability of behavioral interventions for veterans with persistent "medically unexplained" physical symptoms

OBJECTIVE

This study evaluated the factors that led to enrollment in, and satisfaction with, behavioral interventions for Veterans living with Gulf War Illness (GWI).

METHODS

One-on-one interviews were conducted pre- and post-intervention with participants randomized to receive either telephone delivered problem-solving treatment (n = 51) or health education (N = 49). A total of 99 Veterans were interviewed pre-intervention and 60 post-intervention. Qualitative data were thematically coded and similarities in themes across the two interventions were examined.

RESULTS

Before the study began, participants reported desiring to learn new information about their GWI, learn symptom-management strategies, and support improvements to care for other patients with GWI. After the intervention, Veterans felt positively about both interventions because they built strong therapeutic relationships with providers, their experiences were validated by providers, and they were provided GWI information and symptom-management strategies. Results also suggested that interventions do not have to be designed to meet all of the needs held by patients to be acceptable. A minority of participants described that they did not benefit from the interventions.

CONCLUSION

The results suggest that satisfaction with behavioral interventions for GWI is driven by a strong therapeutic relationship, validating patient's experiences with GWI, and the intervention meeting some of the patient's needs, particularly increasing knowledge of GWI and improving symptom management.

Development of a model to predict combined antidepressant medication and psychotherapy treatment response for depression among veterans

BACKGROUND

Although research shows that more depressed patients respond to combined antidepressants (ADM) and psychotherapy than either alone, many patients do not respond even to combined treatment. A reliable prediction model for this could help treatment decision-making. We attempted to create such a model using machine learning methods among patients in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of VHA patients beginning combined depression treatment completed self-report assessments at baseline and 3 months (n = 658). A learning model was developed using baseline self-report, administrative, and geospatial data to predict 3-month treatment response defined by reductions in the Quick Inventory of Depression Symptomatology Self-Report and/or in the Sheehan Disability Scale. The model was developed in a 70 % training sample and tested in the remaining 30 % test sample.

RESULTS

30.0 % of patients responded to treatment. The prediction model had a test sample AUC-ROC of 0.657. A strong gradient was found in probability of treatment response from 52.7 % in the highest predicted quintile to 14.4 % in the lowest predicted quintile. The most important predictors were episode characteristics (symptoms, comorbidities, history), personality/psychological resilience, recent stressors, and treatment characteristics.

LIMITATIONS

Restrictions in sample definition, a low recruitment rate, and reliance on patient self-report rather than clinician assessments to determine treatment response limited the generalizability of results.

CONCLUSIONS

A machine learning model could help depressed patients and providers predict likely response to combined ADM-psychotherapy. Parallel information about potential harms and costs of alternative treatments would be needed, though, to inform optimal treatment selection.

Evaluation of a Model to Target High-risk Psychiatric Inpatients for an Intensive Postdischarge Suicide Prevention Intervention

Importance

The months after psychiatric hospital discharge are a time of high risk for suicide. Intensive postdischarge case management, although potentially effective in suicide prevention, is likely to be cost-effective only if targeted at high-risk patients. A previously developed machine learning (ML) model showed that postdischarge suicides can be predicted from electronic health records and geospatial data, but it is unknown if prediction could be improved by adding additional information.

Objective

To determine whether model prediction could be improved by adding information extracted from clinical notes and public records.

Design, Setting, and Participants

Models were trained to predict suicides in the 12 months after Veterans Health Administration (VHA) short-term (less than 365 days) psychiatric hospitalizations between the beginning of 2010 and September 1, 2012 (299 050 hospitalizations, with 916 hospitalizations followed within 12 months by suicides) and tested in the hospitalizations from September 2, 2012, to December 31, 2013 (149 738 hospitalizations, with 393 hospitalizations followed within 12 months by suicides). Validation focused on net benefit across a range of plausible decision thresholds. Predictor importance was assessed with Shapley additive explanations (SHAP) values. Data were analyzed from January to August 2022.

Main Outcomes and Measures

Suicides were defined by the National Death Index. Base model predictors included VHA electronic health records and patient residential data. The expanded predictors came from natural language processing (NLP) of clinical notes and a social determinants of health (SDOH) public records database.

Results

The model included 448 788 unique hospitalizations. Net benefit over risk horizons between 3 and 12 months was generally highest for the model that included both NLP and SDOH predictors (area under the receiver operating characteristic curve range, 0.747-0.780; area under the precision recall curve relative to the suicide rate range, 3.87-5.75). NLP and SDOH predictors also had the highest predictor class-level SHAP values (proportional SHAP = 64.0% and 49.3%, respectively), although the single highest positive variable-level SHAP value was for a count of medications classified by the US Food and Drug Administration as increasing suicide risk prescribed the year before hospitalization (proportional SHAP = 15.0%).

Conclusions and Relevance

In this study, clinical notes and public records were found to improve ML model prediction of suicide after psychiatric hospitalization. The model had positive net benefit over 3-month to 12-month risk horizons for plausible decision thresholds. Although caution is needed in inferring causality based on predictor importance, several key predictors have potential intervention implications that should be investigated in future studies.

Veterans Crisis Line Call Outcomes: Treatment Contact and Utilization

INTRODUCTION

Crisis lines are a central component of suicide prevention strategies in the U.S. and for the Department of Veterans Affairs. The purpose of this study is to evaluate the impact of calling the Veterans Crisis Line on treatment contact and utilization.

METHODS

Call records from 599 veterans who called in 2019 were linked with medical records and analyzed in 2020. Multilevel generalized linear modeling examined pre-post changes in treatment contact (yes/no) and utilization (number of days of care).

