Multi-method study of the implementation of Cognitive Symptom Management and Rehabilitation Training (CogSMART) in real-world settings.

Cognitive Symptom Management and Rehabilitation Training (CogSMART) and Compensatory Cognitive Training (CCT) are evidence-based compensatory cognitive training interventions that improve cognition in persons with a history of traumatic brain injury or other neuropsychiatric disorders. Despite demonstrated efficacy, use and effectiveness of CogSMART/CCT in real-world settings is not known.We used a multi-method design to collect and analyze quantitative and qualitative survey data from several domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to gather information about use of CogSMART/CCT in real-world settings from provider and patient perspectives. Surveys were sent to email addresses from persons who registered on the CogSMART website seeking access to training manuals and other resources. Descriptive statistics were generated, and we used Natural Language Processing methods to study the self-report free responses. Using n-gram analysis, we identified the most frequently reported responses.We found CogSMART/CCT was broadly used in real-world settings and delivered by a variety of providers for several patient groups with high attendance and overall high satisfaction. CogSMART/CCT seemed to be offered in VA- or university-related clinics more than in private practice or rehabilitation centers. The diversity of providers and variety of formats by which to deliver CogSMART/CCT (i.e., individual, group, telehealth) seemed to play a role in its widespread implementation, as did its adaptability. Most providers made adaptations to the intervention that reduced the length or number of sessions. These changes were most likely to be based on client characteristics. The low rates of formal training, however, may have contributed to lower levels of perceived helpfulness among patients.Reach and Adoption of a cognitive rehabilitation intervention improved by increasing access to the manuals. Attention to characteristics of dissemination and implementation in the design of an intervention may enhance its use in real-world settings. The relevant outcomes, easy access to training manuals, and adaptability of CogSMART/CCT seem to have been important factors in its use in a variety of settings and for several disorders with cognitive impairment. The adoption of CogSMART/CCT by a variety of providers other than neuropsychologists suggests its use may be broadened to other healthcare providers, if adequately trained, to increase access to an intervention with demonstrated efficacy for cognitive rehabilitation for several neuropsychiatric disorders.

Implementing eScreening technology in four VA clinics: a mixed-method study.

BACKGROUND: Technology-based self-assessment (TB-SA) benefits patients and providers and has shown feasibility, ease of use, efficiency, and cost savings. A promising TB-SA, the VA eScreening program, has shown promise for the efficient and effective collection of mental and physical health information. To assist adoption of eScreening by healthcare providers, we assessed technology-related as well as individual- and system-level factors that might influence the implementation of eScreening in four diverse VA clinics. METHODS: This was a mixed-method, pre-post, quasi-experimental study originally designed as a quality improvement project. The clinics were selected to represent a range of environments that could potentially benefit from TB-SA and that made use of the variety eScreening functions. Because of limited resources, the implementation strategy consisted of staff education, training, and technical support as needed. Data was collected using pre- and post-implementation interviews or focus groups of leadership and clinical staff, eScreening usage data, and post-implementation surveys. Data was gathered on: 1) usability of eScreening; 2) knowledge about and acceptability and 3) facilitators and barriers to the successful implementation of eScreening. RESULTS: Overall, staff feedback about eScreening was positive. Knowledge about eScreening ranged widely between the clinics. Nearly all staff felt eScreening would fit well into their clinical setting at pre-implementation; however some felt it was a poor fit with emergent cases and older adults at post-implementation. Lack of adequate personnel support and perceived leadership support were barriers to implementation. Adequate training and technical assistance were cited as important facilitators. One clinic fully implemented eScreening, two partially implemented, and one clinic did not implement eScreening as part of normal practice after 6 months as measured by usage data and self-report. Organizational engagement survey scores were higher among clinics with full or partial implementation and low in the clinic that did not implement. CONCLUSIONS: Despite some added work load for some staff and perceived lack of leadership support, eScreening was at least partially implemented in three clinics. The technology itself posed no barriers in any of the settings. An implementation strategy that accounts for increased work burden and includes accountability may help in future eScreening implementation efforts. Note. This abstract was previously published (e.g., Annals of Behavioral Medicine 53: S1-S842, 2019).

Subjective rating of executive functions in mild Alzheimer's disease.

