Insomnia, anxiety, and depression during the COVID-19 pandemic: an international collaborative study.

IMPORTANCE AND STUDY OBJECTIVE: The COVID-19 pandemic has produced unprecedented changes in social, work, and leisure activities, which all have had major impact on sleep and psychological well-being. This study documented the prevalence of clinical cases of insomnia, anxiety, and depression and selected risk factors (COVID-19, confinement, financial burden, social isolation) during the first wave of the pandemic in 13 countries throughout the world. DESIGN AND PARTICIPANTS: International, multi-center, harmonized survey of 22 330 adults (mean age = 41.9 years old, range 18-95; 65.6% women) from the general population in 13 countries and four continents. Participants were invited to complete a standardized web-based survey about sleep and psychological symptoms during the first wave of the COVID-19 pandemic from May to August 2020. RESULTS: Clinical insomnia symptoms were reported by 36.7% (95% CI, 36.0-37.4) of respondents and 17.4% (95% CI, 16.9-17.9) met criteria for a probable insomnia disorder. There were 25.6% (95% CI, 25.0-26.2) with probable anxiety and 23.1% (95% CI, 22.5-23.6) with probable depression. Rates of insomnia symptoms (>40%) and insomnia disorder (>25%) were significantly higher in women, younger age groups, and in residents of Brazil, Canada, Norway, Poland, USA, and United Kingdom compared to residents from Asian countries (China and Japan, 8% for disorder and 22%-25% for symptoms) (all Ps < 0.01). Proportions of insomnia cases were significantly higher among participants who completed the survey earlier in the first wave of the pandemic relative to those who completed it later. Risks of insomnia were higher among participants who reported having had COVID-19, who reported greater financial burden, were in confinement for a period of four to five weeks, and living alone or with more than five people in same household. These associations remained significant after controlling for age, sex, and psychological symptoms. CONCLUSION AND RELEVANCE: Insomnia, anxiety, and depression were very prevalent during the first wave of the COVID-19 pandemic. Public health prevention programs are needed to prevent chronicity and reduce long-term adverse outcomes associated with chronic insomnia and mental health problems.

Stress-buffering effect of social support on immunity and infectious risk during chemotherapy for breast cancer.

OBJECTIVE: This study investigated the stress-buffering effect of social support on immune function and infectious risk in women with breast cancer, during and after chemotherapy. METHOD: Data were collected from 50 women with breast cancer before and after their chemotherapy, as well as three months later. Stress was measured by daily hassles related to cancer and social support by marital status (MS) and perceived support from friends (Ps-fr). Blood was collected to measure innate immune markers (i.e., T cells, NK cells and neutrophils). Infections were evaluated using a semi-structured interview. Moderation, mediation and moderated mediation models were computed to test the hypotheses. RESULTS: Higher stress at baseline was found to significantly predict a higher occurrence of infections during chemotherapy, but not three months later. The relationship between stress and infections was not significantly explained by any of the immune markers. The interaction between stress and social support was tested using MS alone and combined with Ps-fr. A protective effect of social support on the deleterious effect of stress on infectious risk was found. Single patients reporting lower Ps-fr showed the strongest association between stress and infections, while the weakest association was found in patients in a committed relationship with a higher level of Ps-fr. CONCLUSIONS: Women experiencing more stress before the beginning of chemotherapy would appear to be at a higher risk of developing infections during their treatment. Results of this study also suggest that this effect could be buffered by the presence of a romantic partner and by higher Ps-fr.

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial.

STUDY OBJECTIVES: Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I). METHODS: A total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step. RESULTS: Results indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores. CONCLUSION(S): The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).

COVID-19 Pandemic Stressors and Psychological Symptoms in Breast Cancer Patients.

