A Scoping Study of Insomnia Symptoms in School Teachers.

OBJECTIVES: Although the demands and stress of teaching are generally recognized, little is known about the prevalence and nature of insomnia symptoms in teachers. This scoping study investigated the following questions: How prevalent are insomnia symptoms in teachers? What biopsychosocial variables are associated with insomnia symptoms in teachers? What, if any, interventions for insomnia symptoms in teachers have been studied? METHOD: We searched Medline, PsycINFO, Embase, CINAHL, Education Source, and ERIC for original peer-reviewed research on school teachers (kindergarten through high school) and insomnia symptoms (self-reported trouble falling or staying asleep). RESULTS: We identified 33 relevant articles from 15 countries. The literature was heterogeneous and generally of low quality with respect to the measurement of insomnia. Based on studies that met validity and reliability criteria, 36-61% of teachers reported insomnia symptoms. Associated factors included: being female, classroom violence, low job satisfaction, pain, depression, and rumination. One online intervention, which included stimulus control, sleep restriction, and techniques for reducing rumination, provided evidence of efficacy. CONCLUSION: Despite the importance of teachers and their work, high-quality research on insomnia in teachers is lacking. Research in this area is sorely needed. Studies should investigate insomnia symptoms over the school year, identify antecedents of insomnia, and develop interventions with the ultimate goals of understanding, preventing, and treating insomnia symptoms in teachers.

Cognitive-Behavioral Therapy for Insomnia Tailored to Patients With Cardiovascular Disease: A Pre-Post Study.

Objective: There is little research assessing the use of cognitive-behavioral therapy for insomnia (CBT-I) among patients with cardiovascular disease (CVD), even less on the effects of CBT-I on CVD risk factors such as anxiety and depression, and to our knowledge, only limited studies of the efficacy of CBT-I protocols with cardiac disease-specific modifications. The objective of this study is to evaluate a group-based CBT-I intervention tailored to patients with CVD on sleep quality, duration, and mental health. Participants: A sample of 47 participants (25 men) diagnosed with primary insomnia were included in this study. Methods: This study used a pre-post design comparing outcomes before and after a group intervention. Clinicians in a cardiac center referred CVD patients with self-reported sleep disturbance to the intervention group. Following screening and confirmation of insomnia disorder, participants completed a six-week CBT-I group-based intervention tailored for patients with CVD. Participants completed sleep diaries and questionnaires, including the Insomnia Severity Index, Beck Depression Inventory-II, and Beck Anxiety Inventory, pre- and postintervention. Results: Participants' sleep outcomes (sleep duration, maintenance, efficiency, latency, and quality) were significantly improved and patients reported significantly fewer symptoms of anxiety, depression, and insomnia following the CBT-I intervention (p values < .05). Conclusions: After participating in a CBT-I group intervention tailored for cardiac patients, patients reported improved sleep and significantly lower levels of anxiety and depression. Randomized trials of this intervention are warranted.

Effectiveness of Group Cognitive Behavioral Therapy for Insomnia (CBT-I) in a Primary Care Setting.

Objective/Background: Primary care is where many patients with insomnia first ask for professional help. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia. Although CBT-I's efficacy is well established, its effectiveness in real-life primary care has seldom been investigated. We examined the effectiveness of CBT-I as routinely delivered in a Canadian primary care setting. Participants: The patients were 70 women and 11 men (mean age = 57.0 years, SD = 12.3); 83% had medical comorbidity. Methods: For the first 81 patients who took the six-session group program we compared initial and postprogram sleep diaries, sleep medication use, Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS), and visits to the family physician. Results: Sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and ISI scores improved significantly (p < .001). Mood ratings also improved (p < .001). Use of sleep medication decreased (p < .001). Effect sizes were medium to large. Eighty-eight percent of patients no longer had clinically significant insomnia (ISI score ≤ 14) by the last session; 61% showed at least "moderate" improvement (ISI score reduction > 7). Wait-list data from 42 patients showed minimal sleep and mood improvements with the passage of time. Number of visits to the family physician six months postprogram decreased, although not significantly (p = .108). Conclusions: The CBT-I program was associated with improvement on all sleep and mood measures. Effect sizes were similar to, or larger than, those found in randomized controlled trials, demonstrating the real-world effectiveness of CBT-I in an interdisciplinary primary care setting.

A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer.

