Who benefits from adolescent sleep interventions? Moderators of treatment efficacy in a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep intervention for at-risk adolescents.

BACKGROUND: The aim of this study was to test moderators of therapeutic improvement in an adolescent cognitive-behavioral and mindfulness-based group sleep intervention. Specifically, we examined whether the effects of the program on postintervention sleep outcomes were dependent on participant gender and/or measures of sleep duration, anxiety, depression, and self-efficacy prior to the interventions. METHOD: Secondary analysis of a randomized controlled trial conducted with 123 adolescent participants (female = 59.34%; mean age = 14.48 years, range 12.04-16.31 years) who had elevated levels of sleep problems and anxiety symptoms. Participants were randomized into either a group sleep improvement intervention (n = 63) or group active control 'study skills' intervention (n = 60). The sleep intervention ('Sleep SENSE') was cognitive behavioral in approach, incorporating sleep education, sleep hygiene, stimulus control, and cognitive restructuring, but also had added anxiety-reducing, mindfulness, and motivational interviewing elements. Components of the active control intervention ('Study SENSE') included personal organization, persuasive writing, critical reading, referencing, memorization, and note taking. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Spence Children's Anxiety Scale (SCAS), Center for Epidemiologic Studies Depression Scale (CES-D), and General Self-Efficacy Scale (GSE) and wore an actigraph and completed a sleep diary for five school nights prior to the interventions. Sleep assessments were repeated at postintervention. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001177842; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12612001177842&isBasic=True). RESULTS: The results showed that compared with the active control intervention, the effect of the sleep intervention on self-reported sleep quality (PSQI global score) at postintervention was statistically significant among adolescents with relatively moderate to high SCAS, CES-D, and GSE prior to the intervention, but not among adolescents with relatively low SCAS, CES-D, and GSE prior to the intervention. The results were consistent across genders. However, the effects of the sleep intervention on actigraphy-measured sleep onset latency and sleep diary-measured sleep efficiency at postintervention were not dependent on actigraphy-measured total sleep time, SCAS, CES-D, or GSE prior to the intervention. CONCLUSIONS: This study provides evidence that some sleep benefits of adolescent cognitive-behavioral sleep interventions are greatest among those with higher levels of anxiety and depressive symptoms, suggesting that this may be an especially propitious group to whom intervention efforts could be targeted. Furthermore, adolescents with lower levels of self-efficacy may need further targeted support (e.g. additional motivational interviewing) to help them reach treatment goals.

Oral microbiome composition, but not diversity, is associated with adolescent anxiety and depression symptoms.

PURPOSE: Depression and anxiety are highly prevalent disorders, whose significant burden is compounded by the presence of oral disease. Mental health disorders and oral health may be associated via changes to the oral microbiome, involving increased pro-inflammatory communication and cortisol in saliva. The present study provides the first culture-independent investigation of the oral microbiome considering depression and anxiety symptoms in adolescence, a critical age where these conditions begin to emerge and co-occur. It also investigates whether inflammation and cortisol moderate these relationships. METHODS: Participants (N = 66) aged 14-18 years (69.70% female) self-reported oral health, depression and anxiety symptoms, and collected saliva samples across two days. Saliva was assayed for cortisol and C-reactive protein (CRP), and used for 16S rRNA gene sequencing to estimate the oral microbiome. Multivariate statistical analyses examined associations. RESULTS: Overall diversity of the oral microbiome did not differ between adolescents by anxiety or depression grouping (low versus high symptoms), and was not associated with symptom measures. Depression and anxiety symptoms were instead associated with differential abundance of specific bacterial taxa, including Spirochaetaceae, Actinomyces, Treponema, Fusobacterium and Leptotrichia spp. Several host mood-microbial relationships were moderated by proposed mechanisms, including salivary cortisol and CRP. CONCLUSIONS: Oral microbiome composition, but not diversity, was associated with adolescent anxiety and depression symptoms. Longitudinal studies considering these associations would improve mechanistic understanding. This research indicates that adolescence remains an essential developmental period to identify early targets for intervention.

The bidirectional impact of sleep and circadian rhythm dysfunction in human ischaemic stroke: A systematic review.

