Conceptual overlap of negative thought processes in insomnia: A focus on catastrophizing, worry, and rumination in a student sample.

OBJECTIVES: The association and overlap between different forms of negative thought processes in insomnia is largely unknown. The purpose of the current investigation was to examine conceptual overlap between three insomnia-specific negative thought processes; catastrophizing, worry, and rumination, identify the underlying factors, and explore their associations with insomnia symptoms. METHODS: A total of 360 students completed three insomnia-related negative thought process scales (Catastrophic Thoughts about Insomnia Scale, Anxiety and Preoccupation about Sleep Questionnaire, Daytime Insomnia Symptom Response Scale) and two insomnia symptoms measures (the Insomnia Severity Index and Sleep Condition Indicator). RESULTS: The three scales and their subscales displayed acceptable reliabilities. Further, confirmatory factor analysis was supportive of the notion of catastrophizing, worry, and rumination measures as distinct. The catastrophizing and worry constructs were significantly associated with insomnia symptoms, but the rumination factor was not. CONCLUSIONS: The findings indicate that catastrophizing, worry, and rumination might be viewed as distinct constructs. Although more research is warranted on the topic of conceptual overlap, the current results might have implications for the development of models of insomnia, clinical research, and practice.

Comparing patients treated with CBT for insomnia with healthy sleepers and sleepers with past insomnia on dimensions of sleep health.

OBJECTIVES: To compare patients treated with cognitive behavioral therapy for insomnia (CBT-I) with healthy sleepers and individuals with past but not current insomnia on multidimensional sleep health. METHODS: The study evaluates CBT-I on six dimensions of sleep health (regularity, satisfaction, alertness, timing, efficiency, duration) in a sample of individuals with insomnia compared to two other unique sleep samples. Participants were in one of three groups: insomnia (CUR, n = 299), healthy sleeper (HS, n = 122), or past insomnia (PAST, n = 35). Daily diaries and validated measures were employed to capture six dimensions of sleep health. The CUR group received four 60-minute sessions of CBT-I every 2weeks, and sleep health indices were measured at baseline and post-treatment. The HS and PAST groups were measured only at baseline. RESULTS: Results of the pairwise t tests indicated improvements in sleep satisfaction, alertness (fatigue but not sleepiness), timing, efficiency, and duration (Cohen's d=0.22 to 1.55). ANCOVA models revealed significant differences in sleep health scores between treated insomnia patients and the other two sleep groups. Treated patients demonstrated less bedtime and risetime variability, in addition to lower napping duration. Overall, the study observed significant changes in various domains of sleep health after four sessions of cognitive behavioral therapy for insomnia; however, differences remain when compared to the other groups in the study. CONCLUSION: There may be ongoing sleep vulnerability in patients treated with cognitive behavioral therapy for insomnia though future inclusion of a control group would increase internal validity. Borrowing from transdiagnostic sleep modules may be helpful to support remaining deficits after cognitive behavioral therapy for insomnia.

Sleep effects of psychological therapies for menopausal symptoms in women with hot flashes and night sweats: A systematic review.

Sleep disturbance is frequently reported by women during the menopausal transition due to various physiological changes and environmental factors. Insomnia is a critical treatment target for its deleterious effects on daytime functioning and quality of life and increased risk of developing a depressive disorder. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments that address the myriad of menopausal symptoms, including cognitive-behavioural therapy, clinical hypnosis and mindfulness-based therapies. The objective of this article is to review the effects of psychological treatments for menopausal symptoms on sleep disturbance in peri-/postmenopausal women. We conducted a systematic review of the literature using PubMed and reference lists from inception until May 2023, including 12 studies that evaluated sleep as a secondary outcome. Most studies found that group and self-help (guided and unguided) cognitive-behavioural therapies and clinical hypnosis for menopausal symptoms have positive effects on sleep among women with significant vasomotor symptoms. There was preliminary support for mindfulness-based stress reduction. Future research including more diverse samples and women with sleep disorders is needed. Evaluating the implementation of psychological therapies in clinics where menopausal women seek care is an important next step.

Examining sleep characteristics in Canada through a diversity and equity lens.