OBJECTIVES: Subjective cognitive decline is considered to be a core feature of pre-Alzheimer's disease (AD) conditions, the vast majority of literature having focused on memory concerns. Neuropsychological studies have implicated executive dysfunction on objective performance measures in AD, but no research has evaluated whether individuals with AD have concerns about their executive functions and whether it differs from their caregiver's concerns. In the present study, we sought to evaluate self- and informant ratings of executive functioning in patients with mild AD. METHOD: Participants were 23 patients with mild AD and 32 healthy elderly controls (HC) and their informants who completed the Behavior Rating Inventory of Executive Function - Adult version. RESULTS: Patients with AD and their informants reported greater executive dysfunction than the HC group and their informants, respectively, and patients reported greater difficulty than their informants. The largest effect size for both self- and informant ratings was obtained for the Working Memory scale. CONCLUSIONS: These findings indicate that subjective cognitive concerns in mild AD extend beyond the memory domain to executive functions. That greater difficulty was endorsed by patients than their informants suggests that at least in the mild stage of AD some awareness of executive dysfunction may be maintained in some patients. Implications for clinical care are discussed.

The effects of sleep deprivation on brain functioning in older adults.

Few studies have examined the effects of total sleep deprivation (TSD) on cognitive performance and brain activation using functional MRI (fMRI) in older adults. The current study examines blood oxygen level-dependent (BOLD) activation in older adults and younger adults during the sustained attention (GO) and response inhibition (NOGO) portions of a GO-NOGO cognitive task following 36 hr of total sleep deprivation. No significant performance differences were observed between the groups on the behavioral outcome measures of total hits and false alarms. Neuroimaging results, however, revealed a significant interaction between age-group and sleep-deprivation status. Specifically, older adults showed greater BOLD activation as compared to younger adults after 36 hours total sleep deprivation in brain regions typically associated with attention and inhibitory processes. These results suggest in order for older adults to perform the GO-NOGO task effectively after sleep deprivation, they rely on compensatory recruitment of brain regions that aide in the maintenance of cognitive performance.

Associations Among Environmental Exposures and Physical and Psychiatric Symptoms in a Care-Seeking Sample of U.S. Military Veterans.

INTRODUCTION: Recent research and policy (e.g., the Sergeant First Class (SFC) Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act) have highlighted the potential health consequences of toxic environmental exposures. The purpose of the current study was to assess the self-reported prevalence of such exposures among a sample of U.S. military veterans seeking care at a Veterans Affairs facility and to examine associations between exposures and physical and psychiatric symptoms. MATERIALS AND METHODS: Participants were 4,647 newly enrolling post-9/11 veterans at the VA San Diego Healthcare System who completed standard clinical screening processes between January 2015 and April 2019. Electronic health screening data, including demographic information, military history, environmental exposures, and physical and psychiatric symptoms, were assessed. t-Tests for continuous variables and chi-square tests for categorical variables were used to compare exposed to unexposed veterans on demographic and military characteristics as well as physical and psychiatric symptoms. RESULTS: A total of 2,028 veterans (43.6%) reported exposure to environmental toxins during their military service. Analyses revealed a disproportionate burden of exposure on older, male, educated, combat veterans as well as Asian and Native American veterans. Exposure to any type of environmental toxin was associated with more physical symptoms, particularly pain, fatigue, and insomnia, as well as psychiatric symptoms, including moderate depressive symptomology, mild to moderate anxiety, and scores approaching the threshold for likely post-traumatic stress disorder and alcohol misuse. CONCLUSIONS: The high prevalence and detrimental health correlates of environmental exposures underscore the importance of implementing screening for exposures and providing healthcare services that address the multisystemic nature of exposure-related illness.

The relationship between objective and subjective executive function in Parkinson's disease.

INTRODUCTION: Difficulties in executive functioning (EF) are common in PD; however, the relationship between subjective and objective EF is unclear. Understanding this relationship could help guide clinical EF assessment. This study examined the relationship between subjective self-reported EF (SEF) and objective EF (OEF) and predictors of SEF-OEF discrepancies in PD. METHOD: One-hundred and sixteen non-demented PD participants completed measures of OEF (i.e. problem-solving, cognitive flexibility, inhibition, and working memory) and SEF (Frontal Systems Behavior Scale-Self Executive Dysfunction Subscale). Pearson bivariate correlations and linear regressions were performed to examine the relationship between SEF and OEF and the non-motor symptoms (e.g. mood, fatigue), demographic, and PD characteristic (e.g. MCI status) predictors of discrepancies between OEF and SEF (|OEF minus SEF scores|). Correlates of under-, over-, and accurate-reporting were also explored. RESULTS: Greater SEF complaints and worse OEF were significantly associated (ß =.200, p = .009) and 64% of participants accurately identified their level of OEF abilities. Fewer years of education and greater symptoms of depression, anxiety, and fatigue significantly correlated with greater discrepancies between OEF and SEF. Fatigue was the best predictor of EF discrepancy in the overall sample (ß = .281, p = .022). Exploratory analyses revealed apathy and fatigue associated with greater under-reporting, while anxiety associated with greater over-reporting. CONCLUSIONS: SEF and OEF are significantly related in PD. Approximately 64% of non-demented persons with PD accurately reported their EF skill level, while 28% under-reported and 8% over-reported. SEF-OEF discrepancies were predicted by fatigue in the overall sample. Preliminary evidence suggests reduced apathy and fatigue symptoms relate to more under-reporting, while anxiety relates to greater over-reporting. Given the prevalence of these non-motor symptoms in PD, it is important to carefully consider them when assessing EF in PD.