BACKGROUND: The current Coronavirus disease 2019 (COVID-19) pandemic is a highly stressful event that may lead to significant psychological symptoms, particularly in cancer patients who are at a greater risk of contracting viruses. This study examined the frequency of stressors experienced in relation to the ongoing coronavirus pandemic and its relationship with psychological symptoms (i.e., anxiety, depression, insomnia, fear of cancer recurrence) in breast cancer patients. METHODS: Thirty-six women diagnosed with a non-metastatic breast cancer completed the Insomnia Severity Index, the Hospital Anxiety and Depression Scale, the severity subscale of the Fear of Cancer Recurrence Inventory, and the COVID-19 Stressors Questionnaire developed by our research team. Participants either completed the questionnaires during (30.6%) or after (69.4%) their chemotherapy treatment. RESULTS: Results revealed that most of the participants (63.9%) have experienced at least one stressor related to the COVID-19 pandemic (one: 27.8%, two: 22.2%, three: 11.1%). The most frequently reported stressor was increased responsibilities at home (33.3%). Higher levels of concerns related to the experienced stressors were significantly correlated with higher levels of anxiety, depressive symptoms, insomnia, and fear of cancer recurrence, rs(32) = 0.36 to 0.59, all ps < 0.05. CONCLUSIONS: Cancer patients experience a significant number of stressors related to the COVID-19 pandemic, which are associated with increased psychological symptoms. These results contribute to a better understanding of the psychological consequences of a global pandemic in the context of cancer and they highlight the need to better support patients during such a challenging time.

Prospective Rates, Longitudinal Associations, and Factors Associated With Comorbid Insomnia Symptoms and Perceived Cognitive Impairment.

BACKGROUND: Insomnia and cognitive impairment are both common conditions experienced by people diagnosed with cancer. Individually, these conditions have negative impacts on functioning, but the combined burden has yet to be evaluated. The purpose of this research was to estimate rates of comorbid insomnia and perceived cognitive impairments, examine the longitudinal associations between these two conditions, and identify demographic and clinical factors associated with reporting both insomnia and perceived cognitive impairment. METHODS: In this secondary analysis, a heterogeneous sample of 962 patients completed the Insomnia Severity Index (ISI) and the Cognitive Failures Questionnaire (CFQ) at the time of their cancer surgery (baseline; T1) and then again at 2 (T2), 6 (T3), 10 (T4), 14 (T5), and 18 (T6) months. Correlations and partial correlations, controlling for age and education level, were computed at each time point to assess the relationship between ISI and CFQ scores. Cross-lagged correlations assessed associations between ISI and CFQ scores over time. Proportions of patients with comorbid insomnia and cognitive impairments were calculated and logistic regressions investigated changes over time in these proportions. ANOVAs, logistic regressions, ordinal regressions, and multinomial regressions were used to identify risk factors of having comorbid insomnia and cognitive difficulties. RESULTS: Significant and bidirectional correlations between ISI and CFQ scores were observed at each time point and over time. The proportion of patients having both clinical levels of insomnia and perceived cognitive difficulties ranged from 18.73 to 25.84% across time points and this proportion was significantly greater at T1 and T2 than T4, T5, and T6. Participants who reported comorbid insomnia and cognitive impairment were more likely to be younger, female, not currently working, currently receiving chemotherapy, with clinical levels depression and anxiety, and using antidepressants or anxiolytics. CONCLUSION: Comorbid insomnia and perceived cognitive impairment affects around one in five patients and is more frequent at the beginning of the cancer care trajectory. The relationship between insomnia and cognitive impairment appears to be bidirectional. Insomnia may represent an important patient level vulnerability that when identified and treated can improve perception of cognitive function.

Feasibility of a Preventive Intervention for Insomnia in Women with Breast Cancer Receiving Chemotherapy.

Objective/Background: Breast cancer patients display high rates of insomnia and chemotherapy treatments appear to contribute significantly to the development of sleep disturbances among this population. The efficacy of cognitive-behavioral therapy for insomnia (CBT-I) is now well established for treating insomnia comorbid with cancer but is not widely accessible and is also fairly costly. Its capacity to prevent the onset of insomnia symptoms in cancer patients who are at a high risk of developing these difficulties remains to be demonstrated. The purpose of this study was to assess the feasibility of a brief self-administered preventive intervention of insomnia in breast cancer patients about to undergo chemotherapy. Participants/Methods: A sample of 20 women with breast cancer and with no insomnia were recruited and received the preventive intervention, taking the form of a short booklet, at their first chemotherapy treatment. One month later, a semi-structured phone interview was conducted to assess their satisfaction with different aspects of the booklet (e.g., format, content) and their adherence to the proposed strategies and to collect qualitative information. A 3-month follow-up evaluation was also conducted. Results: Patients reported a higher level of satisfaction than expected (mean score corresponding to "a lot" on the scale) and a moderate level of adherence falling only slightly under the hypothesized level. The open comments collected corroborated the good acceptability of this minimal preventive CBT-I in breast cancer patients initiating chemotherapy. Conclusions: Overall, findings of this study confirm that a self-administered preventive intervention for insomnia is feasible and a promising approach in breast cancer patients about to initiate chemotherapy.