OBJECTIVE: To examine specific sleep characteristics of adults living in Canada according to sex, gender, ethnoracial background, socioeconomic status, immigration status, sexual orientation, and language spoken at home. METHODS: This cross-sectional and nationally representative study used self-reported data from the 2021 Canadian Community Health Survey (n = 39,346 adults aged 18 years and older). Sleep characteristics (sleep duration, nighttime insomnia symptoms, unrefreshing sleep, and difficulty staying awake) were assessed and compared across groups. RESULTS: Females were more likely than males to report nighttime insomnia symptoms (23.1% vs. 14.8%) and unrefreshing sleep (17.2% vs. 13.5%). The same was also observed for gender identity. Although White respondents were more likely to meet sleep duration recommendations (58.3%), they had the highest prevalence of nighttime insomnia symptoms (20.9%) compared to respondents with other ethnoracial backgrounds. Respondents coming from lower socioeconomic backgrounds were more likely to report poorer sleep compared to those coming from higher socioeconomic backgrounds. Insomnia symptoms were lower among immigrants (13.9%) compared to nonimmigrants (21.1%). Respondents with a sexual orientation not classified as heterosexual, gay, or lesbian reported poorer sleep. Finally, for language spoken at home, those who responded "French only" were more likely to meet sleep duration recommendations (64.1%) and were less likely to report unrefreshing sleep (8.8%). Nighttime insomnia symptoms were the lowest among those who reported speaking a language other than French or English at home (9.5%). CONCLUSION: This study highlights important sleep disparities among Canadians. Future intervention strategies should aim to reduce sleep health disparities.

Implementation of a teen sleep app in Canadian high schools: Preliminary evidence of acceptability, engagement, and capacity for supporting healthy sleep habits.

High school students suffer from mental health challenges and poorer academic performance resulting from sleep disturbances. Unfortunately, approaches to this problem sometimes focus on increasing sleep duration by going to bed early; a strategy with limited success because teens experience a phase delay in bedtimes. There is a need for approaches that leverage behavioural sleep science and are accessible, scalable, and easily disseminated to students. DOZE (Delivering Online Zzz's with Empirical Support) is a self-management app that is grounded in sleep and circadian basic science. Although initial testing supports it as a feasible and acceptable app in a research context, it has not been tested as a strategy to use in schools. The present study tested DOZE in private high schools in Canada. Two-hundred and twenty-three students downloaded the app and completed daily sleep diaries over 4 weeks. Students reported a more regularised routine for bedtime, Mdiff = -0.43 h, p < 0.001, 95% CI [-0.65, -0.21], and rise time, Mdiff = -0.61 h, p < 0.001, 95% CI [-0.84, -0.38], in addition to a higher total sleep time, Mdiff = 0.18 h, p < 0.008, 95% CI [0.05, 0.31]. Students also rated DOZE to be highly acceptable. The evidence suggests that students find DOZE to be acceptable and engagement in this nonclinical population was reasonably high under minimal researcher supervision. This makes DOZE an attractive option and a step towards broad-based sleep health services. High powered replications with control groups are needed to increase empirical rigour.

Anxiolytic impact of cognitive behavioural therapy for insomnia in patients with co-morbid insomnia and generalized anxiety disorder.

BACKGROUND: Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia that also improves non-sleep symptoms, such as mood and anxiety. Identifying sleep-specific variables that predict anxiety change after CBT-I treatment may support alternative strategies when people with generalized anxiety disorder (GAD) do not improve from standard GAD treatment. AIMS: To investigate CBT-I on changes in anxiety and evaluate whether changes in sleep-specific variables predict anxiety outcomes. METHODS: Seventy-two participants presenting with insomnia and GAD (GAD-I) completed four sessions of CBT-I. Participants completed daily diaries and self-report measures at baseline and post-treatment. RESULTS: CBT-I in a co-morbid GAD-I sample was associated with medium reductions in anxiety, and large reductions in insomnia severity. Subjective insomnia severity and tendencies to ruminate in response to fatigue predicted post-treatment anxiety change, in addition to younger age and lower baseline anxiety. CONCLUSIONS: The findings suggest that younger GAD-I participants with moderate anxiety symptoms may benefit most from the anxiety-relieving impact of CBT-I. Reducing perceived insomnia severity and the tendency to ruminate in response to fatigue may support reductions in anxiety in those with GAD-I.

An Investigation of Further Strategies to Optimize Early Treatment Gains in Brief Therapies for Insomnia.