RESULTS

In the month after the call, 85% of callers made contact with health care, and 79% made contact with behavioral health care. Callers were more likely to make contact with health care in the month after the call than in the preceding month (AOR=6.27, 95% CI=4.22, 9.32) and more likely to make contact with behavioral health care (AOR=10.21, 95% CI=6.66, 15.67). Days of health care nearly doubled to 4.82, and days of behavioral health care more than doubled to 3.52.

CONCLUSIONS

Among veteran callers who are linked to medical records, calling the Veterans Crisis Line may increase contact and utilization of health care and behavioral health care. These findings support crisis lines that are linked with healthcare systems in public health strategies for suicide prevention.

Agreement between actigraphy and sleep diaries: A 28-day real-time monitoring study among suicidal adolescents following acute psychiatric care

OBJECTIVE

To examine the agreement between, and adherence to, wrist actigraphy and digital sleep diaries as methods for sleep assessment among high-risk adolescents in the 28 days following discharge from acute psychiatric care. Sleep parameters included: number of nighttime awakenings (NWAK), sleep efficiency (SE), sleep onset latency (SOL), total sleep time (TST), and wake after sleep onset (WASO).

METHODS

Fifty-three adolescents (12-18 years) were recruited following discharge from acute psychiatric care for suicide risk. Adolescents completed a baseline assessment followed by a 28-day monitoring period with daily sleep diaries and continuous wrist actigraphy. Bland-Altman and multi-level models examined agreement.

RESULTS

Adherence to actigraphy was high, but lower for sleep diaries; a similar pattern of adherence emerged on weekdays vs. weekends. Bland-Altman analyses revealed no clinically meaningful bias for sleep parameters (except NWAK), but the limits of agreement make interpretation ambiguous. Our base model indicated strong agreement between actigraphy and sleep diaries for TST (r = 0.850), moderate for SOL (r = 0.325) and SE (r = 0.322), and weak for WASO (r = -0.049) and NWAK (r = 0.114). A similar pattern emerged with the insomnia severity models with baseline insomnia influencing agreement on all parameters. There were significant weekday-weekend differences for WASO and NWAK, but not for SOL, SE, and TST.

CONCLUSION

Results suggest that it may be beneficial to find a modeling approach to account for the concordant and discordant information and relevant time-level variables.

Randomized Clinical Trial of Brief Primary Care-Based Mindfulness Training Versus a Psychoeducational Group for Veterans With Posttraumatic Stress Disorder

Objective: Individuals with posttraumatic stress disorder (PTSD) symptoms are often reluctant to engage in traditional mental health care but do seek primary care services. Alternative strategies are needed to develop emotional regulation skills among individuals with PTSD symptoms. This study examined the feasibility and effectiveness of Primary Care Brief Mindfulness Training (PCBMT) compared to a psychoeducational group for reducing PTSD symptoms. Methods: Primary care patients (n = 55) with DSM-5 PTSD symptoms but not engaged in PTSD psychotherapies were randomized to 4-week PCBMT or a PTSD psychoeducation group (EDU). Both groups were cofacilitated by mental health providers and veteran peer specialists. Between January 2019 and March 2020, assessments were completed at baseline, post-treatment, and 16- and 24-week follow-up. Results: PCBMT participants had significantly larger decreases in PTSD symptoms from pre- to post-treatment (d = 0.57) and depression from pre-treatment to 16- and 24-week follow-ups (d = 0.67, 0.60) compared to EDU. PCBMT participants also reported significantly greater improvements in health responsibility (d = 0.79), stress management (d = 0.99), and not feeling dominated by symptoms (d = 0.71). Both interventions resulted in the majority of participants "stepping up" to a higher level of PTSD care. Conclusions: Brief mindfulness training is effective for reducing psychiatric symptoms and improving broader recovery outcomes and health promoting behaviors. For individuals who are not yet willing to engage in trauma-focused PTSD treatment, PCBMT may be preferable and more effective than psychoeducational classes as preliminary treatments. Further research is needed to confirm the effectiveness of PCBMT in a larger sample and investigate factors that will support wider implementation in primary care settings. Clinical Trials Registration: ClinicalTrials.gov identifier: NCT03352011.

Worry-related sleep problems and suicidal thoughts and behaviors among adolescents in 88 low-, middle-, and high-income countries: an examination of individual- and country-level factors

A strong association between sleep problems and suicidal thoughts and behaviors (STBs) has been demonstrated in high-income countries. The sleep-STB relationship, however, is minimally understood among youth in low and middle-incomes countries. There also is a limited understanding of how individual- (i.e., age, sex) and country-level (i.e., economic inequality, economic quality) factors may moderate the magnitude of the sleep-STB association among youth. Data were analyzed from the cross-national Global School-based Health Survey 2003-2017, which assessed a range of health behaviors among school-enrolled adolescents aged 11-18 years from 88 low-, lower-middle, upper-middle, and high-income countries. Multilevel models were used to examine the influence of individual- and country-level factors on the association between past-year worry-related sleep problems and past-year suicide ideation, suicide plans, and suicide attempts. Worry-related sleep problems were significantly associated with suicide ideation, plans, and attempts. Adolescent sex, country economic quality (income group designation), and country economic inequality moderated the sleep-STB association, but age did not. The sleep-STB relationship was stronger for males and across macroeconomic indices, the relationship was generally strongest among upper-middle income countries (economic quality) and countries with a big income gap (economic inequality). When examining how individual-level factors differentially affected the sleep-STB relationship within economic quality (income group designation), the effects were driven by older adolescents in high-income countries for suicide ideation and suicide plans. Study findings suggest an important role for global macroeconomic factors, for males, and older adolescents in high-income countries in the sleep-STB relationship. Future directions include expanding worldwide coverage of countries, assessing a wider range of sleep problems, and longitudinal work to understand potential mechanisms in the sleep-STB relationship.