Video cognitive-behavioral therapy for insomnia in cancer patients: A cost-effective alternative.

OBJECTIVE: Despite its high prevalence, cancer-related insomnia typically remains untreated because of a lack of access to cognitive-behavioral therapy for insomnia (CBT-I), the treatment of choice for this condition. While face-to-face CBT-I appears to be optimal in terms of efficacy, self-administered formats may be more cost-effective. The goal of this secondary analysis of a randomized clinical trial was to compare the cost-effectiveness of a professionally-based CBT-I (PCBT-I) to that of a video-based CBT-I (VCBT-I). METHODS: A total of 161 women with breast cancer received six weekly, individual CBT-I sessions (PCBT-I; n = 81) or a 60-minutes animated video +6 short booklets (VCBT-I; n = 80). Participants completed the Insomnia Severity Index (ISI) and provided information to calculate treatment costs. RESULTS: Total per patient treatment costs were 5.5 times greater for PCBT-I ($1298.90) than VCBT-I ($234.36; P < .0001). Both at posttreatment and 3-month follow-up, the ISI reduction was greater in PCBT-I than VCBT-I, but these differences were not significant (P = .09 and P = .24, respectively). In contrast, the cost-effectiveness ratio was significantly more advantageous for VCBT-I than PCBT-I. Compared to VCBT-I, each reduction of 1 unit on the ISI produced by PCBT-I was associated with a treatment cost that was significantly greater at posttreatment ($186.95 CAD vs $44.87 CAD; P = .001) and follow-up ($154.76 vs $24.97, P = .005). CONCLUSIONS: Although CBT-I is slightly less efficacious when self-administered, it constitutes a much more cost-effective alternative than face-to-face CBT-I and represents an extremely valuable option in settings where monetary and human resources required to administer CBT-I are not available or sufficient.

Correlates of disrupted sleep-wake variables in patients with advanced cancer.

OBJECTIVES: High rates of sleep difficulties have been found in patients with advanced cancer. However, not much is known about factors that are associated with sleep impairments in this population and that could constitute their potential risk factors or consequences. This study conducted in patients with cancer receiving palliative care aimed to evaluate the relationships of subjective (sleep diary; Insomnia Severity Index, ISI) and objective (actigraphy) sleep-wake variables with several physical and psychological symptoms, maladaptive sleep behaviours, erroneous beliefs about sleep, quality of life, time to death and environmental factors. METHODS: The sample was composed of 57 community-dwelling patients with cancer receiving palliative care and with an Eastern Cooperative Oncology Group Scale score of 2 or 3. Actigraphic, light and sound recording and a daily sleep and pain diary were completed for seven consecutive days. A battery of self-report scales was also administered. RESULTS: Greater disruptions of subjective and objective sleep-wake variables were more consistently associated with worse physical symptoms than with psychological variables. Disrupted objective sleep-wake parameters were also associated with a greater frequency of maladaptive sleep behaviours. Finally, a greater nocturnal noise in the bedroom was correlated with more impairments in subjective and objective sleep-wake variables while a lower 24-hour light exposure was associated with more disruption of subjectively assessed sleep only. CONCLUSIONS: Although longitudinal studies are needed to establish the etiology of sleep-wake difficulties in patients with advanced cancer, our findings suggest that physical symptoms, maladaptive sleep behaviours and environmental factors can contribute to their development or their persistence and need to be adequately addressed.

Clusters of Psychological Symptoms in Breast Cancer: Is There a Common Psychological Mechanism?