OBJECTIVES: Identifying those who are most (and least) likely to benefit from a stepped-care approach to cognitive behavioral therapy for insomnia (CBT-I) increases access to insomnia therapies while minimizing resource consumption. The present study investigates non-targeted factors in a single-session of CBT-I that may act as barriers to early response and remission. METHODS: Participants (N = 303) received four sessions of CBT-I and completed measures of subjective insomnia severity, fatigue, sleep-related beliefs, treatment expectations, and sleep diaries. Subjective insomnia severity and sleep diaries were completed between each treatment session. Early response was defined as a 50% reduction in Insomnia Severity Index (ISI) scores and early remission was defined by < 10 on the ISI after the first session. RESULTS: A single-session of CBT-I significantly reduced subjective insomnia severity scores and diary total wake time. Logistic regression models indicated that lower baseline fatigue was associated with increased odds of early remission (B = -.05, p = .02), and lower subjective insomnia severity (B = -.13, p = .049). Only fatigue was a significant predictor of early treatment response (B = -.06, p = .003). CONCLUSIONS: Fatigue appeared to be an important construct that dictates early changes in perceived insomnia severity. Beliefs about the relationship between sleep and daytime performance may hinder perceived improvements in insomnia symptoms. Incorporating fatigue management strategies and psychoeducation about the relationship between sleep and fatigue may target non-early responders. Future research would benefit from further profiling potential early insomnia responders/remitters.

Cognitive factors and processes in models of insomnia: A systematic review.

Cognition is central to the experience of insomnia. Although unhelpful thoughts about and around insomnia are a primary treatment target of cognitive behaviour therapy for insomnia, cognitive constructs are termed and conceptualised differently in different theories of insomnia proposed over the past decades. In search of consensus in thinking, the current systematic review identified cognitive factors and processes featured in theoretical models of insomnia and mapped any commonality between models. We systematically searched PsycINFO and PubMed for published theoretical articles on the development, maintenance and remission of insomnia, from inception of databases to February, 2023. A total of 2458 records were identified for title and abstract screening. Of these, 34 were selected for full-text assessment and 12 included for analysis and data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified nine distinguishable models of insomnia published between 1982 and 2023 and extracted 20 cognitive factors and processes featured in these models; 39 if sub-factors were counted. After assigning similarity ratings, we observed a high degree of overlap between constructs despite apparent differences in terminologies and measurement methods. As a result, we highlight shifts in thinking around cognitions associated with insomnia and discuss future directions.

What are patients completing Cognitive Behavioral Insomnia Therapy telling us with their post-treatment Insomnia Severity Index scores?

STUDY OBJECTIVE: Cognitive Behavioral Insomnia Therapy (CBT-I) is the gold standard insomnia treatment and the Insomnia Severity Index (ISI) is a frequently used treatment outcome measure. The ISI has strong psychometric properties and is purported to measure perceived insomnia symptom severity. However, little is known about the factors that drive insomnia severity perception and the psychometric properties of the ISI post-CBT-I. METHODS: Participants were treatment-seeking adults meeting DSM-5 Insomnia Disorder criteria (n = 203, ages 18-77, M = 45.95 years). Participants completed sleep and mood questionnaires, including the ISI, pre- and post-CBT-I. They completed daily Consensus Sleep Diaries each morning throughout two pre-treatment weeks, eight weeks of treatment and two weeks post-treatment. A hierarchical regression analysis examined what predicted post-CBT-I ISI scores and Cronbach's alpha was computed to examine post-treatment reliability of the ISI. RESULTS: The regression analysis revealed that lower post-treatment ISI scores were associated with lower pre-treatment ISI, and greater decreases in fatigue and generalized anxiety symptoms. The model did not significantly improve when pre-treatment sleep effort or changes in sleep diary indices were added. The post-treatment ISI Cronbach's alpha was .88. CONCLUSIONS: Although the ISI has been shown to have sound psychometric properties, clinicians should consider that post CBT-I ISI scores are not related to their sleep improvements. Instead, they seem to be related to whether patients perceive themselves as poor sleepers pre-treatment and whether they felt less tired and anxious after CBT-I. Researchers should consider the impact of factors other than sleep when using the ISI at post-treatment. Patients are telling us that CBT-I should focus on addressing symptoms of fatigue and general anxiety; perhaps CBT-I could be improved further to address these concerns more effectively. SUMMARY: This investigation shows that when individuals are rating their symptom severity after CBT-I, they are also integrating how they felt before treatment and whether they experienced a change in their fatigue or anxiety.