Executive functioning in older adults with hoarding disorder.

BACKGROUND: Hoarding disorder (HD) is a chronic and debilitating psychiatric condition. Midlife HD patients have been found to have neurocognitive impairment, particularly in areas of executive functioning, but the extent to which this is due to comorbid psychiatric disorders has not been clear. AIMS/METHOD: The purpose of the present investigation was to examine executive functioning in geriatric HD patients without any comorbid Axis I disorders (n = 42) compared with a healthy older adult comparison group (n = 25). We hypothesized that older adults with HD would perform significantly worse on measures of executive functioning (Wisconsin Card Sort Task [Psychological Assessment Resources, Lutz, Florida, USA] ( Psychological Assessment Resources, 2003) and the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests [Pearson, San Antonio, TX, USA]). RESULTS: Older adults with HD showed significant differences from healthy older controls in multiple aspects of executive functioning. Compared with healthy controls, older adults with HD committed significantly more total, non-perseverative errors and conceptual level responses on the Wisconsin Card Sort Task and had significantly worse performance on the Wechsler Adult Intelligence Scale-IV digit span and letter-number sequencing tests. Hoarding symptom severity was strongly correlated with executive dysfunction in the HD group. CONCLUSIONS: Compared with demographically-matched controls, older adults with HD have dysfunction in several domains of executive functioning including mental control, working memory, inhibition, and set shifting. Executive dysfunction is strongly correlated with hoarding severity and is not because of comorbid psychiatric disorders in HD patients. These results have broad clinical implications suggesting that executive functioning should be assessed and taken into consideration when developing intervention strategies for older adults with HD.

Symptoms of major depressive disorder and post-traumatic stress disorder in veterans with mild traumatic brain injury: A network analysis.

Mild Traumatic Brain Injury (mTBI, or concussion) is a debilitating condition that often leads to persistent cognitive and mental health problems post-injury. Post-traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two most commonly occurring mental health problems following mTBI and are suggested to be strong contributors to the persistent post-concussion symptoms. Thus, it is important to understand the symptomatology of PTSD and MDD post-mTBI, to better inform targets for behavioral health interventions. Therefore, the current study examined the symptom structure of post-mTBI co-morbid PTSD and MDD through network approaches; we compared the network structure of participants with a positive mTBI screen (N = 753) to the network structure of participants with a negative mTBI screen (N = 2044); lastly, we examined a network of PTSD and MDD symptoms with clinical covariates in a positive mTBI sample. We found that feeling distant/cutoff (P10) and difficulty concentrating (P15) were the most central symptoms in the positive mTBI network and sleep problems were the most prominent bridge nodes across the disorders. No significant difference between the positive and negative mTBI network were found through network comparison tests. Moreover, anxiety and insomnia were strongly associated with sleep symptoms and irritability symptoms, and emotional support and resilience were potential buffers against most of the PTSD and MDD symptoms. The results of this study might be particularly useful for identifying targets (i.e., feeling distant, concentration and sleep problems) for screening, monitoring and treatment after concussion to better inform post-mTBI mental health care and to improve treatment outcomes.

Relationships among race, ethnicity, and gender and whole health among U.S. veterans.

Racial, ethnic, and gender health care disparities in the United States are well-documented and stretch across the lifespan. Even in large integrated health care systems such as Veteran Health Administration, which are designed to provide equality in care, social and economic disparities persist, and limit patients' achievement of health goals across multiple domains. We explore Veterans' Whole Health priorities among Veteran demographic groups. Participants who were enrolling in Veteran Health Administration provided demographics and Whole Health priorities using eScreening, a web-based self-assessment tool. Veterans had similar health care goals regardless of demographic characteristics but differences were noted in current health appraisals. Non-White and women Veterans reported worse health-relevant functioning. Black Veterans were more likely to endorse a low rating for their personal development/relationships. Multiracial Veterans were more likely to endorse a low rating of their surroundings. Asian Veterans were less likely to provide a high rating of their surroundings. Women Veterans reported lower appraisals for body and personal development but higher appraisals of professional care. Results indicated that demographic factors such as race and gender, and to a lesser extent ethnicity, were associated with health disparities. The Whole Health model provides a holistic framework for addressing these disparities. These findings may inform more culturally sensitive care and enhance Veteran Health Administration equal access initiatives. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Assessing an electronic self-report method for improving quality of ethnicity and race data in the Veterans Health Administration.