BACKGROUND: Breast cancer patients tend to experience numerous concurrent psychological symptoms that form clusters. It has been proposed that a common psychological mechanism may underlie the membership of symptoms in a given cluster, but this hypothesis has never been investigated. Maladaptive emotion regulation (ER) is one possible common mechanism. OBJECTIVE: This study examined cross-sectional and prospective relationships between subjective (experiential avoidance, expressive suppression, and cognitive reappraisal) and objective (high-frequency heart rate variability) measures of ER and clusters of psychological symptoms among women receiving radiation therapy for breast cancer. METHOD: A total of 81 women completed a battery of self-report scales before (T1) and after (T2) radiotherapy, including measures of anxiety, depression, fear of cancer recurrence, insomnia, fatigue, pain, and cognitive impairments. Resting high-frequency heart rate variability was measured at T1. RESULTS: Latent profile analyses identified between 2 and 3 clusters of patients with similar levels of symptoms at T1 and T2 and with a similar profile of symptom changes between T1 and T2. Discriminant analyses showed that higher levels of avoidance and suppression predicted membership in symptom clusters that included more severe symptoms cross-sectionally at T1 and at T2 (both P values < .0001). However, ER at T1 did not significantly predict membership in clusters of symptom changes between T1 and T2 (P = .15). CONCLUSION: Maladaptive ER strategies, more particularly suppression and avoidance, are a possible psychological mechanism underlying clusters of cancer-related psychological symptoms. IMPLICATIONS FOR PRACTICE: Psychological interventions targeting maladaptive ER strategies have the potential to treat several psychological symptoms simultaneously.

Insomnia, immunity, and infections in cancer patients: Results from a longitudinal study.

BACKGROUND: Insomnia is very common in cancer patients receiving chemotherapy. Poor sleep is associated with immune alterations but the actual impact on health resulting from such immune changes has rarely been studied. The aim of this study was to evaluate, in women treated with chemotherapy for breast or gynecological cancer, the relationships between insomnia, immunity, and the occurrence of infections. METHOD: Fifty-two patients were assessed before chemotherapy (Time [T]1), on 4 occasions during the first 2 cycles of chemotherapy (i.e., on immunosuppression and recovery weeks; T2-T5), at posttreatment (T6), and at 3-month (T7) and 6-month (T8) follow-ups. A clinical interview was administered to assess insomnia (Insomnia Interview Schedule) and the occurrence of infections. Patients were categorized into 1 of these 3 subgroups on the basis of the insomnia interview at T1: good sleepers (GS), insomnia symptoms (SX), and insomnia syndrome (SYN). Finally, blood samples were collected at each time point (T1-T8) to measure several immune parameters (e.g., neutrophils, lymphocytes). RESULTS: Mixed-model analyses of covariance revealed that SYN patients at T1 had significantly lower counts of some blood cells after chemotherapy (T6) as compared to GS (i.e., total white blood cells and neutrophils) and as compared to GS and SX patients (i.e., total lymphocytes, CD3+ and CD4+ cells). At T8, SYN patients at T1 showed significantly lower lymphocytes, CD3+ and CD4+ counts as compared to SX patients. Finally, SYN patients at T1 were at a significantly higher risk of reporting infectious episodes at T5 as compared to SX patients. CONCLUSIONS: Although replication is warranted, these results suggest that prechemotherapy insomnia may potentiate the vulnerability to show immune alterations and develop infections due to chemotherapy during the cancer care trajectory. Overall, they further emphasize the need to provide effective treatments for sleep difficulties in patients undergoing chemotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Moderators of Cognitive Therapy and Bright Light Therapy Effects on Depressive Symptoms in Patients with Breast Cancer.

BACKGROUND: Cognitive therapy (CT) and bright light therapy (BLT) have been found to be effective to treat depressive symptoms in breast cancer patients. No study has investigated the baseline patients' characteristics that are associated with better outcomes with CT vs. BLT in this population. This study aimed to assess, in breast cancer patients, the moderating role of eight clinical variables on the effects of CT and BLT on depressive symptoms. METHODS: This is a secondary analysis of a randomized controlled trial conducted in 59 women who received an 8-week CT or BLT and completed questionnaires evaluating depression and possible moderating variables. RESULTS: Patients benefited more from BLT when they had no prior history of major depressive disorder, higher depression scores on the Hospital Anxiety and Depression Scale (HADS-D) at baseline, a greater initial preference for BLT, and when they received BLT during spring or summer. Patients benefited more from CT when they had a lower initial preference for receiving CT, higher depression scores on the HADS-D, and seasonal depressive symptoms. CONCLUSIONS: Although replication is needed, findings of this study suggest the existence of different profiles of patients more likely to benefit from CT and BLT. TRIAL REGISTRATION: NCT01637103 https://clinicaltrials.gov/ct2/show/NCT01637103.