Social problem-solving attitudes and performance as a function of differences in trait and state worry.

BACKGROUND AND OBJECTIVES: This study investigated problem-solving attitudes and state-dependent, performance-based problem-solving abilities of individuals with high trait worry as compared to those low in trait worry. Secondary objectives involved investigating the relationship between problem-solving effectiveness and processes hypothesized to influence worry and problem-solving (i.e., working memory, attentional control, emotional dysregulation, and concreteness of thought). METHODS: A 2 (group: high worry, n = 68, vs. low worry, n = 66) X 2 (induction type: worry vs. neutral mentation) factorial design was employed to investigate the differential effects of state worry, and neutral mentation for comparison, on performance-based problem-solving effectiveness. Independent samples t-tests tested for group differences in self-reported problem-solving attitudes. Multiple regression analyses were used to investigate if aforementioned processes predict problem-solving effectiveness. RESULTS: Previous findings that individuals with high trait worry endorse greater tendencies to self-report unconstructive problem-solving attitudes were replicated. Contrary to predictions, there were no significant within or between group differences on problem-solving performance. Concreteness of problem solutions was the only consistent predictor of problem-solving effectiveness. LIMITATIONS: Study did not directly assess problem-solving for personal problems. CONCLUSIONS: Disparities in self-appraisal may account for lack of worry-related performance differences. Findings suggest that when employing problem-solving interventions with a high worry population, emphasis should be placed on changing maladaptive problem attitudes. Nonclinical and clinical populations alike may benefit from incorporating training in concreteness in problem-solving therapy.

Examining whether Changes in Sleep Habits Predict Long-Term Sustainment of Treatment Gains in Individual Remitted from Insomnia after CBT-I.

OBJECTIVES: Providers of Cognitive-Behavioral Therapy for Insomnia (CBT-I) are often asked whether the behavioral recommendations (e.g., stimulus control, sleep restriction) must be adhered to ad infinitum. We examined whether changes in sleep habits/behaviors are a life sentence, or whether patients who remit can relax their adherence while maintaining their treatment gains at 1-year follow-up (FU). METHODS: Participants (N = 179) completed 2 weeks of sleep diaries and measures of insomnia severity and safety behaviors at baseline and following four sessions of CBT-I. Of the 137 patients that achieved remission, 77 completed these measures at 1-year FU. RESULTS: Improvements in insomnia severity and total wake time (TWT) at post-treatment were maintained at FU (ps ≥ .52). Similarly, reductions in safety behaviors were maintained at FU (p - 1.00), whereas lingering in bed reduced during treatment (p < .001) but increased at FU (p < .001). Changes in sleep habits after treatment did not predict insomnia severity at FU. However, increases in time in bed positively predicted TWT at FU (p = .001). CONCLUSIONS: Those who remit after CBT-I may generally relax their adherence to behavioral recommendations without significantly impacting their perceived insomnia symptoms 1 year after treatment despite some increases in TWT. Results increase our confidence in CBT-I as a brief and durable intervention.

Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause.

OBJECTIVES: Insomnia is frequently reported by women during menopause due to physiological changes and environmental factors and is associated with negative daytime sequelae. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments for menopausal insomnia. The primary objective of this review is to review the efficacy of cognitive-behavioral, behavioral, and mindfulness-based (CBBMB) therapies in treating insomnia in peri- and post-menopausal women. The secondary objective is to review the effect of CBBMB therapies on relevant secondary outcomes to gain a comprehensive understanding of their impacts. METHODS: We conducted a narrative review of the literature. A search of PubMed and Google Scholar was conducted between January 2020 and March 2021. RESULTS: Cognitive-behavioral therapy (CBT) for insomnia is efficacious, with corollary improvements in mood, functional outcomes and potential mechanistic factors (e.g., unhelpful beliefs). Sleep restriction therapy is also efficacious, with somewhat poorer effects on secondary outcomes relative to CBT. Mindfulness meditation and relaxation for insomnia demonstrated promise, but its long-term effects remain unknown. CONCLUSIONS: Research with more diverse samples and head-to-head comparisons is needed. Dissemination of CBBMBs for insomnia in clinics where menopausal women seek care is an important next step.

