A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injury.

OBJECTIVE: To explore feasibility and potential efficacy of on-line interventions for sleep quality following a traumatic brain injury (TBI). DESIGN: A two parallel-group, randomized controlled pilot study. SETTING: Community-based. SUBJECTS: In all, 24 participants (mean age: 35.9 ± 11.8 years) who reported experiencing sleep difficulties between 3 and 36 months after a mild or moderate TBI. INTERVENTIONS: Participants were randomized to receive either a cognitive behaviour therapy or an education intervention on-line. Both interventions were self-completed for 20-30 minutes per week over a six-week period. MAIN MEASURES: The Pittsburgh Sleep Quality Index assessed self-reported sleep quality with actigraphy used as an objective measure of sleep quality. The CNS Vital Signs on-line neuropsychological test assessed cognitive functioning and the Rivermead Post-concussion Symptoms and Quality of Life after Brain Injury questionnaires were completed pre and post intervention. RESULTS: Both programmes demonstrated feasibility for use post TBI, with 83.3% of participants completing the interventions. The cognitive behaviour therapy group experienced significant reductions ( F = 5.47, p = 0.04) in sleep disturbance (mean individual change = -4.00) in comparison to controls post intervention (mean individual change = -1.50) with a moderate effect size of 1.17. There were no significant group differences on objective sleep quality, cognitive functioning, post-concussion symptoms or quality of life. CONCLUSION: On-line programmes designed to improve sleep are feasible for use for adults following mild-to-moderate TBI. Based on the effect size identified in this pilot study, 128 people (64 per group) would be needed to determine clinical effectiveness.

Dissemination of an Internet-based treatment for chronic insomnia into primary care.

This study evaluated the effectiveness of two strategies (provider-targeted, consumer-targeted) in the dissemination of an insomnia treatment into primary care. Results of the study indicated that more patients from the provider-targeted, than the consumer-targeted, clinic followed up on the referral for insomnia treatment, but that overall there was limited uptake. These results did not seem to be associated with low levels of provider interest, although providers expressed need for more education about the insomnia program. Implications of these results are that future research efforts would benefit from expanding upon the education of providers in terms of treatment offered, perhaps teaching providers how to better motivate their patients for behavior change.

Determinants of success for computerized cognitive behavior therapy: examination of an insomnia program.

This study evaluated plausible moderators of outcome in a 6-week computerized treatment for insomnia. Using secondary data from two randomized controlled trials, participants were 228 adults with chronic insomnia. Participants received computerized treatment from their homes. Outcomes were assessed using a sleep diary, as well as several standardized self-report scales. Using linear mixed models with SPSS, treatment was largely robust to comorbid conditions, education, age, and gender. Results showed that psychiatric comorbidity and education moderated the impact of treatment on fatigue and that sleep symptom comorbidity moderated the impact of treatment on maladaptive attitudes about sleep. Implications of these findings are that more widespread use of computerized treatment for insomnia may be warranted.

Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias.

STUDY OBJECTIVES: This pilot study determined whether transdiagnostic cognitive behavioral therapy for parasomnias (CBTp) reduces parasomnia and activity levels during sleep in a sample of adult sleep clinic outpatients. A secondary objective was to assess whether treatment produces improvements in daytime fatigue/sleepiness, perceived cognition, mood, and depression/anxiety/stress, as well as functional impairment in work and leisure activities. METHODS: This was a randomized controlled trial with CBTp and self-monitoring control conditions. Participants were 19 adults with a DSM 5 parasomnia disorder who received individual CBTp virtually from their homes. CBTp consisted of psychoeducation, sleep hygiene and safety instructions, relaxation training, parasomnia techniques, and relapse prevention in a 6-week manualized, structured program. RESULTS: Using a repeated measures analysis of variance model, and relative to a self-monitoring control condition, results showed that CBTp produced statistically significant improvements in parasomnia frequency, severity, nocturnal activity, and sleep efficiency. There was a trend toward reduced sleep-onset latency and improved work and social adjustment. Of treated participants, 100% rated themselves as improved at study conclusion. CONCLUSIONS: Implications of these findings are that cognitive behavioral interventions for parasomnias are effective in lessening parasomnias. More investigation into this type of treatment is warranted. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Impact of Cognitive Behavioral Therapy on Parasomnias; URL: https://clinicaltrials.gov/ct2/show/NCT04633668; Identifier: NCT04633668. CITATION: Vincent N, Dirkse D, Giannouli E, McQuarrie A. Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias. J Clin Sleep Med. 2023;19(3):499-509.