Screening for clinical insomnia in cancer patients with the Edmonton Symptom Assessment System-Revised: a specific sleep item is needed.

OBJECTIVE: We previously investigated the capacity of the original version of the Edmonton Symptom Assessment System-Revised (ESAS-r) and the Canadian Problem Checklist (CPP) to screen for clinical levels of insomnia in cancer patients. The original ESAS-r includes an item assessing drowsiness and an "other symptom" item, both of which are rated on a scale from 0 to 10, while the CPC has a sleep item, a box which is checked when this problem is present. Because none of these items showed an optimal screening capacity, we concluded that it would be best to add a specific 0-10 sleep item to the ESAS-r. This study assessed the capacity of this ESAS-r-sleep item to screen for clinical insomnia in patients with various cancer types. METHODS: A total of 392 patients with mixed cancer sites completed the ESAS-r as part of a routine screening procedure implemented in the radio-oncology department of L'Hôtel-Dieu de Québec (CHU de Québec-Université Laval). They also filled out the Insomnia Severity Index (ISI). RESULTS: Using a score of 8 or greater on the ISI as the standard criterion for clinical insomnia, a score of 2 or higher on the ESAS-r-sleep item (50.8% of the patients) was the one that showed the best screening indices: sensitivity of 86.7%, specificity of 75.3%, positive predictive value of 71.9%, and negative predictive value of 88.6%. An area under the curve of 0.89 was found, which is excellent. CONCLUSIONS: Adding a sleep item to the ESAS significantly improves screening of clinical insomnia in cancer patients.

Is emotion regulation associated with cancer-related psychological symptoms?

OBJECTIVES: This study examined the cross-sectional and prospective relationships between subjective (cognitive reappraisal, expressive suppression and experiential avoidance) and objective (high-frequency heart rate variability [HF-HRV]) measures of emotion regulation (ER) and a set of psychological symptoms (anxiety, depression, fear of cancer recurrence [FCR], insomnia, fatigue, pain, and cognitive impairments) among women receiving radiation therapy for non-metastatic breast cancer. DESIGN: Eighty-one participants completed a battery of self-report scales within 10 days before the start of radiotherapy (T1) and within 10 days after its end (T2; approximately 6 weeks after T1). HF-HRV at rest was measured at T1. RESULTS: Canonical correlation analyses revealed that higher levels of experiential avoidance and expressive suppression were cross-sectionally associated with higher levels of all symptoms, except pain, at T1 and at T2 (both p's < 0.0001). Higher levels of suppression and reappraisal at T1 were marginally associated with reduced FCR and with increased depression and fatigue between T1 and T2 (p = 0.07). HF-HRV was not associated with symptoms cross-sectionally or prospectively. CONCLUSIONS: Although preliminary, these results are consistent with the hypothesis that maladaptive ER strategies, assessed subjectively, may cross-sectionally act as a transdiagnostic mechanism underlying several cancer-related psychological symptoms.

A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self-administered cognitive-behavioral therapy for insomnia in cancer patients.