Objective: Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods: We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921). Results: Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P < .05), but higher rates of "decline to answer" (7% vs 0.5% and 1.2%, P < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P < .05). Race: No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P > .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P < .05), which despite the lowest rate of "decline to answer" (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans. Conculsions: eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.

Adaptation of a quality improvement approach to implement eScreening in VHA healthcare settings: innovative use of the Lean Six Sigma Rapid Process Improvement Workshop.

BACKGROUND: The Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges. METHODS: This was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process "mini interviews" were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach. RESULTS: Pilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2. CONCLUSIONS: Our use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

Implementing eScreening for suicide prevention in VA post-9/11 transition programs using a stepped-wedge, mixed-method, hybrid type-II implementation trial: a study protocol.

BACKGROUND: Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment, thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve the rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening. METHODS: This is an eight-site 4-year, stepped-wedge, mixed-method, hybrid type-II implementation trial comparing eScreening to screening as usual while also evaluating the potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper-based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high- and low-eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews. DISCUSSION: The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real-world clinical care programs. TRIAL REGISTRATION: ClinicalTrials.gov : NCT04506164; date registered: August 20, 2020; retrospectively registered.

Post-9/11 Veteran Satisfaction With the VA eScreening Program.

INTRODUCTION: eScreening is a mobile health technology resource for veterans and staff to support Veterans Health Administration initiatives such as early identification of health problems, shared decision-making, and measurement-based care. METHODS: We conducted an exploratory mixed methods retrospective study with newly enrolling post-9/11 veterans to (1) understand eScreening user experience and obtain practical feedback on the technology to guide improvements, (2) assess veteran satisfaction with eScreening following improvements to the technology, and (3) examine veteran characteristics associated with eScreening satisfaction. Focus group data were collected on user experience with eScreening from a sample of veterans who participated in an eScreening pilot. Guided by a user-centered design approach, findings informed improvements to the technology. Survey data were subsequently collected from a large cohort of veterans to assess satisfaction with the improved program. Questionnaire data were also collected to examine variables associated with eScreening satisfaction. Qualitative focus group data were analyzed using content analysis. Descriptive statistics were used to characterize sociodemographic variables, questionnaires, and satisfaction ratings. Correlations were run to examine the relationship between certain veteran characteristics (eg, age, resiliency, anxiety, insomnia, post-traumatic stress disorder, somatic symptoms, depression, pain) and satisfaction with eScreening. All research activities were conducted at VA San Diego Healthcare System and approved by the Institutional Review Board. RESULTS: Focus group data revealed that veterans were largely satisfied with eScreening, but they suggested some improvements (eg, to interface functionality), which were integrated into an updated version of eScreening. Following these changes, survey data revealed that veterans were highly satisfied with eScreening, including its usability, information security, and impact on health services. There were statistically significant, though not clinically meaningful relationships between health-related characteristics and satisfaction with eScreening. However, millennials showed significantly higher satisfaction ratings compared with non-millennials. CONCLUSIONS: These findings support the use of patient experiences and feedback to aide product development. In addition, post-9/11 veterans support the use of eScreening to assist health screening. However, evaluating the eScreening program in more diverse veteran groups and Veterans Affairs settings is needed to improve the generalizability of these findings to the larger veteran population.

Prevalence rates and correlates of insomnia disorder in post-9/11 veterans enrolling in VA healthcare.