Effect of Problem-solving Treatment on Self-reported Disability Among Veterans With Gulf War Illness: A Randomized Clinical Trial

IMPORTANCE

Few evidence-based treatments are available for Gulf War illness (GWI). Behavioral treatments that target factors known to maintain the disability from GWI, such as problem-solving impairment, may be beneficial. Problem-solving treatment (PST) targets problem-solving impairment and is an evidence-based treatment for other conditions.

OBJECTIVE

To examine the efficacy of PST to reduce disability, problem-solving impairment, and physical symptoms in GWI.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial conducted in the US Department of Veterans Affairs compared PST with health education in a volunteer sample of 511 Gulf War veterans with GWI and disability (January 1, 2015, to September 1, 2019); outcomes were assessed at 12 weeks and 6 months. Statistical analysis was conducted between January 1, 2019, and December 31, 2020.

INTERVENTIONS

Problem-solving treatment taught skills to improve problem-solving. Health education provided didactic health information. Both were delivered by telephone weekly for 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was reduction from baseline to 12 weeks in self-report of disability (World Health Organization Disability Assessment Schedule). Secondary outcomes were reductions in self-report of problem-solving impairment and objective problem-solving. Exploratory outcomes were reductions in pain, pain disability, and fatigue.

RESULTS

A total of 268 veterans (mean [SD] age, 52.9 [7.3] years; 88.4% male; 66.8% White) were randomized to PST (n = 135) or health education (n = 133). Most participants completed all 12 sessions of PST (114 of 135 [84.4%]) and health education (120 of 133 [90.2%]). No difference was found between groups in reductions in disability at the end of treatment. Results suggested that PST reduced problem-solving impairment (moderate effect, 0.42; P = .01) and disability at 6 months (moderate effect, 0.39; P = .06) compared with health education.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of the efficacy of PST for GWI, no difference was found between groups in reduction in disability at 12 weeks. Problem-solving treatment had high adherence and reduced problem-solving impairment and potentially reduced disability at 6 months compared with health education. These findings should be confirmed in future studies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02161133.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BACKGROUND

Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.

OBJECTIVE

To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.

DESIGN

Patient self-report surveys at treatment initiation linked to medical records.

SETTING

Veterans Health Administration (VA) clinics nationally, 2018-2020.

PARTICIPANTS

A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.

KEY RESULTS

More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.

CONCLUSIONS

Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness

OBJECTIVE

Conditions defined by persistent "medically unexplained" physical symptoms and syndromes (MUS) are common and disabling. Veterans from the Gulf War (deployed 1990-1991) have notably high prevalence and disability from MUS conditions. Individuals with MUS report that providers do not recognize their MUS conditions. Our goal was to determine if Veterans with MUS receive an ICD-10 diagnosis for a MUS condition or receive disability benefits available to them for these conditions.

METHODS

A chart review was conducted with US Veterans who met case criteria for Gulf War Illness, a complex MUS condition (N = 204, M = 53 years-old, SD = 7). Three coders independently reviewed Veteran's medical records for MUS condition diagnosis or service-connection along with comorbid mental and physical health conditions. Service-connection refers to US Veterans Affairs disability benefits eligibility for conditions or injuries experienced during or exacerbated by military service.

RESULTS

Twenty-nine percent had a diagnosis of a MUS condition in their medical record, the most common were irritable colon/irritable bowel syndrome (16%) and fibromyalgia (11%). Slightly more Veterans were service-connected for a MUS condition (38%) as compared to diagnosed. There were high rates of diagnoses and service-connection for mental health (diagnoses 76% and service-connection 74%), musculoskeletal (diagnoses 86%, service-connection 79%), and illness-related conditions (diagnoses 98%, service-connection 49%).

CONCLUSION

Given that all participants were Gulf War Veterans who met criteria for a MUS condition, our results suggest that MUS conditions in Gulf War Veterans are under-recognized with regard to clinical diagnosis and service-connected disability. Veterans were more likely to be diagnosed and service-connected for musculoskeletal-related and mental health conditions than MUS conditions. Providers may need education and training to facilitate diagnosis of and service-connection for MUS conditions. We believe that greater acknowledgement and validation of MUS conditions would increase patient engagement with healthcare as well as provider and patient satisfaction with care.

Initial Session Effects of Brief Cognitive Behavioral Therapy for Insomnia: A Secondary Analysis of A Small Randomized Pilot Trial

Objective/Background: While cognitive-behavioral therapy for insomnia (CBT-I) is typically delivered over six-eight sessions, the field has introduced ever briefer versions. We examined session by session effects on both insomnia and depression outcomes in a brief, four-session version of CBT-I.Participants: This is a secondary analysis of data drawn from participants randomized to brief cognitive behavioral therapy for insomnia (bCBTi) in a pilot clinical trial. All participants (n = 19) were veterans enrolled in primary care who screened positive for insomnia and co-occurring PTSD and/or depression.Methods: Participants received four, weekly, individual sessions of bCBTi during which they provided self-report data on insomnia, depression, and sleep parameters over the preceding week. Baseline and follow-up assessments were also collected.Results: Changes in insomnia and depression severity between baseline and the beginning of session one were non-significant. Statistically significant decreases were observed, however, for insomnia severity between sessions one to two (g = -.65) and sessions two to three (g = -.59). This pattern was mirrored for depression severity with significant decreases between sessions one and two (g = -.65) and sessions two to three (g = -.68). However, there was little change for either outcome from session three to session four (insomnia g = -.16; depression g = -.14).Conclusions: This session by session analyses of bCBTi revealed that the majority of the treatment effect occurred over the first two sessions. Findings suggest that even brief interventions addressing insomnia may have a positive impact on both insomnia and co-occurring depression.

