The validity and reliability of the Persian version of the Athlete Sleep Screening Questionnaire.

Background: Sleep as a biological phenomenon is effective in the performance and recovery of athletes. Questionnaires can be used as a cost-effective initial assessment tool for sleep. The Athlete Sleep Screening Questionnaire (ASSQ) demonstrated a clinically valid instrument for screening relevant sleep issues in athletic populations. Due to the lack of validated tools for adequate screening for sleep difficulties in the Iranian athlete population, the present study was conducted to evaluate the validity and reliability of the Persian version of the ASSQ. Materials and Methods: The translation process was performed using instructions by Beaton et al. Content validity was assessed by a panel of experts. Exploratory and confirmatory factor analysis was performed for two 5-item sleep difficulty scores (SDS) and a 4-item chronotype score. Internal consistency based on Cronbach's alpha and McDonald's omega and stability reliability were used to evaluate reliability. Results: The ASSQ achieved conceptual and semantic equivalence with the original scale. The item-level content validity index (I-CVI) of each item ranged from 0.87 to 1, and the averaging scale-level CVI/average was 0.95. In factor analysis, one factor for SDS and one factor for chronotype score were identified and confirmed. The internal consistency of the SDS scale (α =0.77, Ω =0.83) and chronotype (α =0.74, Ω =0.77) was acceptable. Stability reliability was confirmed for SDS scale (intra-class correlation [ICC] =0.87) and for chronotype (ICC = 0.83). Conclusion: Persian ASSQ has acceptable psychometric measurement properties as a screening tool to assess sleep in Iranian athletes.

Sleep Health, Individual Characteristics, Lifestyle Factors, and Marathon Completion Time in Marathon Runners: A Retrospective Investigation of the 2016 London Marathon.

Despite sleep health being critically important for athlete performance and well-being, sleep health in marathoners is understudied. This foundational study explored relations between sleep health, individual characteristics, lifestyle factors, and marathon completion time. Data were obtained from the 2016 London Marathon participants. Participants completed the Athlete Sleep Screening Questionnaire (ASSQ) along with a brief survey capturing individual characteristics and lifestyle factors. Sleep health focused on the ASSQ sleep difficulty score (SDS) and its components. Linear regression computed relations among sleep, individual, lifestyle, and marathon variables. The analytic sample (N = 943) was mostly male (64.5%) and young adults (66.5%). A total of 23.5% of the sample reported sleep difficulties (SDS ≥ 8) at a severity warranting follow-up with a trained sleep provider. Middle-aged adults generally reported significantly worse sleep health characteristics, relative to young adults, except young adults reported significantly longer sleep onset latency (SOL). Sleep tracker users reported worse sleep satisfaction. Pre-bedtime electronic device use was associated with longer SOL and longer marathon completion time, while increasing SOL was also associated with longer marathon completion. Our results suggest a deleterious influence of pre-bedtime electronic device use and sleep tracker use on sleep health in marathoners. Orthosomnia may be a relevant factor in the relationship between sleep tracking and sleep health for marathoners.

Associations between time zone changes, travel distance and performance: A retrospective analysis of 2013-2020 National Hockey League Data.

OBJECTIVES: Many studies have investigated the role that travel plays in athletic performance. However, these studies lacked a holistic representation of travel. For instance, they do not consider travel distance and uniquely focuses on travel direction. DESIGN: An open source (www.evolving-hockey.com) provided NHL (2013-2020) game data. In total, this resulted in 17,088 regular season games. METHODS: Linear and quadratic versions of time zone change (TZΔ) and adjusted jet lag (AJL) were formulated. TZΔ captured circadian delay/advance based on travel for a game, with each TZ going eastward and westward reflected by -1 and +1, respectively. AJL advances TZΔ by allowing TZ acclimation, with each day resulting in a 1-unit change towards circadian neutral. AJL is a season-long rolling summation, which was computed using two different travel approaches: Approach A (AJL_A) assumes travel the day before each game, whereas Approach B (AJL_B) was designed to prioritize being home. A standardized flight tracker determined travel distance for each game. Team ability differences, characterized as difference in total season points, served as an analytic covariate. Outcome variables included goal differential, difference between actual and expected Fenwick save percentage (dFSv%), and goals saved above average (GSAA). RESULTS: GameDistance (ß = -0.14, p = 0.0007), AJL_B2 (ß = -0.15, p = 0.0006), and their interaction (p = 0.0004) associated with GoalDifferential. GameDistance (ß = -0.18, p = 0.02) and AJL_B2 (ß = 0.12, p = 0.03) associated with dFSv%, whereas only AJL_B2 (ß = 0.03, p = 0.05) associated with GSAA. CONCLUSIONS: Results suggest that circadian change, in both direction, and greater traveled distance can negatively impact NHL athletes.