PURPOSE: This study aims to provide recommendations on the optimal strategies and interventions for the prevention, screening, assessment, and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) in adult cancer populations. METHODS: A systematic search of the published health literature was conducted to identify randomized controlled trials, clinical practice guidelines, systematic reviews, and other guidance documents. The Sleep Disturbance Expert Panel [comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers, and guideline methodologists] reviewed, discussed, and approved the final version of the guideline. Health care professionals across Canada were asked to provide feedback through an external review process. RESULTS: Three clinical practice guidelines and 12 randomized controlled trials were identified as the evidence base. Overall, despite the paucity of evidence, the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using standardized screening tools on a routine basis. While prevention of sleep disturbance is the desired objective, cognitive behavioral therapies are effective in improving sleep outcomes. As part of the external review with 16 health care providers, 81 % indicated that they agreed with the recommendations as written. CONCLUSIONS: Sleep difficulty is a prevalent problem in cancer populations that needs greater recognition by health professionals. Prevention, screening, assessment, and treatment strategies supported by the best available evidence are critical. Recommendations and care path algorithms for practice are offered.

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.

National strategy on the integration of sleep and circadian rhythms into public health research and policies: Report from the Canadian Sleep and Circadian Network.

Scientists in sleep and circadian rhythms, public health experts, healthcare providers, partners, and stakeholders convened in 2020 for a 2-day meeting organized by the Canadian Sleep and Circadian Network to develop a national strategy for integrating sleep and circadian rhythms into public health and policies in Canada. The objective of this paper is to present the national strategy that emerged from this meeting of 60 participants from across Canada. The meeting focused on 4 key target priorities: (1) atypical working schedules, (2) sleep and circadian rhythms of children and adolescents, (3) insomnia, and (4) impact of sleep apnea on health. Following constructive discussions, it was decided that the following 4 strategic objectives should be prioritized to accelerate the integration of sleep and circadian rhythms into public health policies in Canada: (1) increase public health sleep and circadian rhythm research, (2) increase public health education and knowledge mobilization on sleep, (3) inform and support public health sleep interventions and policies, and (4) promote sleep health training. Participants recommended that research and public health efforts address needs along the continuum of sleep health. The committee noted that strategies and interventions could differ across contexts, settings, sectors, and jurisdictions. The national strategy also identified high-priority research questions in public health and recommended mechanisms to build research capacity, providing a path forward for the integration of sleep and circadian rhythms into public health research and policies.

Patterns of reporting health-related quality of life outcomes in randomized clinical trials: implications for clinicians and quality of life researchers.

PURPOSE: To assess the patterns of, and trends over time in, health-related quality of life (HRQL) reporting in randomized controlled trials (RCTs). METHODS: The English-language literature of RCTs published in 2002-2008 was identified using Medline, Embase, and Healthstar databases, in addition to the Cochrane Clinical Trials Registry. Eligible trials were phase III studies that included an HRQL outcome. Data were abstracted on eight outcomes derived from previously recommended quality standards for reporting HRQL, and on four outcomes describing how HRQL data are presented in RCT reports. Two readers examined each article; discrepancies were resolved through discussion and third review if required. RESULTS: A sample of 794 RCTs was identified. HRQL was a primary outcome in 25.4% (200/794). One hundred and ten RCTs (14%) used "supplementary" reports (separate from the first publication) to report HRQL findings. The proportion of RCTs that met the eight quality indicators ranged from 15% (HRQL used in the calculation of sample size) to 81% (reporting instrument validity). RCTs with HRQL as a primary outcome or with a supplementary report had higher concordance on the quality measures. Reporting improved on many indicators over time. Substantive variation in how HRQL data are presented in RCTs was evident. CONCLUSIONS: Current practice of reporting HRQL outcomes in RCTs remains highly variable, both with regard to quality of reporting and the patterns of data analysis and presentation. This variation presents challenges for clinicians to apply these data in clinical practice. Consistent reporting practices, which are interpretable by clinicians, are required, as are processes to achieve this consistency in future reports.

Characteristics of individuals with insomnia who seek treatment in a clinical setting versus those who volunteer for a randomized controlled trial.

The generalizability of outcome data derived from insomnia clinical trials is based largely on the extent to which research volunteers resemble clinical patients. This study compared sociodemographic, sleep, psychological, and medical characteristics of individuals who volunteered for an insomnia treatment study (n = 120) to patients who sought treatment in a clinical setting (n = 106). The samples did not differ on most sleep and medical variables, but clinical patients had a higher prevalence of mood disorders, greater anxiety and depression symptoms, and higher perceived insomnia severity. Differences on psychological variables were accentuated by the research selection process. It is suggested to minimize exclusion based on psychological comorbidity in order to enhance ecological validity of randomized controlled trials of insomnia treatments.

Cognitive behavioural treatment for insomnia in primary care: a systematic review of sleep outcomes.