Shorter and longer-term risk for non-fatal suicide attempts among male U.S. military veterans after discharge from psychiatric hospitalization

Although there are key differences in shorter-term (days 1-90) and longer-term (days 91-365) risk factors for suicide after discharge from inpatient psychiatry, there are no comparable data on non-fatal suicide attempts. Risk factors for non-fatal attempts in the first 90 days after discharge were compared with those over the remainder of the year to identify temporal changes in risk. Records were extracted from 208,554 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models identified correlates of non-fatal attempts for 1-90 days and 91-365 days; adjusted piecewise proportional hazards regression compared risk between these time frames. 5010 (2.4%) veterans made a non-fatal attempt, 1261 (0.60%) on days 1-90 and 3749 (1.78%) on days 91-365. Risk across both time frames was highest among younger veterans ages 18-59, and those hospitalized with a suicide attempt or suicidal ideation. It was lowest among those with a dementia diagnosis. Risk estimates were generally stable over time but increased among those with substance use disorders and decreased among those with sleep disturbance and discharged against medical advice. Estimates of some risk factors for non-fatal attempts change over time in the year after discharge and differ from those that change for suicide. Different preventive approaches may be needed to reduce shorter and longer-term risk for non-fatal attempts and suicide in the year after discharge.

The Relationship Between Pain Severity, Insomnia, and Suicide Attempts Among a National Veteran Sample Initiating Pain Care

OBJECTIVE

We assessed the longitudinal association of suicide attempts by moderate to severe pain and insomnia before and after the initiation of pain services among veterans.

METHODS

A cohort of 221,817 veterans initiating pain care was divided into four subgroups: a) no/mild pain + no insomnia (LowPain-NoINS), b) no/mild pain + insomnia (LowPain-INS), c) moderate/severe pain + no insomnia (HighPain-NoINS), and d) moderate/severe pain + insomnia (HighPain-INS). Data on diagnoses, pain severity, demographics, medications, and suicide attempts were extracted from Veterans Health Administration data sets.

RESULTS

Overall, there were 2227 (1.0%) suicide attempts before initiating pain services and 1655 (0.8%) after initiating pain services. Cox proportional hazard models accounting for key covariates revealed that patients in the HighPain-INS group were significantly more likely to attempt suicide in the year after the initiation of pain services relative to all subgroups (versus LowPain-NoINS: hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.21-1.72; versus LowPain-INS: HR = 1.71, 95% CI = 1.23-2.38; versus HighPain-NoINS: HR = 1.17, 95% CI = 1.01-1.34) even after accounting for prior attempts. Adjusted logistic regression analyses found that patients with moderate/severe pain and insomnia had higher odds of attempting suicide in the year before initiating pain services compared to all subgroups (versus LowPain-NoINS: HR = 1.75, 95% CI = 1.50-2.05; versus LowPain-INS: HR = 1.41, 95% CI = 1.09-1.82; versus HighPain-NoINS: HR = 1.21, 95% CI = 1.07-1.37).

CONCLUSIONS

These results suggest that those with both moderate/severe pain and insomnia are more likely to have a history of suicide attempts and are at greater risk of a suicide attempt relative to those with insomnia with low/mild pain and those with moderate/severe pain with no insomnia. Suicide prevention efforts for chronic pain and insomnia could address pain and insomnia within the same intervention or in parallel.

A Randomized Clinical Trial of Cognitive-Behavioral Therapy for Insomnia to Augment Posttraumatic Stress Disorder Treatment in Survivors of Interpersonal Violence

INTRODUCTION

Individuals exposed to interpersonal violence (IPV) commonly develop posttraumatic stress disorder (PTSD) with co-occurring depression and insomnia. Standard PTSD interventions such as cognitive processing therapy (CPT) do not typically lead to remission or improved insomnia. Cognitive behavioral therapy for insomnia (CBTi) improves insomnia in individuals with PTSD, but PTSD severity remains elevated.

OBJECTIVE

To determine whether sequential treatment of insomnia and PTSD is superior to treatment of only PTSD.

METHODS

In a 20-week trial, 110 participants exposed to IPV who had PTSD, depression and insomnia were randomized to CBTi followed by CPT or to attention control followed by CPT. Primary outcomes following CBTi (or control) were the 6-week change in score on the Insomnia Severity Index (ISI), the Clinician-Administered PTSD Scale (CAPS), and the Hamilton Rating Scale for Depression (HAM-D). Primary outcomes following CPT were the 20-week change in scores.

RESULTS

At 6 weeks, the CBTi condition had greater reductions in ISI, HAM-D, and CAPS scores than the attention control condition. At 20 weeks, participants in the CBTi+CPT condition had greater reductions in ISI, HAM-D, and CAPS scores compared to control+CPT. Effects were larger for insomnia and for depression than for PTSD. Similar patterns were observed with respect to clinical response and remission. A tipping point sensitivity analyses supported the plausibility of the findings.

CONCLUSIONS

The sequential delivery of CBTi and CPT had plausible, significant effects on insomnia, depression, and PTSD compared to CPT alone. The effects for PTSD symptoms were moderate and clinically meaningful.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

Comorbid mental disorders, depression symptom severity, and role impairment among Veterans initiating depression treatment through the Veterans Health Administration

BACKGROUND

Psychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates.

METHODS

2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments.

RESULTS

Nearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities.