Study Objectives: Thirty to sixty percent of cancer patients have insomnia symptoms, a condition which may lead to numerous negative consequences and for which an efficacious management is required. This randomized controlled trial aimed to assess the efficacy of a 6-week home-based aerobic exercise program (EX) compared to that of a 6-week self-administered cognitive-behavioral therapy for insomnia (CBT-I) to improve sleep in cancer patients. Method: Forty-one patients (78.1% female, mean age 57 years) with various types of cancer and having insomnia symptoms (Insomnia Severity Index [ISI] score ≥ 8) were randomized to the EX (n = 20) or the CBT-I (n = 21) groups. Measures were completed at pretreatment and posttreatment, as well as at 3- and 6-month follow-ups. Results: The EX intervention was statistically inferior to CBT-I in reducing ISI scores at posttreatment but was non-inferior at follow-up. However, no significant group-by-time interaction was found on any outcome and both interventions led to a significant improvement of subjectively-assessed sleep impairments on the ISI, the Pittsburgh Sleep Quality Index (PSQI) and most sleep parameters from a daily sleep diary at posttreatment corresponding to medium to large time effects (ds > 0.50 for ISI, PSQI, sleep onset latency, wake after sleep onset, total wake time and sleep efficiency). Conclusion: Both interventions produced significant improvements of sleep. However, EX was found to be significantly inferior to CBT-I in reducing ISI scores at posttreatment, which contradicts the initial non-inferiority hypothesis. These findings suggest that CBT-I remains the treatment of choice for cancer-related insomnia, although EX can lead to some beneficial effects. ClinicalTrials.gov Identifier: NCT02774369 https://clinicaltrials.gov/ct2/show/NCT02774369?term=NCT02774369&rank=1.

Utilization of health care services in cancer patients with elevated fear of cancer recurrence.

BACKGROUND: Cancer patients commonly report experiencing fear of cancer recurrence (FCR), which may lead to several negative consequences. This study aimed at examining whether clinical levels of FCR are linked to a greater use of health care services. METHOD: This is a secondary analysis of a longitudinal study of 962 cancer patients on the epidemiology of cancer-related insomnia. They completed the Fear of Cancer Recurrence Inventory-Short form (FCRI-SF) and reported information on their consultations (medical, psychosocial, and complementary and alternative medicine [CAM]) and medication usage (anxiolytics/hypnotics and antidepressants) at 6 time points over an 18-month period. RESULTS: Results indicated that clinical FCR at baseline was associated with greater consultation rates of medical and psychosocial professionals and a greater usage of anxiolytics/hypnotics and antidepressants. No significant association was found between the FCR level and use of CAM services. While consultation rates of medical and CAM professionals and usage of antidepressants generally increased over time, consultation rates of psychosocial professionals and usage of anxiolytics/hypnotics tended to decrease. CONCLUSIONS: Cancer patients with clinical levels of FCR are more likely to consult health care providers and to use psychotropic medications, which may translate into significant costs for society and the patients themselves.

Sleep-wake difficulties in community-dwelling cancer patients receiving palliative care: subjective and objective assessment.

OBJECTIVE: Prevalence rates of sleep difficulties in advanced cancer patients have varied widely across studies (12 to 96%), and none of these employed a diagnostic interview to distinguish different types of sleep-wake disorders. Moreover, very limited information is available on subjective and objective sleep parameters in this population. Our study was conducted in palliative cancer patients and aimed to assess rates of sleep-wake disorders and subsyndromal symptoms and to document subjective and objective sleep-wake parameters across various types of sleep-wake difficulties. METHOD: The sample was composed of 51 community-dwelling cancer patients receiving palliative care and having an Eastern Cooperative Oncology Group score of 2 or 3. Relevant sections of the Duke Interview for Sleep Disorders were administered over the phone. An actigraphic recording and a daily sleep diary were completed for 7 consecutive days. RESULTS: Overall, 68.6% of the sample had at least one type of sleep-wake difficulty (disorder or symptoms): 31.4% had insomnia and 29.4% had hypersomnolence as their main sleep-wake problem. Participants with insomnia as their main sleep difficulty had greater disruptions of subjective sleep parameters, while objectively-assessed sleep was more disrupted in patients with hypersomnolence comorbid with another sleep-wake difficulty.Significance of the Results:The high rates of sleep-wake difficulties found in this study indicate a need to screen more systematically for sleep-wake disorders, including insomnia and hypersomnolence, in both palliative care research and clinical practice, and to develop effective nonpharmacological interventions specifically adapted to this population.

To be or not to be positive: Development of a tool to assess the relationship of negative, positive, and realistic thinking with psychological distress in breast cancer.

There is a widespread belief that positive thinking is a key strategy to cope with cancer. While dispositional optimism is associated with lower psychological distress, the literature supporting the efficacy of cognitive-behavioral therapy indirectly suggests that realistic thinking is also effective. This article describes the development of the Thoughts and Anticipations about Cancer questionnaire designed to directly compare the effect of realistic thinking versus positive thinking on adjustment to cancer. Preliminary data on its relationships with psychological distress gathered in 10 breast cancer patients are promising. The validity of the Thoughts and Anticipations about Cancer questionnaire will need to be confirmed in larger studies.

