The efficacy of a transdiagnostic sleep intervention for outpatients with sleep problems and depression, bipolar disorder, or attention deficit disorder: study protocol for a randomized controlled trial.

BACKGROUND: Patients with mental disorders have a higher prevalence of sleep problems than the general population. Sleep problems may include insomnia, circadian rhythm disorders, or hypersomnia. A transdiagnostic approach combining cognitive behavioral therapy for insomnia (CBT-I) with chronotherapy addressing a broad range of sleep problems has shown promising results in a limited number of studies. The aim of the study is to investigate the efficacy of a transdiagnostic sleep intervention for patients with sleep problems comorbid to bipolar disorder, unipolar depression, or attention deficit disorders. The primary hypothesis is that the intervention improves sleep quality compared with a control group. The secondary hypotheses are that the intervention increases subjective and objective sleep efficiency, reduces sleep onset latency, wake after sleep onset, number of awakenings, and severity of insomnia; and that it improves well-being, personal recovery, work ability, and consumption of sleep medication compared with a control group. METHODS: The study is a randomized controlled trial enrolling 88 outpatients with bipolar disorder, major depression, or attention deficit disorder with symptoms of various sleep problems (insomnia, circadian rhythm disorders, or hypersomnia). Patients are allocated to either an intervention group receiving six sessions of transdiagnostic sleep treatment or to a control group receiving a single session of sleep hygiene education. Assessments are made at baseline, at week two, and after 6 weeks in both groups. Actigraphy is performed continuously throughout the 6-week study period for all patients. The primary outcome is changes in the subjective appraisal of sleep quality (Pittsburgh Sleep Quality Index). The secondary outcomes are changes in sleep efficiency, sleep onset latency, wake after sleep onset, number of nocturnal awakenings (based on actigraph and sleep diary data), changes in insomnia severity (Insomnia Severity Index), well-being (WHO-5 Well-Being Index), personal recovery (INSPIRE-O), work ability (Work Ability Index), and consumption of sleep medication (sleep-diaries). DISCUSSION: The study was initiated in 2022 and the inclusion period will continue until mid-2024. The results may have implications for the development and implementation of additional treatment options for patients with mental disorders and comorbid sleep problems. TRIAL REGISTRATION: ClinicalTrials.gov. NCT05406414. Registered on June 6, 2022.

Experiences of adult patients living with depression-related insomnia: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to identify and synthesize the best available evidence on how adult patients experience living with depression-related insomnia. In particular, the review will examine the experiences related to pharmacological and non-pharmacological interventions to improve sleep. INTRODUCTION: Approximately 80% to 90% of patients with depression have insomnia, which is associated with substantial personal and social costs. Despite these costs, insomnia is often underdiagnosed and viewed as a symptom that disappears when depression abates. However, research indicates that insomnia and depression are overlapping but distinct disorders. Thus, it is important to treat both disorders simultaneously, as improving sleep may, in turn, ease core symptoms of depression. Optimal care and treatment rely on patients' experiences of insomnia and their attitudes toward treatment options. Therefore, it is important to synthesize evidence of patients' experiences of living with insomnia, and the experiences of pharmacological and non-pharmacological sleep interventions, to understand the consequences of insomnia and to optimize sleep interventions. INCLUSION CRITERIA: This systematic review will synthesize qualitative studies exploring how adults with depression experience living with insomnia and how they experience pharmacological or non-pharmacological sleep interventions. Both inpatient and outpatient populations will be considered. METHODS: Databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, SveMed+, Scopus, and Web of Science Core Collection. Google Scholar and ProQuest Dissertations and Theses will be searched for unpublished studies. Studies in English, German, Danish, Swedish, and Norwegian will be included. Databases will be searched from their inception to the present date. All studies will be screened against the inclusion criteria and critically appraised for methodological quality. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021276048.

[Light therapy for depression].

Artificial light has been used as a treatment for depression since the 1980s. The indications have since broadened from seasonal depression to non-seasonal depression including bipolar, geriatric, and chronic depression. Light acts through retinohypothalamic connections from specialised retinal neurons to central nuclei involved in circadian and emotional regulation. This review illuminates the current strategies directed towards utilising natural daylight or electric lighting mimicking the dynamic spectrum and intensity of daylight to improve treatment in modern hospital settings.

Experience of Treatment and Adherence to Cognitive Behavioral Therapy for Insomnia for Patients with Depression: An Interview Study.

OBJECTIVE/BACKGROUND: Research supports the efficacy of Cognitive Behavioral Therapy for Insomnia (CBT-I) for patients suffering from depression and insomnia, but little is known about how they experience treatment and adhere to it. Our objective, therefore, was to explore how patients with depression experience treatment components and how their experiences influence adherence to CBT-I as a full-package treatment. PARTICIPANTS/METHODS: Twelve patients with depression and comorbid insomnia were interviewed after six sessions of CBT-I, and a conventional qualitative content analysis was conducted. RESULTS: Two themes were found. The theme "I picked what I needed" showed that participants chose among CBT-I methods. Behavioral methods were considered hard but so effective that they reduced the need to learn other methods. Participants had difficulty learning cognitive methods, such as the restructuring of negative thoughts, owing to lack of energy and cognitive problems aggravated by sleep loss. Sleep hygiene education was regarded as common knowledge. The theme "Staying on track" highlighted factors promoting adherence, such as a preference for non-pharmacological treatment, rapid improvement, and support from relatives and therapists. Factors impeding adherence were: a perceived lack of support from the ongoing group setting, side effects of medication, changes in daily routine, and daytime fatigue influencing cognitive and emotional functioning. CONCLUSION: The study suggests: focusing on adherence throughout treatment; actively using support from relatives and therapists; preferring individual treatment; and prioritizing behavioral treatment components, with cognitive components introduced later in the treatment course when the negative effects on cognitive functioning due to sleep restriction have diminished.