BACKGROUND: Practice guidelines recommend that chronic insomnia be treated first with cognitive behavioural therapy for insomnia (CBT-I), and that hypnotic medication be considered only when CBT-I is unsuccessful. Although there is evidence of CBT-I's efficacy in research studies, systematic reviews of its effects in primary care are lacking. AIM: To review the effects on sleep outcomes of CBT-I delivered in primary care. DESIGN AND SETTING: Systematic review of articles published worldwide. METHOD: Medline, PsycINFO, EMBASE, and CINAHL were searched for articles published from January 1987 until August 2018 that reported sleep results and on the use of CBT-I in general primary care settings. Two researchers independently assessed and then reached agreement on the included studies and the extracted data. Cohen's d was used to measure effects on sleep diary outcomes and the Insomnia Severity Index. RESULTS: In total, 13 studies were included. Medium-to-large positive effects on self-reported sleep were found for CBT-I provided over 4-6 sessions. Improvements were generally well maintained for 3-12 months post-treatment. Studies of interventions in which the format or content veered substantially from conventional CBT-I were less conclusive. In only three studies was CBT-I delivered by a GP; usually, it was provided by nurses, psychologists, nurse practitioners, social workers, or counsellors. Six studies included advice on withdrawal from hypnotics. CONCLUSION: The findings support the effectiveness of multicomponent CBT-I in general primary care. Future studies should use standard sleep measures, examine daytime symptoms, and investigate the impact of hypnotic tapering interventions delivered in conjunction with CBT-I.

Association between human leukocyte antigen polymorphism and human papillomavirus 16-positive vulval intraepithelial neoplasia in British women.

Polymorphisms in human leukocyte antigen (HLA) genes have been implicated in the risk for developing human papillomavirus (HPV)-associated cervical neoplasia. By comparison with local cadaver controls typed for HLA class I (n = 946) and II (n = 144) antigens, HPV-16-positive high grade vulval intraepithelial neoplasia patients (n = 42) showed significantly different frequencies of HLA-A2 [odds ratio (OR), 2.1; confidence interval (CI), 1.4-3.9], HLA-B7 (OR, 2.6; CI, 1.4-4.7), HLA-DRB1*01(01/02/04) (OR, 0.1; CI, 0.03-0.5), HLA-DRB1*11 (OR, 3.3; CI, 1.4-7.1), HLA-DRB1*13 (OR, 0), HLA-DQB1*05 (OR, 0.2; CI, 0.05-0.6), and HLA-DQB1*03032 (OR, 4.6; CI, 1.5-14.0). With the exception of HLA-B7 and HLA-DRB1*11, these significant differences were also seen comparative to local HPV-16-positive cervical carcinoma patients (n = 114), suggesting a specific immunogenetic contribution that is independent of HPV-16 infection in high-grade vulval intraepithelial neoplasia. Such factors are important to the development of HPV vaccines for treatment of cervical and vulval neoplasia.

The association between nocturnal hot flashes and sleep in breast cancer survivors.

This study examined the relationship between objectively measured nocturnal hot flashes and objectively measured sleep in breast cancer survivors with insomnia. Twenty-four women who had completed treatment for non-metastatic breast cancer participated. All were enrolled in a study of cognitive-behavioral treatment for chronic insomnia. Nocturnal hot flashes and sleep were measured by skin conductance and polysomnography, respectively. The 10-minute periods around hot flashes were found to have significantly more wake time, and more stage changes to lighter sleep, than other 10-minute periods during the night. Nights with hot flashes had a significantly higher percentage of wake time, a lower percentage of Stage 2 sleep, and a longer REM latency compared to nights without hot flashes. Overall, hot flashes were found to be associated with less efficient, more disrupted sleep. Nocturnal hot flashes, or their underlying mechanisms, should be considered as potential contributors to sleep disruption in women with breast cancer who report poor sleep.

Sleep disturbance in cancer patients.

Sleep difficulty is a prominent concern of cancer patients, yet there has been no large study of the prevalence and nature of sleep disturbance in cancer patients. This cross-sectional survey study examined: (a) the prevalence of reported sleep problems in patients attending six clinics at a regional cancer centre; (b) sleep problem prevalence in relation to cancer treatment; and (c) the nature of reported insomnia (type, duration, and associated factors). For three months, all patients attending clinics for breast, gastrointestinal, genitourinary, gynecologic, lung, and non-melanoma skin cancers were offered a brief sleep questionnaire. Response rate was 87%; the final sample size was 982. Mean age of respondents was 64.9 years (SD 12.5). The most prevalent problems were excessive fatigue (44% of patients), leg restlessness (41%). insomnia (31%), and excessive sleepiness (28%). Chi square tests showed significant variation among clinics in the prevalence of most sleep problems. The lung clinic had the highest or second-highest prevalence of problems. The breast clinic had a high prevalence of insomnia and fatigue. Recent cancer treatment was associated with excessive fatigue and hypersomnolence. Insomnia commonly involved multiple awakenings (76% of cases) and duration > or = 6 months (75% of cases). In 48% of cases, insomnia onset was reported to occur around the time of cancer diagnosis (falling within the period 6 months pre-diagnosis to 18 months post-diagnosis). The most frequently identified contributors to insomnia were thoughts, concerns, and pain/discomfort. In a multivariate logistic regression analysis, variables associated with increased odds of insomnia were fatigue, age (inverse relationship), leg restlessness, sedative/hypnotic use, low or variable mood, dreams, concerns, and recent cancer surgery. This study provides new information about sleep-related phenomena in cancer patients, information which will be useful in planning supportive care services for cancer patients.