LIMITATIONS

The screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities.

CONCLUSIONS

Although positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.

Baseline sleep as a predictor of delirium after surgical aortic valve replacement: A feasibility study

OBJECTIVE

The goal is to assess the feasibility of conducting unattended (type II) sleep studies before surgical aortic valve replacement (SAVR) to examine the relationship between baseline sleep measures and postoperative delirium.

METHODS

This single-site study recruited 18 of 20 study referrals with aortic stenosis undergoing first lifetime SAVR. Subjects completed a home-based type II sleep study. Delirium was assessed postoperative days 1-5. Exact logistic regression was used to determine whether sleep efficiency or apnea/hypopnea index predicts delirium.

RESULTS

Of 18 study participants, 15 successfully completed a home sleep study (mean age: 71.7 +/- 8.1 years old; 10 male subjects). Five subjects (33.3%) developed delirium. Preliminary analyses found that greater sleep efficiency was associated with a large reduction in delirium odds but was not statistically significant (OR = 0.31, 95% CI: 0.06, 1.03, p = 0.057). The point estimate of the relationship between apnea/hypopnea index and delirium was not similarly sizeable (OR 1.10, 95% CI: 0.35, 3.37, p = 0.85).

CONCLUSIONS

Our findings suggest that home type II sleep studies before SAVR are feasible, and they support adequately powered studies investigating type II home sleep studies as a predictor of postoperative delirium and other important postsurgical outcomes.

Sleep and Interpersonal Violence: A Systematic Review

Sleep disturbance is a significant public health issue that disproportionately affects survivors of interpersonal violence (IPV). This systematic review presents data on the relationship of IPV and sleep. Inclusion criteria for this review were studies that included subjects 18 years of age or older, used an IPV measure and sleep disturbance measure, and were published in a peer-reviewed journal in English. A total of 23 articles met full inclusion criteria and were included in the present review. Studies were largely cross sectional, were conducted in a wide range of clinical and nonclinical samples, and utilized a variety of measures to assess IPV (sexual violence, physical violence, or psychological aggression perpetrated by an intimate partner or sexual or physical violence by any perpetrator in childhood or adulthood) and sleep disturbances (both general sleep disturbance excluding specific sleep disorders and the two specific sleep disorders of insomnia and nightmares). The findings examined the prevalence and association of sleep disturbance in IPV samples from population and community studies, the prevalence and association of sleep disturbance in IPV studies, and the associations between post-traumatic stress disorder and sleep disturbance in IPV samples. All studies identified a relationship between IPV and sleep disturbance. The results of this review provide important information for clinicians, researchers, and policy makers on the prevalence of and relationship between IPV and sleep disturbance.

Treating depressive symptoms among veterans in primary care: A multi-site RCT of brief behavioral activation

BACKGROUND

Behavioral activation is ideal for embedded behavioral health providers (BHPs) working in primary care settings treating patients reporting a range of depressive symptoms. The current study tested whether a brief version of Behavioral Activation (two 30-minute appointments, 2 boosters) designed for primary care (BA-PC) was more effective than primary care behavioral health treatment-as-usual (TAU) in reducing depressive symptoms and improving quality of life and functioning.

METHODS

Parallel-arm, multi-site randomized controlled trial. 140 Veterans were randomized to BA-PC or TAU and completed assessments at baseline, 6 weeks, 12 weeks, and 24 weeks.

RESULTS

Reductions in depressive symptoms were observed in both groups between baseline and 3-weeks prior to any treatment, with continued reductions among those in the BA-PC condition through 12-weeks. However, there was no significant condition X time interaction at 12-weeks. Quality of life and mental health functioning were significantly improved for those in the BA-PC condition, compared to TAU, at 12 weeks.

LIMITATIONS

Generalizability to a broader population may be limited as this sample consisted of veterans. Although engagement in TAU matched other prior work, it was lower than engagement in BA-PC, which also may compromise results.

CONCLUSIONS

Although this study found that both TAU and BA-PC participants showed a decline in depressive symptoms, improvements in functioning and quality of life within those assigned to BA-PC, strong treatment retention and feasibility of BA-PC, and significant reductions in depressive symptoms among those with more severe baseline depressive symptoms are encouraging and support continued research on BA-PC. This trial was registered in clinicaltrials.gov as Improving Mood in Veterans in Primary Care (NCT02276807).

Development of digital measures for nighttime scratch and sleep using wrist-worn wearable devices

Patients with atopic dermatitis experience increased nocturnal pruritus which leads to scratching and sleep disturbances that significantly contribute to poor quality of life. Objective measurements of nighttime scratching and sleep quantity can help assess the efficacy of an intervention. Wearable sensors can provide novel, objective measures of nighttime scratching and sleep; however, many current approaches were not designed for passive, unsupervised monitoring during daily life. In this work, we present the development and analytical validation of a method that sequentially processes epochs of sample-level accelerometer data from a wrist-worn device to provide continuous digital measures of nighttime scratching and sleep quantity. This approach uses heuristic and machine learning algorithms in a hierarchical paradigm by first determining when the patient intends to sleep, then detecting sleep–wake states along with scratching episodes, and lastly deriving objective measures of both sleep and scratch. Leveraging reference data collected in a sleep laboratory (NCT ID: NCT03490877), results show that sensor-derived measures of total sleep opportunity (TSO; time when patient intends to sleep) and total sleep time (TST) correlate well with reference polysomnography data (TSO: r = 0.72, p < 0.001; TST: r = 0.76, p < 0.001; N = 32). Log transformed sensor derived measures of total scratching duration achieve strong agreement with reference annotated video recordings (r = 0.82, p < 0.001; N = 25). These results support the use of wearable sensors for objective, continuous measurement of nighttime scratching and sleep during daily life.