Treatment of depressive symptoms in patients with breast cancer: A randomized controlled trial comparing cognitive therapy and bright light therapy.

OBJECTIVE: This randomized controlled trial (RCT), conducted in patients with breast cancer, aimed to compare the effects of cognitive therapy (CT), bright light therapy (BLT), and a waiting-list control condition (WLC) on depressive symptoms. METHOD: Sixty-two women were randomly assigned to an 8-week CT (n = 25), BLT (n = 26), or WLC (n = 11). Participants completed the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), the Beck Depression Inventory-II (BDI-II), and the Hamilton Depression Rating Scale (HDRS) at pre- and posttreatment (and postwaiting for WLC), as well as 3 and 6 months later. RESULTS: At posttreatment, CT patients had a significantly greater reduction of depressive symptoms than WLC on the HADS-D and the BDI-II. BLT patients had a greater reduction of depressive symptoms than WLC on the HADS-D only. After WLC participants were reassigned to CT or BLT, a superiority of CT over BLT was found on the BDI-II at posttreatment. Patients of both active conditions showed a good sustainment of treatment gains at follow-ups. CONCLUSIONS: Although replication with larger samples is needed, these results confirm the efficacy of CT for depression in the context of breast cancer and suggest that BLT could be of some utility when CT is not available or desired. (PsycINFO Database Record

Disruptions in sleep-wake cycles in community-dwelling cancer patients receiving palliative care and their correlates.

Significant disruptions in sleep-wake cycles have been found in advanced cancer patients in prior research. However, much remains to be known about specific sleep-wake cycle variables that are impaired in patients with a significantly altered performance status. More studies are also needed to explore the extent to which disrupted sleep-wake cycles are related to physical and psychological symptoms, time to death, maladaptive sleep behaviors, quality of life and 24-h light exposure. This study conducted in palliative cancer patients was aimed at characterizing patients' sleep-wake cycles using various circadian parameters (i.e. amplitude, acrophase, mesor, up-mesor, down-mesor, rhythmicity coefficient). It also aimed to compare rest-activity rhythm variables of participants with a performance status of 2 vs. 3 on the Eastern Cooperative Oncology Group scale (ECOG) and to evaluate the relationships of sleep-wake cycle parameters with several possible correlates. The sample was composed of 55 community-dwelling cancer patients receiving palliative care with an ECOG of 2 or 3. Circadian parameters were assessed using an actigraphic device for seven consecutive 24-h periods. A light recording and a daily pain diary were completed for the same period. A battery of self-report scales was also administered. A dampened circadian rhythm, a low mean activity level, an early mean time of peak activity during the day, a late starting time of activity during the morning and an early time of decline of activity during the evening were observed. In addition, a less rhythmic sleep-wake cycle was associated with a shorter time to death (from the first home visit) and with a lower 24-h light exposure. Sleep-wake cycles are markedly disrupted in palliative cancer patients, especially, near the end of life. Effective non-pharmacological interventions are needed to improve patients' circadian rhythms, including perhaps bright light therapy.

Moderators of Treatment Effects of a Video-Based Cognitive-Behavioral Therapy for Insomnia Comorbid With Cancer.

PURPOSE: To assess the moderating role of demographic and clinical variables on the efficacy of a video-based cognitive behavioral therapy for insomnia (VCBT-I) among breast cancer patients. PATIENTS AND METHODS: As part of a randomized controlled trial, 80 women received VCBT-I. RESULTS: Patients with a more advanced breast cancer were less likely to show reductions on the Insomnia Severity Index (ISI) and increased sleep efficiency at posttreatment. Patients using an antidepressant medication showed a larger reduction of ISI scores and a higher rate of insomnia remission. Remission of insomnia was also significantly more likely in individuals with a higher annual income. When using a multivariate binary classification tree analysis, the best and unique predictor of insomnia remission was having a less severe baseline ISI score. CONCLUSION: Although efficacious in general, VCBT-I does not appear to be an optimal format for everybody.