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH).

PURPOSE: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries. METHOD: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist. RESULTS: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status. CONCLUSIONS: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.

Young drivers' perceptions of culpability of sleep-deprived versus drinking drivers.

INTRODUCTION: Sleep-deprived driving can be as dangerous as alcohol-impaired driving, however, little is known about attitudes toward sleep-deprived drivers. This study examined the extent to which young drivers regard sleep-deprived compared to drinking drivers as culpable for a crash, and how their perceptions of driving while in these conditions differ. METHOD: University student participants (N=295; M=20.4years, SD=1.3; 81% women) were randomly assigned to read one of five fatal motor-vehicle crash scenarios, which differed by aspects of the driver's condition. Culpability ratings for the drinking driver were higher than those for the sleep-deprived driver. RESULTS: Qualitative findings revealed that driving while sleep-deprived was viewed as understandable, and driving after drinking was viewed as definitely wrong. The dangers of sleep-deprived driving remain under-recognized.

A cross-sectional study of post-amputation pain in upper and lower limb amputees, experience of a tertiary referral amputee clinic.

PURPOSE: To determine the pain characteristics and health-related quality of life (HR-QOL) of upper and lower limb amputees. METHOD: Amputees attending the Prince of Wales Prosthetic Clinics in 2006 were administered a questionnaire survey of their pain experiences, Short form McGill pain questionnaire, Short Form 36 (SF 36) and Pain Self-Efficacy Questionnaire (PSEQ). RESULTS: Of the 17 who were upper limb amputees (including the two multiple limb amputees), only 1 was pain free and of the 39 who were lower limb amputees 14 were pain free. Upper limb amputees experienced significantly greater proportion, frequency and severity of post-amputation pain than lower limb amputees. The presence of significant pre-operative pain did not correlate with the development of persistent post-amputation pain. In quality of life measures, the amputees experienced a better physical function, role physical and confidence in performance of activities than chronic pain patients attending the pain clinic. Lower limb amputees fared better than upper limb amputees in terms of bodily pain, social function and mental health. However, the amputee groups have a reduced health status in almost all domains compared to the aged matched Australian population norm. CONCLUSIONS: The study suggests that upper limb amputees are significantly more likely to suffer post-amputation pain which is more frequent, longer lasting and more severe in intensity when compared to lower limb amputees. This is accompanied by reduced HR-QOL especially that related to bodily pain, social function and mental health. The overall health status of amputees are also significantly lower compared to the Australian population norm.

Insomnia treatment options for women.

This article describes the circumstances under which women may develop insomnia and the various treatment options, including hypnotic medication and nonpharmacologic approaches. The efficacy and safety of these treatments are reviewed. The choice of treatment depends on the nature of the insomnia, the stage of a woman's life, the presence of medical or mental health conditions, the availability of treatments, and personal preference. For immediate, short-term relief of acute insomnia, hypnotic medication, especially the nonbenzodiazepines (zolpidem, zopiclone, eszopiclone) are options. For chronic insomnia, insomnia-specific cognitive and behavioral therapies are generally the interventions of choice.

How to provide insomnia interventions to people with cancer: insights from patients.

Chronic insomnia affects approximately one quarter of cancer patients. Non-pharmacologic interventions are the treatment of choice for chronic insomnia, yet they are rarely offered to people with cancer. The study question was how to make these interventions available to cancer patients. Twenty-six cancer patients who had sleep difficulty participated in focus groups or one-to-one interviews. The key questions included: What would be the best way for you to find out about a service for insomnia treatment? What would make it easy/difficult for you to participate? Transcripts were examined independently by three readers who identified participants' answers to the questions, as well as themes that emerged from participants' reflections on their experience with cancer and sleep difficulty. The readers then worked together to reach consensus on a final classification system for describing the content of patients' responses. Participants provided many practical answers to our specific questions. In addition, the following themes emerged: sleep difficulty needs greater recognition by health professionals; patients wish to receive more information about sleep and sleep difficulty; and that although patients perceive sleep as being important, they are reluctant to report sleep problems to doctors. Furthermore, participants recommended that the assessment and treatment of sleep difficulty be integrated into the health care system while considering the cancer-treatment status and energy level of patients.