A cross-sectional examination of sudden-death bereavement in university students.

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Psychometric Properties of the Sleep Locus of Control (SLOC) Scale in a Portuguese Sample.

Over the past few decades, research has suggested that cognitive variables play a key role in sleep disorders, particularly, in insomnia. The SLOC (Sleep Locus of Control Scale) evaluates the sleep locus of control, which is associated with the degree to which an individual attributes her/his experiences of sleep to chance or internal causes. The aim of this study was to develop the first translation and adaptation of the SLOC into the European Portuguese, as well as to analyze its psychometric properties. In this study, it was recruited a sample of 2029 Portuguese Higher Education students, aged ≥ 18 years, where approximately 75% of the sample were women and 25% men. The results showed that the SLOC had acceptable internal consistency value (α = .64), considering that it is a measure with a reduced number of items. As in the original study, a principal component analysis with varimax rotation identified two components. A parallel analysis was also conducted, identifying two factors. The correlation between the two subscales "internal sleep locus of control" and "chance sleep locus of control" was positive albeit of low magnitude (r = .15). Through the analysis carried out, it was also observed that individuals with "insomnia", relative to those without, had a more chance sleep locus of control. Overall, these findings show similarities with the original study. The SLOC seems to be a useful psychological assessment measure to be used in clinical and research settings.

Efficacy of a minimally guided internet treatment for alcohol misuse and emotional problems in young adults: Results of a randomized controlled trial.

Many young adults struggle with comorbid alcohol misuse and emotional problems (i.e., depression and anxiety). However, there is currently a paucity of evidence-based, integrated, accessible treatment options for individuals with these comorbidities. The main goal of this study was to examine efficacy of a novel online, minimally guided, integrated program for comorbid alcohol misuse and emotional problems in young adults. Method: The study was an open-label two-arm RCT. Participants (N = 222, M age = 24.6, 67.6% female) were randomized to one of two conditions: the Take Care of Me program (an 8-week, online integrated treatment condition consisting of 12 modules), or an online psychoeducational control condition. Intervention modules incorporated content based on principles of cognitive behavioral therapy and motivational interviewing. Participants completed assessment data at baseline, at the end of treatment (i.e., 8 weeks), and at follow-up (i.e., 24 weeks). Data were analyzed using generalized linear mixed models. Results: We observed that participants in the treatment condition showed larger reductions in depression, hazardous drinking, as well as increases in psychological quality of life and confidence at the end of treatment. We did not find group differences on total alcohol use at follow-up, but participants in the treatment group reduced their hazardous drinking and improved their quality of life at 24-week follow-up. Conclusions: Our study provides promising initial evidence for the first iteration of the comorbid alcohol misuse and emotional problems online program.

Attrition and adherence in the online treatment of chronic insomnia.

This study examined the ability of the Theory of Planned Behavior (TPB; Ajzen, 1985) and the Transtheoretical Model of Behavior Change (TTM; Prochaska & DiClemente, 1983) to explain adherence and attrition in an online treatment program for chronic insomnia. Responses to questionnaire measures of the TPB and TTM were used to predict adherence and dropout over the subsequent 5 weeks of treatment. Results showed that there was a 17% dropout rate and that perceived behavioral control, social support, and intention to complete the program were significantly associated with adherence to sleep hygiene homework. Attrition was predicted only by symptom severity and psychiatric comorbidity. Implications are that these models should be considered to maximize adherence.

Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia.

STUDY OBJECTIVES: Despite effective cognitive behavioral treatments for chronic insomnia, such treatments are underutilized. This study evaluated the impact of a 5-week, online treatment for insomnia. DESIGN: This was a randomized controlled trial with online treatment and waiting list control conditions. PARTICIPANTS: Participants were 118 adults with chronic insomnia. SETTING: Participants received online treatment from their homes. INTERVENTION: Online treatment consisted of psychoeducation, sleep hygiene, and stimulus control instruction, sleep restriction treatment, relaxation training, cognitive therapy, and help with medication tapering. MEASUREMENT AND RESULTS: From pre- to post-treatment, there was a 33% attrition rate, and attrition was related to referral status (i.e., dropouts were more likely to have been referred for treatment rather than recruited from the community). Using a mixed model analysis of variance procedure (ANOVA), results showed that online treatment produced statistically significant improvements in the primary end points of sleep quality, insomnia severity, and daytime fatigue. Online treatment also produced significant changes in process variables of pre-sleep cognitive arousal and dysfunctional beliefs about sleep. CONCLUSIONS: Implications of these findings are that identification of who most benefits from online treatment is a worthy area of future study.