STUDY OBJECTIVES: Post-9/11 veterans are particularly vulnerable to insomnia disorder. Having accurate prevalence rates of insomnia disorder in this relatively young, diverse population, is vital to determine the resources needed to identify and treat insomnia disorder. However, there are no accurate prevalence rates for insomnia disorder in post-9/11 veterans enrolling in the VA Healthcare System (VHA). We present accurate prevalence of insomnia disorder, and correlates, in a large sample of post-9/11 veterans enrolling in a VHA. METHODS: This was an observational study of 5,552 post-9/11 veterans newly enrolling for health care in a VHA. Data were collected using VA eScreening. Insomnia diagnosis was determined using a clinical cutoff score of ≥ 11 on the Insomnia Severity Index. Measures also included sociodemographic, service history, posttraumatic stress disorder (PTSD), depression, suicidal ideation, alcohol misuse, military sexual trauma, traumatic brain injury (TBI), and pain intensity. RESULTS: About 57.2% of the sample population had insomnia disorder. Our sample was nationally representative for age, sex, ethnicity, branch of the military, and race. The sample also was at high-risk for a host of clinical disorders, including PTSD, TBI, and pain; all of which showed higher rates of insomnia disorder (93.3%, 77.7%, and 69.6%, respectively). CONCLUSIONS: The findings suggest alarmingly high rates of insomnia disorder in this population. Examining and treating insomnia disorder, especially in the context of co-occurring disorders (e.g. PTSD), will be a necessity in the future.

Predictors of treatment outcome and attrition in adults with hoarding disorder.

While a number of hoarding disorder-specific therapeutic interventions have been developed over recent years, hoarding disorder (HD) remains difficult to treat. The purpose of this investigation is to inform HD treatment efforts by examining factors that influence treatment attrition and treatment response. Secondary data analysis of baseline and post-treatment data from two previously published psychotherapy treatment studies for hoarding were performed to identify predictors of hoarding symptom improvement and treatment attrition in 106 adults with HD. No demographic variables were associated with symptom improvement or treatment attrition. However, higher levels of avoidant coping (i.e., self-distraction combined with behavioral disengagement) significantly predicted symptom improvement. The maintenance stage of change along with high readiness for change also significantly predicted symptom improvement. Participants who dropped from treatment had significantly higher baseline levels of denial and clutter, both of which independently predicted treatment attrition. The findings from this study suggest that emotion-related constructs, such as managing stress and motivation for change, may play an important role in patients' response to and participation in HD treatment.

Neural correlates of working memory performance in primary insomnia.

STUDY OBJECTIVES: To examine neural correlates of working memory performance in patients with primary insomnia (PIs) compared with well-matched good sleepers (GSs). DESIGN: Twenty-five PIs and 25 GSs underwent functional MRI while performing an N-back working memory task. SETTING: VA hospital sleep laboratory and University-based functional imaging center. PATIENTS OR PARTICIPANTS: 25 PIs, 25 GSs. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Although PIs did not differ from GSs in cognitive performance, PIs showed the expected differences from GSs in both self-reported and objective sleep measures. PIs, relative to GSs, showed reduced activation of task-related working memory regions. This manifested both as an overall reduction in activation of task-related regions and specifically as reduced modulation of right dorsolateral prefrontal cortex with increasing task difficulty. Similarly, PIs showed reduced modulation (i.e., reduced deactivation) of default mode regions with increasing task difficulty, relative to GSs. However, PIs showed intact performance. CONCLUSIONS: These data establish a profile of abnormal neural function in primary insomnia, reflected both in reduced engagement of task-appropriate brain regions and an inability to modulate task-irrelevant (i.e., default mode) brain areas during working memory performance. These data have implications for better understanding the neuropathophysiology of the well established, yet little understood, discrepancy between ubiquitous subjective cognitive complaints in primary insomnia and the rarely found objective deficits during testing.

Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders.

OBJECTIVE: To compare a mindfulness-based intervention with cognitive behavioral therapy (CBT) for the group treatment of anxiety disorders. METHOD: One hundred five veterans (83% male, mean age=46 years, 30% minority) with one or more DSM-IV anxiety disorders began group treatment following randomization to adapted mindfulness-based stress reduction (MBSR) or CBT. RESULTS: Both groups showed large and equivalent improvements on principal disorder severity thru 3-month follow up (ps<.001, d=-4.08 for adapted MBSR; d=-3.52 for CBT). CBT outperformed adapted MBSR on anxious arousal outcomes at follow up (p<.01, d=.49) whereas adapted MBSR reduced worry at a greater rate than CBT (p<.05, d=.64) and resulted in greater reduction of comorbid emotional disorders (p<.05, d=.49). The adapted MBSR group evidenced greater mood disorders and worry at Pre, however. Groups showed equivalent treatment credibility, therapist adherence and competency, and reliable improvement. CONCLUSIONS: CBT and adapted MBSR were both effective at reducing principal diagnosis severity and somewhat effective at reducing self-reported anxiety symptoms within a complex sample. CBT was more effective at reducing anxious arousal, whereas adapted MBSR may be more effective at reducing worry and comorbid disorders.