Economic burden of insomnia symptoms in Canada.

OBJECTIVE: To estimate health care and productivity costs associated with insomnia symptoms in Canadian adults. METHODS: Three pieces of information were needed to calculate estimates based on a prevalence-based approach: (1) the pooled relative risk estimates of health outcomes consistently associated with insomnia symptoms obtained from recent meta-analyses of prospective cohort studies; (2) the direct (health care) and indirect (lost productivity due to premature mortality) costs of these health outcomes using the Economic Burden of Illness in Canada information; and (3) the prevalence of insomnia symptoms in Canadian men (18.1%) and women (29.5%) obtained from a nationally-representative survey. RESULTS: The direct, indirect, and total costs of insomnia symptoms in Canada in 2021 were $1.9 billion, $12.6 million, and $1.9 billion, respectively. This value represents 1.9% of the overall burden of illness costs for 2021 in Canada. The 2 most expensive chronic diseases attributable to insomnia symptoms were type 2 diabetes ($754 million) and depression ($706 million). The main contributor to the costs for type 2 diabetes and depression was prescription drugs. A 5% decrease in insomnia symptoms (from 23.8% to 18.8%) would result in an estimated $353 million in avoided costs while a 5% increase in insomnia symptoms (from 23.8% to 28.8%) would result in an estimated $333 million in additional expenditures yearly. CONCLUSIONS: Insomnia symptoms greatly contribute to the economic burden of illness in Canada. Reducing the prevalence of insomnia symptoms would reduce its societal burden.

The role of beliefs about sleep in nightly perceptions of sleep quality across a depression continuum.

BACKGROUND: Poor sleep quality is common in depression, but complaints of poor sleep quality are not necessarily tied to objective sleep, and the construct of sleep quality remains poorly understood. Previous work suggests that beliefs about sleep may influence sleep quality appraisals, as might sleep variability from night to night. OBJECTIVE: We tested whether beliefs about sleep predict daily sleep quality ratings above and beyond nightly variability of actigraphy and diary-assessed sleep over the course of multiple nights. METHODS: Eighty-eight participants aged 18-65 years across a depressive continuum completed sleep diaries and reported their sleep quality and mood each morning; actigraphy was also completed for 67 of those participants. Multilevel models were used to test previous night's total sleep time and sleep efficiency as predictors of self-reported sleep quality (VAS-SQ) and mood (VAS-M), and whether unhelpful beliefs about sleep predicted VAS-SQ and VAS-M above and beyond the sleep variables. RESULTS: Individuals across a depression continuum with greater unhelpful beliefs about sleep reported worse sleep quality and worse mood upon awakening, even when accounting for nightly variation in actigraphy or diary assessed total sleep time and sleep efficiency. CONCLUSIONS: These results suggest that people are influenced by unhelpful sleep beliefs when making judgements about sleep quality and mood, regardless of how well they slept the previous night. Working with these unhelpful sleep beliefs in cognitive behavioral therapy can thus promote better sleep and mood in people across the depressive continuum.

Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials.

STUDY OBJECTIVES: We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence. RESULTS: Thirty-nine trials (5100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (weighted mean difference of -0.19 cm [95%CI, -0.36 to -0.03 cm]; interaction p = .03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%). CONCLUSION: Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.

A Transdiagnostic Self-management Web-Based App for Sleep Disturbance in Adolescents and Young Adults: Feasibility and Acceptability Study.