Insomnia, Posttraumatic Stress Disorder Symptoms, and Danger: Their Impact on Victims' Return to Court for Orders of Protection

The linkages between intimate partner violence (IPV), posttraumatic stress disorder (PTSD), and insomnia have been the subject of inquiry. This study is the first to explore the associations between clinical-level insomnia, PTSD symptoms, danger, and victim socio-demographics, and whether IPV victims pursue permanent orders of protection (OPs). Data for this secondary analysis were collected through surveys, interviews, and reviews of court records on 112 women who resided in upstate New York. Women initiated actions to obtain OPs from the Domestic Violence Intensive Intervention Court (DVIIC), from 2007 to 2008. The following factors were analyzed to determine their impact on whether a woman returned to court: (a) age, (b) race, (c) employment status, (d) perceived danger, (e) PTSD symptoms, and (f) clinical-level insomnia. This study finds that the following factors significantly relate to return to court: race, clinical-level insomnia and perceived danger, clinical-level insomnia and PTSD symptoms, and severe danger level. However, in the final multivariate logistic regression, only race emerged as a predictor of whether a woman returned to court. Specifically, women of color were a third less likely to return to court than White women. These results have significant implications for future research and clinical intervention.

Shorter- and Longer-Term Risk for Suicide Among Male US Military Veterans in the Year After Discharge From Psychiatric Hospitalization

OBJECTIVE

Risk for suicide is highest in the first 3 months (days 1-90) after discharge from acute psychiatric hospitalization yet remains elevated for the remainder of the year (days 91-365). The purpose of this study was to compare risk factors for suicide in the first 90 days to those over the remainder of the year to identify changes across time frames.

METHODS

The study included 316,707 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models were used to identify predictors of suicide death in the first 90 days and in days 91-365, defined via ICD-10 codes. Adjusted piecewise proportional hazard regression was used to compare risk across time frames.

RESULTS

Among the 1,037 veterans (< 1%) who died by suicide, 471 (45%) died between days 1 and 90 and 566 (55%) died between days 91 and 365. There was little change regarding the strength of risk factors over time, with two exceptions: risk increased among those aged 18-29 years compared to those aged ≥ 65 years (days 1-90: hazard ratio [HR] = 0.83; 95% CI, 0.57-1.20 vs days 91-365: HR = 1.42; 95% CI, 1.03-1.97; P < .05), whereas, risk associated with suicidal ideation decreased (days 1-90: HR = 1.89; 95% CI, 1.57-2.28 vs days 91-365: HR = 1.40; 95% CI, 1.17-1.66, P < .05).

CONCLUSIONS

The strength of association between common risk factors and suicide remains relatively stable during the year following psychiatric hospitalization. However, risk among veterans aged 19-29 years increased over time, whereas risk among those with suicidal ideation decreased.

Veterans with Gulf War Illness perceptions of management strategies

AIMS

Gulf War Illness (GWI) is a prevalent and disabling condition characterized by persistent physical symptoms. Clinical practice guidelines recommend self-management to reduce the disability from GWI. This study evaluated which GWI self-management strategies patients currently utilize and view as most effective and ineffective.

MATERIALS AND METHODS

Data were collected from 267 Veterans during the baseline assessment of a randomized clinical trial for GWI. Respondents answered 3 open-ended questions regarding which self-management strategies they use, view as effective, and view as ineffective. Response themes were coded, and code frequencies were analyzed.

KEY FINDINGS

Response frequencies varied across questions (in-use: n = 578; effective: n = 470; ineffective: n = 297). Healthcare use was the most commonly used management strategy (38.6% of 578), followed by lifestyle changes (28.5% of 578), positive coping (13% of 578), and avoidance (13.7% of 578). When asked about effective strategies, healthcare use (25.9% of 470), lifestyle change (35.7% of 470), and positive coping (17.4% of 470) were identified. Avoidance was frequently identified as ineffective (20.2% of 297 codes), as was invalidating experiences (14.1% of 297) and negative coping (10.4% of 297).

SIGNIFICANCE

Patients with GWI use a variety of self-management strategies, many of which are consistent with clinical practice guidelines for treating GWI, including lifestyle change and non-pharmacological strategies. This suggests opportunities for providers to encourage effective self-management approaches that patients want to use.

Association Between Pretreatment Sleep Disturbance and Radiation Therapy-Induced Pain in 573 Women With Breast Cancer

CONTEXT

Pain can be a debilitating side effect of radiation therapy (RT). Data from the general population have shown that sleep disturbance can influence pain incidence and severity; however, less is known about this relationship in patients with breast cancer receiving RT.

OBJECTIVES

This secondary analysis examined the association of pretreatment moderate/severe levels of sleep disturbance with subsequent RT-induced pain after adjusting for pre-RT pain.

METHODS

We report on 573 female patients with breast cancer undergoing RT from a previously completed Phase II clinical trial for radiation dermatitis. Sleep disturbance, total pain, and pain subdomains-sensory pain, affective pain, and perceived pain intensity were assessed at pre-RT and post-RT. At pre-RT, patients were dichotomized into two groups: those with moderate/severe sleep disturbance (N = 85) vs. those with no/mild sleep disturbance (control; N = 488).