Sleep and circadian rhythm disruption are potentially modifiable risk factors and consequences of ischaemic stroke. Pre-clinical evidence suggests a direct effect of sleep and endogenous circadian rhythm dysfunction on lesion volumes and post-stroke recovery. In humans, sleep and stroke literature has focused primarily on obstructive sleep apnoea. However, the bidirectional impact of non-apnoea related sleep disorders, sleep architecture, and endogenous circadian rhythm dysfunction in ischaemic stroke remains unclear. A systematic search of publications in three major databases from inception to August 7 2018 identified 67 studies meeting inclusion criteria. Long sleep duration or sleep disorders significantly increased the risk of ischaemic stroke. Inversely, ischaemic stroke was associated with sleep architectural and endogenous circadian rhythm disruption which were generally associated with post-stroke severity and functional outcome. Importantly, no studies examined direct measures of circadian rhythm dysfunction as a risk factor for ischaemic stroke. Most studies were moderate to high quality. However, methodology and stroke characteristics (e.g., stroke topography, stroke severity) were heterogenous thereby limiting generalisable conclusions. Furthermore, a priori neuroimaging outcomes in conjunction with sleep and circadian features were seldom assessed. The clinical pathogenic implications and methodological limitations of studies are discussed, and a research agenda for future studies is outlined.

The Post Ischaemic Stroke Cardiovascular Exercise Study: Protocol for a randomised controlled trial of fitness training for brain health.

INTRODUCTION: Compared to healthy individuals, stroke patients have five times the rate of dementia diagnosis within three years. Aerobic exercise may induce neuroprotective mechanisms that help to preserve, and even increase, brain volume and cognition. We seek to determine whether aerobic fitness training helps to protect brain volume and cognitive function after stroke compared to an active, non-aerobic control. METHODS: In this Phase IIb, single blind, randomised controlled trial, 100 ischaemic stroke participants, recruited at two months post-stroke, will be randomly allocated to either the intervention (aerobic and strength exercise) or active control (stretching and balance training). Participants will attend one-hour, individualised exercise sessions, three days-per-week for eight weeks. Assessments at two months (baseline), four months (post-intervention), and one year (follow-up) post-stroke will measure brain volume, cognition, mood, cardiorespiratory fitness, physical activity, blood pressure and blood biomarkers.Study outcome: Our primary outcome measure is hippocampal volume at four months after stroke. We hypothesise that participants who undertake the prescribed intervention will have preserved hippocampal volume at four months compared to the control group. We also hypothesise that this group will have preserved total brain volume and cognition, better mood, fitness, and higher levels of physical activity, than those receiving stretching and balance training. DISCUSSION: The promise of exercise training to prevent, or slow, the accelerated rates of brain atrophy and cognitive decline experienced by stroke survivors needs to be tested. Post Ischaemic Stroke Cardiovascular Exercise Study has the potential, if proven efficacious, to identify a new treatment that could be readily translated to the clinic.

A cognitive-behavioral and mindfulness-based group sleep intervention improves behavior problems in at-risk adolescents by improving perceived sleep quality.

OBJECTIVE: The aim of this study was to test whether a cognitive-behavioral and mindfulness-based group sleep intervention would improve behavior problems in at-risk adolescents, and whether these improvements were specifically related to improvements in sleep. METHOD: Secondary analysis of a randomized controlled trial conducted with 123 adolescent participants (female = 60%; mean age = 14.48, range 12.04-16.31 years) who had high levels of sleep problems and anxiety symptoms. Participants were randomized into either a sleep improvement intervention (n = 63) or an active control "study skills" intervention (n = 60). Participants completed sleep and behavior problems questionnaires, wore an actiwatch and completed a sleep diary for five school nights, both before and after the intervention. RESULTS: Parallel multiple mediation models showed that postintervention improvements in social problems, attention problems, and aggressive behaviors were specifically mediated by moderate improvements in self-reported sleep quality on school nights, but were not mediated by moderate improvements in actigraphy-assessed sleep onset latency or sleep diary-measured sleep efficiency on school nights. CONCLUSION: This study provides evidence, using a methodologically rigorous design, that a cognitive-behavioral and mindfulness-based group sleep intervention improved behavior problems in at-risk adolescent by improving perceived sleep quality on school nights. These findings suggest that sleep interventions could be directed towards adolescents with behavior problems. CLINICAL TRIAL REGISTRATION: This study was part of The SENSE Study (Sleep and Education: learning New Skills Early). URL: ACTRN12612001177842; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12612001177842&isBasic=True.