The impact of modified mania assessment scale (MAS-M) implementation on the use of mechanical restraint in psychiatric units.

BACKGROUND AND AIM: During recent years, there has been an increased focus on reducing use of mechanical restraint in psychiatric care. Studies show that implementing an assessment tool could potentially prevent or decrease the number of episodes of mechanical restraint. This study aims to examine the association between use of the Danish assessment tool for psychiatric inpatients diagnosed with mania (MAS-M) and mechanical restraint to highlight if number, type, and duration of restraint could be prevented or reduced by this procedure. MATERIALS AND METHOD: This historical cohort study included psychiatric inpatients diagnosed with bipolar disorder and hospitalized with symptoms of mania at the departments of affective disorders during the years 2012-2015. Logistic regression was used in the statistical analyses. RESULT: A total of 218 patients were included, 74 of whom were scored with MAS-M. Thirty-five episodes of mechanical restraint were recorded. A crude OR of 1.58 (95% CI: 0.75-3.30) of the association was estimated. The study showed a tendency toward patients scored with MAS-M being more frequently restrained with both belt and straps, however, in shorter duration, compared to the control group. CONCLUSION: This study reported relevant clinical information concerning staff's use of MAS-M, however, did not show a significant association between the use of MAS-M and mechanical restraint. Nevertheless, conflicting results about the impact of MAS-M on preventing and reducing these coercive measures have been highlighted, suggesting that more complex factors influence the use of mechanical restraint. No causal effect was examined thus further studies are needed.

[Psychiatry and circadian rhythms].

Circadian and seasonal rhythm disturbances are prominent in patients with psychiatric disorders. Properly timed and dosed light of specific spectral composition stabilises mood and sleep through serotonergic mechanisms and through input to the master circadian clock in the hypothalamus. Correctly administered, light can be used as an effective treatment for seasonal and non-seasonal depression and for stabilising the sleep-wake cycle. Blocking blue light in the evening may provide a non-pharmacological anti-manic tool. Current developments use dynamic lighting built into somatic and psychiatric hospitals to maximise the beneficial effects of light.

Predictors of response to combined wake and light therapy in treatment-resistant inpatients with depression.

There is growing evidence for combined chronotherapeutic interventions as adjunctive treatments for major depression. However, as the treatments can be demanding, we need to identify predictors of response. This study aimed to describe predictors of response, remission and deterioration in the short-term phase, as well as predictors of long-term response. The predictors investigated were gender, type of depression, severity of depression, treatment resistance, quetiapine use, general self-efficacy, educational level and positive diurnal variation. Follow-up data from 27 inpatients with moderate-to-severe depression participating in a chronotherapeutic intervention were analysed. As a supplement to standard treatment, they completed 3 wake therapy sessions in the first week, 30 min daily light treatment and sleep-time stabilisation in the entire 9-week study period. Patients had a significant decrease of depressive symptoms during the first 6 days measured by HAM-D6. At Day 6, 41% of the patients responded to the treatment and 19% fulfilled the criteria of remission. Deterioration by the end of wake therapy sessions was however not uncommon. In the short-term phase, mild degree of treatment resistance was associated with remission and low educational level associated with deterioration. Positive diurnal variation (mood best in the evening) was a predictor of both short-term and long-term response to combined wake and light therapy. Furthermore, patients with evening chronotypes (measured with morningness-eveningness score) were more responsive. Our results suggest that targeting the combined chronotherapeutic intervention at patients with positive diurnal variation and evening types is a viable option.

Experiences of wake and light therapy in patients with depression: A qualitative study.

Wake therapy can reduce depressive symptoms within days, and response rates are high. To sustain the effect, it is often combined with light therapy. Few studies have focussed on factors related to patients' adherence to the regime, and none has used qualitative methods to examine their experience of these combined interventions. Therefore, the aim of the present study was to illuminate patients' experiences with wake and light therapy and factors related to adherence. Thirteen inpatients with depression were included. They participated in an intervention consisting of three wake therapies during the first week, 30 min of daily light treatment for the entire 9 weeks, and ongoing psychoeducation regarding good sleep hygiene. Patients kept a diary, and individual semistructured interviews were conducted. Data were analysed using qualitative content analysis. The participants' overall experience with the treatment was positive. Some experienced a remarkable and rapid antidepressant effect, whereas others described more long-term benefits (e.g. improved sleep and diurnal rhythm). Yet recovery was fragile, and patients were only cautiously optimistic. Social support was important for maintaining the motivation to stay awake and receive daily light therapy. Overall, participants found the treatment worthwhile and would recommend it to others with depression. The study revealed a lack of knowledge among participants about the connection between regular sleep patterns and depression. In conclusion, this study provides insight into patients' experiences, and knowledge that can contribute to guidelines for future adherence-promoting organization of wake and light therapy.

[Wake therapy for major depression]. / Vågenterapi mod depression

Patients admitted with depression are highly tormented and many are suicidal. Standard treatment does not offer full effect until after several weeks. Wake therapy is a method that may reduce depressive symptoms within days. In this paper, the literature regarding wake therapy is reviewed. The response rates in wake therapy are high, but the effect is often transitory. However, recent studies indicate that wake therapy in combination with other chronotherapeutic interventions, e.g. light therapy, can produce a rapid and sustained antidepressant effect.