BACKGROUND: Sleep disturbance and its daytime sequelae, which comprise complex, transdiagnostic sleep problems, are pervasive problems in adolescents and young adults (AYAs) and are associated with negative outcomes. Effective interventions must be both evidence based and individually tailored. Some AYAs prefer self-management and digital approaches. Leveraging these preferences is helpful, given the dearth of AYA treatment providers trained in behavioral sleep medicine. We involved AYAs in the co-design of a behavioral, self-management, transdiagnostic sleep app called DOZE (Delivering Online Zzz's with Empirical Support). OBJECTIVE: This study tests the feasibility and acceptability of DOZE in a community AYA sample aged 15-24 years. The secondary objective is to evaluate sleep and related outcomes in this nonclinical sample. METHODS: Participants used DOZE for 4 weeks (2 periods of 2 weeks). They completed sleep diaries, received feedback on their sleep, set goals in identified target areas, and accessed tips to help them achieve their goals. Measures of acceptability and credibility were completed at baseline and end point. Google Analytics was used to understand the patterns of app use to assess feasibility. Participants completed questionnaires assessing fatigue, sleepiness, chronotype, depression, anxiety, and quality of life at baseline and end point. RESULTS: In total, 83 participants created a DOZE account, and 51 completed the study. During the study, 2659 app sessions took place with an average duration of 3:02 minutes. AYAs tracked most days in period 1 (mean 10.52, SD 4.87) and period 2 (mean 9.81, SD 6.65), with a modal time of 9 AM (within 2 hours of waking). DOZE was appraised as highly acceptable (mode≥4) on the items "easy to use," "easy to understand," "time commitment," and "overall satisfaction" and was rated as credible (mode≥4) at baseline and end point across all items (logic, confident it would work, confident recommending it to a friend, willingness to undergo, and perceived success in treating others). The most common goals set were decreasing schedule variability (34/83, 41% of participants), naps (17/83, 20%), and morning lingering in bed (16/83, 19%). AYAs accessed tips on difficulty winding down (24/83, 29% of participants), being a night owl (17/83, 20%), difficulty getting up (13/83, 16%), and fatigue (13/83, 16%). There were significant improvements in morning lingering in bed (P=.03); total wake time (P=.02); sleep efficiency (P=.002); total sleep time (P=.03); and self-reported insomnia severity (P=.001), anxiety (P=.002), depression (P=.004), and energy (P=.01). CONCLUSIONS: Our results support the feasibility, acceptability, credibility, and preliminary efficacy of DOZE. AYAs are able to set and achieve goals based on tailored feedback on their sleep habits, which is consistent with research suggesting that AYAs prefer autonomy in their health care choices and produce good results when given tools that support their autonomy. TRIAL REGISTRATION: ClinicalTrials.gov NCT03960294; https://clinicaltrials.gov/ct2/show/NCT03960294.

Testing the contiguity of the sleep and fatigue relationship: a daily diary study.

STUDY OBJECTIVES: There is mixed evidence for the relationship between poor sleep and daytime fatigue, and some have suggested that fatigue is simply caused by lack of sleep. Although retrospective measures of insomnia and fatigue tend to correlate, other studies fail to demonstrate a link between objectively disturbed sleep and fatigue. The current study prospectively explored the relationship between sleep and fatigue among those with and without insomnia disorder. METHODS: Participants meeting Research Diagnostic Criteria for insomnia disorder (n = 33) or normal sleepers (n = 32) completed the Consensus Sleep Diary (CSD) and daily fatigue ratings for 2 weeks. Baseline questionnaires evaluated cognitive factors including unhelpful beliefs about sleep and rumination about fatigue. Hierarchical linear modeling tested the within- and between-participant relationships between sleep quality, total sleep time, and daily fatigue ratings. Mediation analyses tested if cognitive factors mediated the relationship between insomnia and fatigue. RESULTS: Self-reported nightly sleep quality significantly predicted subsequent daily fatigue ratings. Total sleep time was a significant predictor of fatigue within, but not between, participants. Unhelpful sleep beliefs and rumination about fatigue mediated the relationship between insomnia and fatigue reporting. CONCLUSIONS: The results suggest that perception of sleep plays an important role in predicting reports of daytime fatigue. These findings could be used in treatment to help shift the focus away from total sleep times, and instead, focus on challenging maladaptive sleep-related cognitions to change fatigue perception.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

INTRODUCTION: The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations. METHODS: The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations. RESULTS: The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline.

INTRODUCTION: This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults. METHODS: The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine and sleep psychology to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force evaluated a summary of the relevant literature and the quality of evidence, the balance of clinically relevant benefits and harms, patient values and preferences, and resource use considerations that underpin the recommendations. The AASM Board of Directors approved the final recommendations. RECOMMENDATIONS: The following recommendations are intended as a guide for clinicians in choosing a specific behavioral and psychological therapy for the treatment of chronic insomnia disorder in adult patients. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and to strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG). 2. We suggest that clinicians use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 3. We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 4. We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 5. We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 6. We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL).