Identifying predictors of the amount of veteran participation in cognitive behavioral therapy for insomnia in the Veterans Affairs health care system.

Insomnia is a prevalent and negatively impactful disorder among veterans. The Department of Veterans Affairs (VA) has committed significant resources to the development and dissemination of training related to cognitive behavioral therapy for insomnia (CBT-I), the recommended first-line intervention for chronic insomnia disorder. It has been established that VA clinicians can be effectively trained to deliver high fidelity CBT-I and that treatment results in significant improvements in insomnia. However, there is a paucity of research examining rates and predictors of veterans' participation in CBT-I in routine VA clinical care. In this study, we conducted a secondary analysis of data from VA electronic health records (EHR) to determine individual predisposing, enabling, and need factors associated with CBT-I participation. The sample included veterans who had at least one CBT-I templated note from the VA mid-Atlantic region of the United States (VISN4) between 2015 and 2019 in their chart (N = 2,801). CBT-I participation was defined by number of CBT-I templated notes occurring within a 6-month period from the initial note. Findings indicated that veterans most often completed only one session of CBT-I and, on average, completed approximately three sessions. Results from multinomial logistic regression identified significant associations of race, the presence of comorbid mental health disorders, rurality, presence of insomnia diagnosis, and insomnia medication with CBT-I participation; associations varied depending on how CBT-I participation was defined. More work is needed to better understand factors contributing to participation and reasons for completion and noncompletion of CBT-I. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Does insomnia treatment prevent depression?

Rates of major depressive disorder (MDD) are increasing globally, in part due to the coronavirus disease 2019 pandemic, contributing to disease burden. It has long been known that insomnia is intricately connected with depression as indicated by greater depression severity and lower treatment response. Furthermore, insomnia is a significant risk factor for new-onset depression. Treatment of insomnia is thus a logical target for prevention of incidents and recurrent MDD. This systematic review sought to evaluate the current evidence for the preventive effects of insomnia treatment on depression onset. A database search yielded 186 studies, six of which met criteria for inclusion in this review. All of the studies utilized cognitive behavioral treatment for insomnia (CBT-I) as the target intervention and most delivered treatment via a digital platform. Four of the studies found significantly lower rates of MDD onset in those who received CBT-I compared to a control condition. The two remaining studies failed to confirm these effects in primary analyses but secondary analyses suggested evidence of a preventive effect. There was significant methodologic heterogeneity across studies in terms of sample selection, outcomes, and follow-up periods, limiting the ability to draw firm conclusions. The evidence overall is in the direction of insomnia treatment reducing the risk for onset of MDD, but further research is warranted.

Do financial incentives increase mental health treatment engagement? A meta-analysis.

OBJECTIVE: Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management. METHOD: We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies. RESULTS: About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior. CONCLUSIONS: Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Identifying and characterizing longitudinal patterns of insomnia across the deployment cycle in active duty Army soldiers.

STUDY OBJECTIVES: The present study characterized a sample of 4,667 Army soldiers based on their patterns of insomnia before, during, and after deployment, and explored pre-deployment factors predictive of these patterns. METHODS: Data were analyzed from the Army Study to Assess Risk and Resilience in Service members (STARRS)-Pre/Post Deployment Study (PPDS), using surveys that captured data approximately 1-2 months pre-deployment, and 3- and 9-month post-deployment from soldiers deployed to Afghanistan. Patterns of insomnia across time were examined. Theoretically derived variables linked to sleep disturbance were examined as predictors of the insomnia patterns. RESULTS: Five longitudinal patterns of insomnia characterized the majority of the sample: "No Insomnia" (no insomnia symptoms at any timepoint; 31%), "Deployment-related Insomnia" (no pre-deployment insomnia, developed insomnia symptoms during deployment and recovered; 40%), "Incident Insomnia" (development insomnia during or shortly after deployment that did not remit; 14%), "Chronic Insomnia" (insomnia both pre- and post-deployment; 11%), and "Other Insomnia" (reported insomnia at ≥1 timepoint, but no clear pattern across the deployment cycle; 4%). Several pre-deployment factors were predictive of insomnia trajectories, including lifetime major depressive episodes, traumatic brain injury history, posttraumatic stress disorder, and past year personal life stressors. CONCLUSIONS: Distinct longitudinal patterns of insomnia were identified, with more than half of the sample reporting insomnia at some point in the deployment cycle. Identifying mental health conditions that are associated with different insomnia patterns prior to deployment can inform targeted interventions to reduce long-term sleep difficulty.

An Integrated Sleep and Reward Processing Model of Major Depressive Disorder.

Major depressive disorder with comorbid sleep disturbance has been associated with negative outcomes, including lower rates of treatment response and a greater likelihood of depressive relapse compared to those without sleep disturbance. However, little, if any, research has been conducted to understand why such negative treatment outcomes occur when sleep disturbance is present. In this conceptual review, we argue that the relationship of sleep disturbance and negative treatment outcomes may be mediated by alterations in neural reward processing in individuals with blunted trait-level reward responsivity. We first briefly characterize sleep disturbance in depression, discuss the nature of reward processing impairments in depression, and summarize the sleep/reward relationship in healthy human subjects. We then introduce a novel Integrated Sleep and Reward model of the course and maintenance of major depressive disorder and present preliminary evidence of sleep and reward interaction in unipolar depression. Finally, we discuss limitations of the model and offer testable hypotheses and directions for future research.

Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression?

BACKGROUND: Pre-treatment sleep disturbance has been shown to predict antidepressant treatment outcomes. How changes in sleep disturbance during acute treatment affect longitudinal outcomes, or whether continuation-phase treatment further improves sleep disturbance, is unclear. METHODS: We assessed sleep disturbance repeatedly in: a) 523 adults with recurrent MDD who consented to 12-14 weeks of acute-phase cognitive therapy (A-CT) and b) 241 A-CT responders at elevated risk for depression relapse/recurrence who were randomized to 8 months of continuation-phase treatment (CCT vs. fluoxetine vs. matched pill placebo) and followed protocol-treatment-free for 24 months. Trajectories of change in sleep and depression during and after A-CT were evaluated with multilevel models; individual intercepts and slopes were retained and input into Cox regression models to predict remission, recovery, relapse, and recurrence of MDD. RESULTS: Sleep disturbance improved over the course of A-CT, but most patients continued to report clinically significant sleep complaints. Response and remission were more likely in patients with less overall sleep disturbance and those with greater reduction in sleep disturbance during A-CT; these patients also achieved post-A-CT remission and recovery sooner. Sleep improvements endured throughout follow-up but were not enhanced by continuation-phase treatment. Sleep disturbance did not predict relapse or recurrence consistently. LIMITATIONS: Objective sleep disturbance was not assessed. Analyses were not specifically powered to use sleep changes to predict outcomes. CONCLUSIONS: Improvements in sleep disturbance during A-CT are linked to shorter times to remission and recovery, supporting consideration of monitoring and targeting sleep disturbance in adults with depression.

Social rhythm regularity moderates the relationship between sleep disruption and depressive symptoms in veterans with post-traumatic stress disorder and major depressive disorder.

Approximately 50% to 80% of individuals with posttraumatic stress disorder (PTSD) also meet criteria for major depressive disorder (MDD). Sleep disturbance is a major concern in both PTSD and MDD, and is associated with poor treatment response, poor functional outcome and increased suicide risk. Social rhythm regularity, or the consistency of daily habitual behaviors, is theoretically linked to circadian rhythms and may be disturbed in both PTSD and MDD. The present study examined the relationship between social rhythm regularity, sleep disruption and MDD and PTSD symptoms in a sample of veterans with comorbid PTSD and MDD. Baseline data were obtained from 56 male veterans who met DSM-IV criteria for PTSD and MDD. Veterans completed the Social Rhythm Metric (SRM), a self-report questionnaire that assesses the regularity of routines by determining how regularly individuals completed 17 different types of activities. In a linear regression model, increased minutes awake after sleep onset (WASO) was a significant predictor of increased depression scores on the Hamilton Rating Scale for Depression (p < .05). SRM scores did not significantly predict depressive symptoms, however the interaction of WASO and SRM significantly predicted depressive symptoms (p = <.05), with significant relationships found at SRM scores less than 3.62. Neither minutes awake after sleep onset, SRM scores, nor their interaction was associated with PTSD symptom severity. Social and possibly circadian rhythm regularity may represent a risk or resilience factor for individuals with comorbid PTSD and MDD. Findings highlight the importance of exploring the interactions of sleep and social/circadian rhythms in depression in order to inform continued treatment development.

Effects of slow-wave activity on mood disturbance in major depressive disorder.

BACKGROUND: Studies have demonstrated that decreases in slow-wave activity (SWA) predict decreases in depressive symptoms in those with major depressive disorder (MDD), suggesting that there may be a link between SWA and mood. The aim of the present study was to determine if the consequent change in SWA regulation following a mild homeostatic sleep challenge would predict mood disturbance. METHODS: Thirty-seven depressed and fifty-nine healthy adults spent three consecutive nights in the sleep laboratory. On the third night, bedtime was delayed by 3 h, as this procedure has been shown to provoke SWA. The Profile of Mood States questionnaire was administered on the morning following the baseline and sleep delay nights to measure mood disturbance. RESULTS: Results revealed that following sleep delay, a lower delta sleep ratio, indicative of inadequate dissipation of SWA from the first to the second non-rapid eye movement period, predicted increased mood disturbance in only those with MDD. CONCLUSIONS: These data demonstrate that in the first half of the night, individuals with MDD who have less SWA dissipation as a consequence of impaired SWA regulation have greater mood disturbance, and may suggest that appropriate homeostatic regulation of sleep is an important factor in the disorder.

Preliminary support for the role of reward relevant effort and chronotype in the depression/insomnia comorbidity.

BACKGROUND: The presence of insomnia in the context of depression is linked to a number of poor outcomes including reduced treatment response, increased likelihood of relapse, and greater functional impairment. Given the frequent co-occurrence of depression and insomnia, research into systems and processes relevant to both disorders, specifically reward processing and circadian rhythm disruption, may help parse this complex comorbidity. METHODS: A pilot study was conducted on a sample of 10 veterans with clinically significant depression and insomnia symptoms. Participants completed objective (actigraphy) and subjective (sleep diary) assessments of sleep, self-reports of chronotype, and behavioral tasks assessing reward relevant effort before and after 6 sessions of Cognitive Behavioral Therapy for Insomnia. RESULTS: Insomnia and depression significantly improved following CBT-I. Subjective sleep parameters significantly improved with large effect sizes. Actigraphy results were nonsignificant, but effect sizes for sleep efficiency and onset latency were in the medium range. Chronotype shifted significantly toward morningness following CBT-I, and an earlier chronotype at baseline was associated with increased reward effort following treatment. Changes in chronotype, depression and insomnia were not associated with changes in effort. LIMITATIONS: Findings are limited by small sample size and lack of randomized control group. CONCLUSIONS: Findings should be interpreted as hypothesis generating in the service of furthering research aimed at uncovering potential mechanisms underlying the depression/insomnia comorbidity. Analyses of sleep data in extant datasets of reward processing impairments in depression as well as original projects aimed at exploring potential sleep, circadian rhythm, and reward interactions in depression are encouraged.

Prevalence, predictors and correlates of insomnia in US army soldiers.

The objective of this study was to investigate the rates, predictors and correlates of insomnia in a national sample of US Army soldiers. Data were gathered from the cross-sectional survey responses of the All-Army Study, of the Army Study to Assess Risk and Resilience in Service members. Participants were a representative sample of 21 499 US Army soldiers who responded to the All-Army Study self-administered questionnaire between 2011 and 2013. Insomnia was defined by selected DSM-5 criteria using the Brief Insomnia Questionnaire. The results highlight significant functional difficulties associated with insomnia among US soldiers, as well as insights into predictors of insomnia specific to this population. Insomnia was present in 22.76% of the sample. Predictors of insomnia status in logistic regression included greater number of current mental health disorders, less perceived open lines of communication with leadership, less unit member support and less education. Insomnia had global, negative associations with health, social functioning, support, morale, work performance and Army career intentions. The results provide the strongest evidence to-date that insomnia is common in a military population, and is associated with a wide array of negative factors in the domains of health, military readiness and intentions to remain in military careers.

A qualitative analysis of gabapentin misuse and diversion among people who use drugs in Appalachian Kentucky.

Gabapentin, an anticonvulsant and analgesic for postherpetic neuralgia, has been thought to have no abuse potential despite numerous published reports to the contrary. Gabapentin has been linked with impaired driving and opioid use, highlighting the need to more fully understand its risk profile. Thirty-three individuals reporting recent nonmedical use of gabapentin were recruited from two ongoing longitudinal studies of drug users in Appalachian Kentucky to participate in focus groups. Four sessions were held (two in the community and two in jail settings), during which participants responded to questions regarding their personal experiences with gabapentin misuse. Focus group participants were similar to other gabapentin users in the larger cohort studies with respect to demographics and drug use behaviors. Overall, the sample reported having initiated gabapentin more than 10 years earlier after having it prescribed for a legitimate, though generally off-label, medical indication (e.g., pain, anxiety, opioid detoxification). Participants reported use of gabapentin in combination with buprenorphine, other opioids, cocaine, and caffeine to produce sought-after central nervous system effects (e.g., muscle relaxation, pain reduction, sleep induction, feeling drunk, and feeling "high"). Focus group responses highlighted the low cost of gabapentin for the purpose of getting high and noted increasing popularity in the community, particularly over the last 2 years. Gabapentin was a prominent drug of abuse in two cohorts of the primarily opioid-using individuals. Providers should be aware of gabapentin's abuse potential, and a reexamination of the need for scheduling is warranted. (PsycINFO Database Record

Meta-Analysis of the Antidepressant Effects of Acute Sleep Deprivation.

OBJECTIVE: To provide a quantitative meta-analysis of the antidepressant effects of sleep deprivation to complement qualitative reviews addressing response rates. DATA SOURCES: English-language studies from 1974 to 2016 using the keywords sleep deprivation and depression searched through PubMed and PsycINFO databases. STUDY SELECTION: A total of 66 independent studies met criteria for inclusion: conducted experimental sleep deprivation, reported the percentage of the sample that responded to sleep deprivation, provided a priori definition of antidepressant response, and did not seamlessly combine sleep deprivation with other therapies (eg, chronotherapeutics, repetitive transcranial magnetic stimulation). DATA EXTRACTION: Data extracted included percentage of responders, type of sample (eg, bipolar, unipolar), type of sleep deprivation (eg, total, partial), demographics, medication use, type of outcome measure used, and definition of response (eg, 30% reduction in depression ratings). Data were analyzed with meta-analysis of proportions and a Poisson mixed-effects regression model. RESULTS: The overall response rate to sleep deprivation was 45% among studies that utilized a randomized control group and 50% among studies that did not. The response to sleep deprivation was not affected significantly by the type of sleep deprivation performed, the nature of the clinical sample, medication status, the definition of response used, or age and gender of the sample. CONCLUSIONS: These findings support a significant effect of sleep deprivation and suggest the need for future studies on the phenotypic nature of the antidepressant response to sleep deprivation, on the neurobiological mechanisms of action, and on moderators of the sleep deprivation treatment response in depression.

Psychiatric disorders moderate the relationship between insomnia and cognitive problems in military soldiers.

BACKGROUND: There has been a great deal of research on the comorbidity of insomnia and psychiatric disorders, but much of the existing data is based on small samples and does not assess the full diagnostic criteria for each disorder. Further, the exact nature of the relationship between these conditions and their impact on cognitive problems are under-researched in military samples. METHOD: Data were collected from the All Army Study of the Army Study to Assess Risk and Resilience in Service members (unweighted N = 21, 449; weighted N = 674,335; 18-61 years; 13.5% female). Participants completed the Brief Insomnia Questionnaire to assess for insomnia disorder and a self-administered version of the Composite International Diagnostic Interview Screening Scales to assess for psychiatric disorders and cognitive problems. RESULTS: Military soldiers with current major depressive episode (MDE) had the highest prevalence of insomnia disorder (INS; 85.0%), followed by current generalized anxiety disorder (GAD; 82.6%) and current posttraumatic stress disorder (PTSD; 69.7%), respectively. Significant interactions were found between insomnia and psychiatric disorders; specifically, MDE, PTSD, and GAD status influenced the relationship between insomnia and memory/concentration problems. LIMITATIONS: Cross-sectional nature of the assessment and the absence of a comprehensive neurocognitive battery. CONCLUSION: Psychiatric disorders moderated the relationship between insomnia and memory/concentration problems, suggesting that psychiatric disorders contribute unique variance to cognitive problems even though they are associated with insomnia disorder. Results highlight the importance of considering both insomnia and psychiatric disorders in the diagnosis and treatment of cognitive deficits in military soldiers.

Kindling of Life Stress in Bipolar Disorder: Effects of Early Adversity.

Most theoretical frameworks regarding the role of life stress in bipolar disorders (BD) do not incorporate the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. The kindling hypothesis theorizes that over the longitudinal course of recurrent affective disorders, the relationship between major life stressors and episode initiation declines (Post, 1992). The present study aimed to test an extension of the kindling hypothesis in BD by examining the effect of early life adversity on the relationship between proximal life events and prospectively assessed mood episodes. Data from 145 bipolar participants (59.3% female, 75.2% Caucasian, and mean age of 20.19 years; SD = 1.75 years) were collected as part of the Temple-Wisconsin Longitudinal Investigation of Bipolar Spectrum Project (112 Bipolar II; 33 Cyclothymic disorder). Participants completed a self-report measure of early adversity at baseline and interview-assessed mood episodes and life events at regular 4-month follow-ups. Results indicate that early childhood adversity sensitized bipolar participants to the effects of recent stressors only for depressive episodes and not hypomanic episodes within BD. This was particularly the case with minor negative events. The current study extends prior research examining the kindling model in BD using a methodologically rigorous assessment of life stressors and mood episode occurrence. Clinicians should assess experiences of early adversity in individuals with BD as it may impact reactivity to developing depressive episodes in response to future stressors.