RESULTS

At pre-RT, women with moderate/severe sleep disturbance were younger, less likely to be married, more likely to have had mastectomy and chemotherapy, and more likely to have depression/anxiety disorder and fatigue than the control group (all Ps < 0.05). Generalized estimating equations model, after controlling for pre-RT pain and other covariates (e.g., trial treatment condition and covariates that were significantly correlated with post-RT pain), showed that women with moderate/severe sleep disturbance at pre-RT vs. control group had significantly higher mean post-RT total pain as well as sensory, affective, and perceived pain (effect size = 0.62, 0.60, 0.69, and 0.52, respectively; all Ps < 0.05).

CONCLUSION

These findings suggest that moderate/severe disturbed sleep before RT is associated with increased pain from pre-to-post-RT in patients with breast cancer.

Why Treat Insomnia?

"Why treat insomnia?" This question grows out of the perspective that insomnia is a symptom that should only receive targeted treatment when temporary relief is needed or until more comprehensive gains may be achieved with therapy for the parent or precipitating medical or psychiatric disorders. This perspective, however, is untenable given recent data regarding the prevalence, course, consequences, and costs of insomnia. Further, the emerging data that the treatment of insomnia may promote better medical and mental health (alone or in combination with other therapies) strongly suggests that the question is no longer "why treat insomnia," but rather "when isn't insomnia treatment indicated?" This perspective was recently catalyzed with the American College of Physicians' recommendation that chronic insomnia should be treated and that the first line treatment should be cognitive-behavioral therapy for insomnia (CBT-I).

Sleep Disturbances and Atopic Dermatitis: Relationships, Methods for Assessment, and Therapies

Atopic dermatitis is one of the most common chronic inflammatory skin conditions and is associated with sleep disturbances in 47% to 80% of children and 33% to 90% of adults. Herein, we review the literature on sleep disturbances experienced by patients with atopic dermatitis, as well as the mechanisms that may underlie this. We present subjective and objective methods for measuring sleep quantity and quality and discuss strategies for management. Unfortunately, the literature on this topic remains sparse, with most studies evaluating sleep as a secondary outcome using subjective measures. The development of portable, at-home methods for more objective measures offers new opportunities to better evaluate sleep disturbances in atopic dermatitis research studies and in clinical practice.

Effects of mindfulness training on posttraumatic stress symptoms from a community-based pilot clinical trial among survivors of intimate partner violence

Objective: Exposure to intimate partner violence (IPV) is a significant public health issue associated with deleterious mental and medical health comorbidities, including posttraumatic stress disorder (PTSD). The hallmark symptoms of posttraumatic stress (PTS), even when not meeting the threshold for a diagnosis of PTSD, appear to be underpinned by poor self-regulation in multiple domains, including emotion, cognitive control, and physiological stress. Mindfulness-based stress reduction (MBSR) holds promise for treating PTS symptoms because evidence suggests it targets these domains. The current study was a pilot randomized clinical trial designed to examine changes in emotion regulation, attentional function, and physiological stress dysregulation among women IPV survivors with elevated PTS symptoms after participation in a group-based, 8-week MBSR program. Method: In total, 29 participants were randomized to receive MBSR (n = 19) or an active control (n = 10). Assessments were conducted at study entry, as well as 8 and 12 weeks later. Results: Between-group differences on primary outcomes were nonsignificant; however, when exploring within groups, statistically significant decreases in PTS symptoms, F(1.37, 16.53) = 5.19, p < .05, and emotion dysregulation, F(1.31, 14.46) = 9.36, p < .01, were observed after MBSR but not after the control intervention. Further, decreases in PTSD and emotion dysregulation were clinically significant for MBSR participants but not control participants. Conclusions: These preliminary data signal that MBSR may improve PTS symptoms and emotion regulation and suggest further study of the effectiveness of PTSD interventions guided by integrative models of MBSR mechanisms and psychophysiological models of stress regulation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial

Insomnia co-occurs frequently with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD); all three conditions are prevalent among primary care patients and associated with suicidal ideation (SI). The purpose of the article was to test the effects of a brief cognitive behavioral therapy for insomnia (bCBTi) and the feasibility of delivering it to primary care patients with SI and insomnia in addition to either MDD and/or PTSD. Fifty-four patients were randomized to receive either bCBTi or treatment-as-usual for MDD and/or PTSD. The primary outcome was SI intensity as measured by the Columbia-Suicide Severity Rating Scale; secondary clinical outcomes were measured by the Insomnia Severity Index, Patient Health Questionnaire for depression, and PTSD Symptom Checklist. Effect sizes controlling for baseline values and sample size were calculated for each clinical outcome comparing pre-post differences between the two conditions with Hedge's g. The effect size of bCBTi on SI intensity was small (0.26). Effects were large on insomnia (1.91) and depression (1.16) with no effect for PTSD. There was a marginally significant (p = .069) effect of insomnia severity mediating the intervention's effect on SI. Findings from this proof-of-concept trial support the feasibility of delivering bCBTi in primary care and its capacity to improve mood and sleep in patients endorsing SI. The results do not support bCBTi as a stand-alone intervention to reduce SI, but this or other insomnia interventions may be considered as components of suicide prevention strategies.

1087 Early Session Effects of CBT-I on Insomnia and Depression

Introduction

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to reduce depressive symptomatology among patients with co-occurring insomnia and depression. Brief forms of CBT-I have been tested in various settings including primary care. As delivery formats of CBT-I broaden, it is important to enhance our understanding of what doses and what components of CBT-I, provide the optimal balance of treatment efficacy and brevity. In the present study, we examine session-by-session effects of CBT-I on insomnia and depression.

Methods

Fifty-four Veterans with insomnia and co-occurring depression or posttraumatic stress disorder were randomized to either four sessions of CBT-I or treatment as usual in a published parent study. We report here on the effects among those who received CBT-I (n =22). At each session participants provided a completed sleep diary and completed the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9 for depression (PHQ-9).