Are personality dimensions associated with sleep length in a large nationally representative sample?

OBJECTIVES: The purpose of this hypothesis-generating study was to determine whether personality domains and specific personality traits are uniquely associated with sleep duration using data obtained from the National Comorbidity Survey (NCS). METHODS: Using trained interviewers, we administered to the 5877 noninstitutionalized adults living in the United States the Composite International Diagnostic Interview (World Health Organization. Composite International Diagnostic Interview. Geneva, Switzerland: WHO, 1990) to assess for any DSM-III-R psychiatric diagnoses, and they completed self-report measures of personality and sleep. This was a secondary data analysis using information from a large existing public use data set (NCS-part II). The NCS-part II was an epidemiologic survey based on a stratified multistage area probability method with a response rate of 82.4%. RESULTS: Using a multivariate logistic regression technique, we found significant and positive associations between short sleep (defined as or=9 hours per 24 hour period) and a diagnosis of dysthymia (OR = 1.52), the use of a sedating medication in the past 12 months (OR = 1.52), emotional reliance on another person (OR = 1.37), employment status (OR = 1.31), and marital status (OR = 1.20). CONCLUSIONS: Findings suggest that personality, even after controlling for psychiatric and medical conditions, is associated with sleep length and may be an additional factor to consider when assessing any individual patient.

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia.

In this study, 67 participants (95% female) with fibromyalgia (FM) were randomly assigned to an online acceptance and commitment therapy (online ACT) and treatment as usual (TAU; ACT + TAU) protocol or a TAU control condition. Online ACT + TAU participants were asked to complete 7 modules over an 8-week period. Assessments were completed at pre-treatment, post-treatment, and 3-month follow-up periods and included measures of FM impact (primary outcome), depression, pain, sleep, 6-minute walk, sit to stand, pain acceptance (primary process variable), mindfulness, cognitive fusion, valued living, kinesiophobia, and pain catastrophizing. The results indicated that online ACT + TAU participants significantly improved in FM impact, relative to TAU (P <.001), with large between condition effect sizes at post-treatment (1.26) and follow-up (1.59). Increases in pain acceptance significantly mediated these improvements (P = .005). Significant improvements in favor of online ACT + TAU were also found on measures of depression (P = .02), pain (P = .01), and kinesiophobia (P = .001). Although preliminary, this study highlights the potential for online ACT to be an efficacious, accessible, and cost-effective treatment for people with FM and other chronic pain conditions. PERSPECTIVE: Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

Efficacy of an Online Self-Help Treatment for Comorbid Alcohol Misuse and Emotional Problems in Young Adults: Protocol for a Randomized Controlled Trial.

BACKGROUND: Alcohol misuse and emotional problems (ie, depression and anxiety) are highly comorbid among Canadian young adults. However, there is a lack of integrated, accessible, and evidence-based treatment options for these young adults. OBJECTIVE: The main goal of this study is to develop and test the efficacy of an integrated, online self-help program designed to target both alcohol misuse and emotional problems. METHODS: A two-arm randomized controlled trial design will be used to compare the efficacy of the online integrated treatment to a psychoeducational control group. A target sample of 214 participants will be recruited and randomly assigned to either condition. The integrated treatment will last 8 weeks, and participants will work through 12 modules. Modules will incorporate content based on principles of cognitive behavioral therapy and motivational interviewing. Participants in the control group will receive links to psychoeducational resources and will have access to the full treatment after follow-up. The primary outcome will be the number of Canadian standard drinks consumed in the week leading up the assessment. Secondary outcomes of interest include symptoms of depression, anxiety, alcohol-related problems, quality of life, and use of other drugs. Assessments will be completed at 3 time-points: at baseline, at the end of treatment (ie, 8 weeks), and at follow-up (ie, 24 weeks). Upon completion, data will be analyzed using generalized linear mixed models. RESULTS: Data collection began in June 2018 and will continue until January 2020. Final study results will be submitted for publication by July 2020. CONCLUSIONS: Currently, there are no integrated treatments designed to target alcohol misuse and the range of emotional problems experienced by young adults. This research stands to provide an effective, accessible (ie, Web-based), and feasible option to treat the many struggling young adults in this country. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT03406039; https://clinicaltrials.gov/ct2/show/NCT03406039 (Archived by WebCite at http://www.webcitation.org/72fDefnrh). REGISTERED REPORT IDENTIFIER: PRR1-10.2196/11298.

Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships.

Eating disorders are complex, multifactorially determined phenomena. When individuals with eating disorders present for treatment with comorbid conditions, case conceptualization is further complicated and, as a result, it may be difficult to determine optimal psychological or pharmacological treatment. This article reviews the evidence of the association between eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) and Axis I depression, obsessive-compulsive disorder (OCD), substance abuse, and Axis II personality disorders, for the purposes of increasing awareness about the different options for case conceptualization. Although other diagnoses comorbid with eating disorders are of interest to clinicians (e.g., posttraumatic stress disorder [PTSD] and social phobia), their comprehensive review is currently premature due to a lack of empirical scrutiny. Finally, future directions for research, including suggestions for the use of particular assessment tools and more sophisticated research designs, are discussed.

Stepped care for insomnia: an evaluation of implementation in routine practice.

STUDY OBJECTIVES: Stepped care models for chronic insomnia are in their infancy. This study evaluated predictors of movement in a stepped care pathway using a sample of 50 adult outpatients with chronic insomnia. METHODS: At assessment periods, participants completed daily sleep diaries, the Insomnia Severity Index, the Multi-Dimensional Fatigue Inventory (MFI), and the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-10). Following this, data were collected regarding whether the individual went on to receive more intensive services (i.e., individual consultation, group or individual therapy). Data were analyzed using multi-nomial logistic regression. RESULTS: Results showed that age, employment status, and sleep (quality, latency) predicted use of more intensive services. Results showed that psychiatric and sleep comorbidity, sleep attitudes, and insomnia severity did not. CONCLUSIONS: Implications of these findings are that stepped care resulted in a 69% improvement in efficiency, and that low-intensity treatment delivered in step 1 may have been particularly sufficient for the young and employed, and for those with better sleep.

Control and coping in chronic insomnia: a daily diary study.

This daily diary study evaluated the relationships between perceived control over sleep, coping with sleeplessness, and subjective sleep in a sample of 45 adults with chronic insomnia. For seven consecutive days, newspaper-recruited adults completed daily self-report measures of perceived control, coping, general fatigue, mood, and sleep. Using a mixed-model analysis with SAS, we examined the lagged impact of perceived control and coping (either assimilative or accommodative) on next day sleep, mood, and fatigue. Results showed that perceived control over sleep was a significant predictor of next day sleep quality. For those with more chronic presentations, perceived control over sleep was a significant predictor of next day accommodative coping. Results indicated that those with more chronic presentations were more likely to use accommodative coping, and that this was associated with worsened next-day mood and no improvements in sleep. Implications of these findings are that changes in perceived control precede, and do not follow from, changes in sleep. Additionally, results suggest that accommodative coping should be discouraged as it is more likely to worsen next-day mood.

A population-based study of fatigue and sleep difficulties in inflammatory bowel disease.

BACKGROUND: There has been little investigation of fatigue, a common symptom in inflammatory bowel disease (IBD). The aim of this study was to evaluate fatigue more comprehensively, considering relationships with psychological and biological factors simultaneously in a population-based IBD community sample. METHODS: Manitoba IBD Cohort Study participants (n = 318; 51% Crohn's disease [CD]) were assessed by survey, interview, and blood sample. Fatigue, sleep quality, daytime drowsiness, stress, psychological distress, and quality of life were measured with validated scales. Hemoglobin (Hg) and C-reactive protein (CRP) levels were also obtained. Differences were tested across disease activity and disease subtype. RESULTS: Elevated CRP was found for 23% of the sample and 12% were anemic; 46% had active disease. Overall, 72% of those with active and 30% with inactive disease reached clinical thresholds for fatigue (Multidimensional Fatigue Inventory; P < 0.001); 77% and 49% of those with active or inactive disease, respectively, experienced poor sleep (P < 0.001). There were few differences between those with CD and ulcerative colitis (UC) on the factors assessed, except for higher CRP levels in CD (mean 8.8 versus 5.3, P < 0.02). Multiple logistic regression analyses found that elevated fatigue was associated with active disease (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.2-7.8), poor sleep quality (OR 4.0, 95% CI 1.9-8.6), and perceived stress (OR 4.2, 95% CI 2.2-8.1), but not with hours of sleep, Hg, or CRP. CONCLUSIONS: Fatigue and poor sleep are not only highly prevalent in active disease, but both are still significant concerns for many with inactive disease. Psychological factors are associated with fatigue in IBD in addition to disease and sleep considerations.

Barriers to engagement in sleep restriction and stimulus control in chronic insomnia.