Circadian Rhythm Dysregulation in Bipolar Spectrum Disorders.

PURPOSE OF REVIEW: We review recent evidence for circadian rhythm dysregulation in bipolar spectrum disorders (BSDs). We examine evidence for endogenous abnormalities in the biological clock and disruptions in the external entrainment of circadian rhythms in BSDs. We also address whether circadian dysregulation provides vulnerability to onset of BSD and evidence for a new integration of reward and circadian dysregulation in BSD. RECENT FINDINGS: Relative circadian phase delay (e.g., later melatonin peak, evening chronotype) is associated with BSD, particularly in the depressive phase. More consistent evidence supports irregularity of social rhythms, sleep/wake and activity patterns, and disruptions of social rhythms by life events, as stable trait markers of BSD and potential vulnerabilities for BSD onset. Growing research supports an integrative reward/circadian model. Both endogenous abnormalities in the biological clock pacemaking function and disruptions in the external entrainment of circadian rhythms by physical and social cues are involved in BSDs. Circadian dysregulation may provide vulnerability to BSD onset.

Affective Disruption from Social Rhythm and Behavioral Approach System (BAS) Sensitivities: A Test of the Integration of the Social Zeitgeber and BAS Theories of Bipolar Disorder.

The Behavioral Approach System (BAS)/Reward Hypersensitivity Theory and the Social Zeitgeber Theory are two biopsychosocial theories of bipolar spectrum disorders (BSD) that may work together to explain affective dysregulation. The present study examined whether BAS sensitivity is associated with affective symptoms via a) increased social rhythm disruption in response to BAS-relevant life events, or b) greater exposure to BAS events leading to social rhythm disruption and subsequent symptoms. Results indicated that high BAS individuals were more likely to experience social rhythm disruption following BAS-relevant events. Social rhythm disruption mediated the association between BAS-relevant events and symptoms (hypothesis a). High BAS individuals experienced significantly more BAS-relevant events, which predicted greater social rhythm disruption, which predicted greater levels of affective symptoms (hypothesis b). Individuals at risk for BSD may be sensitive to BAS-relevant stimuli, experience more BAS-relevant events, and experience affective dysregulation due to the interplay of the BAS and circadian rhythms.

Recent Advances in the Study of Sleep in the Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder.

Sleep disturbance is frequently associated with generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. This article reviews recent advances in understanding the mechanisms of the sleep disturbances in these disorders and discusses the implications for developing improved treatments.

Low social rhythm regularity predicts first onset of bipolar spectrum disorders among at-risk individuals with reward hypersensitivity.

The social zeitgeber model (Ehlers, Frank, & Kupfer, 1988) suggests that irregular daily schedules or social rhythms provide vulnerability to bipolar spectrum disorders. This study tested whether social rhythm regularity prospectively predicted first lifetime onset of bipolar spectrum disorders in adolescents already at risk for bipolar disorder based on exhibiting reward hypersensitivity. Adolescents (ages 14-19 years) previously screened to have high (n = 138) or moderate (n = 95) reward sensitivity, but no lifetime history of bipolar spectrum disorder, completed measures of depressive and manic symptoms, family history of bipolar disorder, and the Social Rhythm Metric. They were followed prospectively with semistructured diagnostic interviews every 6 months for an average of 31.7 (SD = 20.1) months. Hierarchical logistic regression indicated that low social rhythm regularity at baseline predicted greater likelihood of first onset of bipolar spectrum disorder over follow-up among high-reward-sensitivity adolescents but not moderate-reward-sensitivity adolescents, controlling for follow-up time, gender, age, family history of bipolar disorder, and initial manic and depressive symptoms (ß = -.150, Wald = 4.365, p = .037, odds ratio = .861, 95% confidence interval [.748, .991]). Consistent with the social zeitgeber theory, low social rhythm regularity provides vulnerability to first onset of bipolar spectrum disorder among at-risk adolescents. It may be possible to identify adolescents at risk for developing a bipolar spectrum disorder based on exhibiting both reward hypersensitivity and social rhythm irregularity before onset occurs.