Results

At baseline, participants endorsed a moderate level of both insomnia (ISI score = 18.5 [SD=4.2]) and depression (PHQ-9 score = 15.6 [SD=5.2]). A mean decrease of 4.0 points in ISI total score was observed between sessions 1 and 2 [t(21)=-3.88, p&lt;.001] and a 3.3 points between sessions 2 and 3 [t(19)=-2.63, p&lt;.05]. Mean PHQ-9 scores decreased by 2.9 points between sessions 1 and 2 [t(21)=-2.84, p&lt;.01] and a 2.8 points between sessions 2 and 3 [t(19)=-2.77, p&lt;.05]. In contrast, changes in ISI and PHQ-9 scores between baseline and session 1, and sessions 3 and 4 did not reach significance.

Conclusion

The majority of improvements in both insomnia and depression were observed following sessions 1 and 2 of CBT-I. Findings suggest that even a limited exposure to CBT-I may have a clinically significant impact on functioning across multiple domains. Whether such early improvements represent an optimal balance compared with the more modest additional improvements achieved by adding more sessions is discussed.

Support

This work was supported by the VISN 2 Center of Excellence for Suicide Prevention at the Canandaigua VAMC.

Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors

BACKGROUND

Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship.

METHODS

The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis.

RESULTS

Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior.

CONCLUSIONS

These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02161133.

Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment

OBJECTIVE

Sleep problems are transdiagnostic symptoms that confer significant risk for suicidal thoughts and behaviors (STBs) in adults. However, less is known about the sleep-STB association in adolescence-a developmental period when rates of STBs increase drastically, and sleep problems may be particularly pernicious. This article provides a systematic review of research on the sleep-STB association in youth, an overview of changes in sleep regulation during adolescence that may make sleep problems particularly detrimental for youth, and a discussion of the clinical implications of the sleep-STB association for hospitalized youth.

METHOD

The systematic review included all longitudinal studies in which sleep problems were examined as prospective predictors of STBs in adolescents (aged 10-24 years). The search was conducted on December 1, 2017 using PsychINFO, PubMed, and Web of Science databases.

RESULTS

Ten studies qualified for inclusion in this review. Of these, seven studies found at least one type of sleep problem significantly predicted a STB outcome.

CONCLUSIONS

Although findings are mixed, growing research suggests that sleep problems may be a unique risk factor for STBs in youth. Sleep problems may be particularly important intervention target because they are easily assessed across healthcare settings and are amenable to treatment.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

Team-based suicide prevention: lessons learned from early adopters of collaborative care

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

Influence of Yoga on Cancer-Related Fatigue and on Mediational Relationships Between Changes in Sleep and Cancer-Related Fatigue: A Nationwide, Multicenter Randomized Controlled Trial of Yoga in Cancer Survivors

BACKGROUND

Cancer-related fatigue (CRF) often co-occurs with sleep disturbance and is one of the most pervasive toxicities resulting from cancer and its treatment. We and other investigators have previously reported that yoga therapy can improve sleep quality in cancer patients and survivors. No nationwide multicenter phase III randomized controlled trial (RCT) has investigated whether yoga therapy improves CRF or whether improvements in sleep mediate the effect of yoga on CRF. We examined the effect of a standardized, 4-week, yoga therapy program (Yoga for Cancer Survivors [YOCAS]) on CRF and whether YOCAS-induced changes in sleep mediated changes in CRF among survivors.

STUDY DESIGN AND METHODS

Four hundred ten cancer survivors were recruited to a nationwide multicenter phase III RCT comparing the effect of YOCAS to standard survivorship care on CRF and examining the mediating effects of changes in sleep, stemming from yoga, on changes in CRF. CRF was assessed by the Multidimensional Fatigue Symptom Inventory. Sleep was assessed via the Pittsburgh Sleep Quality Index. Between- and within-group intervention effects on CRF were assessed by analysis of covariance and 2-tailed t test, respectively. Path analysis was used to evaluate mediation.

RESULTS

YOCAS participants demonstrated significantly greater improvements in CRF compared with participants in standard survivorship care at post-intervention ( P < .01). Improvements in overall sleep quality and reductions in daytime dysfunction (eg, excessive napping) resulting from yoga significantly mediated the effect of yoga on CRF (22% and 37%, respectively, both P < .01).

CONCLUSIONS

YOCAS is effective for treating CRF among cancer survivors; 22% to 37% of the improvements in CRF from yoga therapy result from improvements in sleep quality and daytime dysfunction. Oncologists should consider prescribing yoga to cancer survivors for treating CRF and sleep disturbance.

SLOW WAVE SLEEP AND PAIN AFTER BEHAVIORAL INSOMNIA TREATMENT IN ADULTS OVER AGE 50 WITH KNEE OSTEOARTHRITIS

Sleep disturbance can aggravate pain, and we recently found that insomnia treatment improved osteoarthritis (OA) pain, lowered inflammation, and improved quality of life in middle-to-older aged adults. Inadequate slow wave sleep (SWS), known as deep or restorative sleep, can decline with aging and is linked to pain and inflammation. We examined how insomnia treatment affects SWS, and the relationship between SWS and pain. In a pilot trial, 33 adults, ages 51 to 74 years with OA-related knee pain and insomnia, were randomized to 6-session CBTi (n=16) or a weekly phone contact control group (n=17). The CBT-I group showed significantly more laboratory-measured SWS across a study night than controls after controlling for baseline SWS. Greater SWS intensity was associated with lower OA-related pain among the CBT-I group, but not among controls. These preliminary data suggest that behavioral sleep treatment may strengthen the beneficial influence of restorative sleep on pain.