Sleep restriction (SRT) and stimulus control (SC) have been found to be effective interventions for chronic insomnia (Morgenthaler et al., 2006), and yet adherence to SRT and SC varies widely. The objective of this study was to investigate correlates to adherence to SC/SRT among 40 outpatients with primary or comorbid insomnia using a correlational design. Participants completed a self-report measure of sleepiness prior to completion of a 6-week cognitive behavioral treatment group for insomnia. At the posttreatment period, they rated their ability to engage in SC/SRT using a survey. Results from standard multiple regression analyses showed that perceiving fewer barriers (i.e., less boredom, annoyance) to engaging in SC/SRT and experiencing less pretreatment sleepiness were each associated with better adherence to SC/SRT. Adherence to SC/SRT was associated with outcome. Implications of these findings are that more work is needed to make SC/SRT less uncomfortable, possibly by augmenting energy levels prior to introducing these approaches.

What predicts patients' perceptions of improvement in insomnia?

Although there has been considerable research into the effectiveness of individual cognitive behavioral treatment for chronic insomnia, less is known about patients' perceptions of what constitutes actual improvement. This study utilized 70 outpatients (mean age = 49.7 years, SD = 12.0) with insomnia who completed a 6-week cognitive behavioral group for sleep. Participants completed a number of primary (Pittsburgh Sleep Quality Index) and secondary measures (the Dysfunctional Beliefs about Sleep Scale, Insomnia Severity Index, Beck Depression Inventory, Penn State Worry Questionnaire) at pre- and post-treatment. Perceived improvement was measured using the Clinical Global Improvement Scale (CGI). Results were analyzed using a combination of Logistic Regression analysis and receiver operating curve characteristic analysis (ROC). Results demonstrated that sleep quality and sleep duration were the most sensitive primary measures, or best predicted perceived improvement, whereas sleep efficiency was the most specific primary measure, or best predicted perceived lack of improvement (defined as only mild improvement). Of the secondary measures, results showed that daytime impairment was the most sensitive predictor of perceived improvement and that mood was the most specific predictor of perceived lack of improvement. Implications of these findings are that sleep quality, sleep duration, and sleep efficiency may offer different types of information and the choice of measure for predicting global improvement in insomnia will depend on the needs of the researcher/clinician.

Relation between adherence and outcome in the group treatment of insomnia.

This study evaluated adherence to group cognitive behavioral treatment in 50 adults with chronic insomnia. Adherence was measured using questionnaire data, consistency of sleep scheduling, and % of sessions attended. Results showed that therapists' rated 48% of participants as "very much" to "extremely" adherent. Using stepwise regression, only therapist-rated adherence explained a significant amount of variance in post-treatment outcome. Therapist-rated adherence predicted post-treatment ratings of sleep-related impairment, dysfunctional beliefs about sleep, and overall sleep quality (but not actual sleep duration or efficiency). Using a multivariate analysis of variance (MANOVA) procedure, results revealed that a diagnosis of dysthymia, based on a structured clinical interview, was associated with reduced adherence and less improvement in sleep-onset latency and sleep efficiency, but that scores on a dimensional measure of depression were not associated with either adherence or outcome. Implications of these findings are that the practice of treatment techniques is related to an improved perception of sleep and more healthy and appropriate beliefs about the causes of poor sleep. Therapists should continue to pay close attention to the adherence behavior of those with insomnia, particularly if they are depressed.

Sleep locus of control: report on a new scale.

The psychometric properties of a new 8-item measure, the Sleep Locus of Control Scale (SLOC), were investigated. A sample of 425 adult alumnae from the University of Manitoba and 57 community volunteers with chronic insomnia were surveyed. Results showed that the SLOC had acceptable reliability (i.e., internal consistency) and demonstrated convergent and discriminant validity through patterns of association with the Multidimensional Health Locus of Control Scale (Wallston, Wallston, & DeVellis, 1978). Principal factors extraction with varimax rotation identified two factors underlying the SLOC Scale. One factor captured an internal sleep locus of control orientation and the other reflected a chance sleep locus of control orientation. In the adult alumnae sample, having a more chance sleep locus of control was associated with greater perfectionism, depression, and anxiety. In adults with chronic insomnia, having a more internal sleep locus of control orientation was associated with increased sleep-related anxiety. One implication of the study is that too much emphasis on developing an internal sleep locus of control may be counterproductive (i.e., associated with increased sleep-related anxiety). Instead, achieving a balance between an internal and chance sleep locus of control orientation may be an important goal when treating individuals with chronic insomnia.