National strategy on the integration of sleep and circadian rhythms into public health research and policies: Report from the Canadian Sleep and Circadian Network.

Scientists in sleep and circadian rhythms, public health experts, healthcare providers, partners, and stakeholders convened in 2020 for a 2-day meeting organized by the Canadian Sleep and Circadian Network to develop a national strategy for integrating sleep and circadian rhythms into public health and policies in Canada. The objective of this paper is to present the national strategy that emerged from this meeting of 60 participants from across Canada. The meeting focused on 4 key target priorities: (1) atypical working schedules, (2) sleep and circadian rhythms of children and adolescents, (3) insomnia, and (4) impact of sleep apnea on health. Following constructive discussions, it was decided that the following 4 strategic objectives should be prioritized to accelerate the integration of sleep and circadian rhythms into public health policies in Canada: (1) increase public health sleep and circadian rhythm research, (2) increase public health education and knowledge mobilization on sleep, (3) inform and support public health sleep interventions and policies, and (4) promote sleep health training. Participants recommended that research and public health efforts address needs along the continuum of sleep health. The committee noted that strategies and interventions could differ across contexts, settings, sectors, and jurisdictions. The national strategy also identified high-priority research questions in public health and recommended mechanisms to build research capacity, providing a path forward for the integration of sleep and circadian rhythms into public health research and policies.

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society.

CITATION: Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: (1) a recognition of the factors contributing to fatigue and fatigue-related risks; (2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and (3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society.

Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: (1) a recognition of the factors contributing to fatigue and fatigue-related risks; (2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and (3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.

Impacts of travel distance and travel direction on back-to-back games in the National Basketball Association.

STUDY OBJECTIVES: Travel fatigue and circadian disruptions are known factors that can hinder performance in professional athletes. The present study focused on travel distance and direction on back-to-back games over the 2013-2020 seasons in the National Basketball Association (NBA). METHODS: The outcomes were based on winning percentage with additional covariates including the direction of travel (eastward or westward), the distance traveled (0-500 km; 501-1,000 km; 1,001-1,500 km; 1,501 km and more), team quality, and season. If a team played both games of a back-to-back sequence on the road, they were considered Away-Away; if a team played the first game of a back-to-back sequence at home they were considered Home-Away; if a team played the first game of a back-to-back sequence on the road they were considered Away-Home. RESULTS: The sequence Away-Home significantly increases the likelihood of winning compared with the Away-Away and Home-Away sequences: 54.4% (95% confidence interval [CI], 54.4%-54.5%), 39.2% (95% CI, 37.2%-41.2%), and 36.8% (95% CI, 36.7%-36.8%), respectively. When teams travel back home, every additional 500 km reduces the likelihood of winning by approximately 4% (P = .038). Finally, after withdrawing the Away-Home sequence, traveling eastward significantly increases the chance of winning (P = .024) compared with westward travel but has no significant impact on the probability of winning compared with neutral time zone travel (P = .091). CONCLUSIONS: The accumulation of travel fatigue and the chronic circadian desynchronization that occurs over the NBA season can acutely disturb sleep and recovery. It appears that tailored sleep and recovery strategies need to be dynamically developed throughout the season to overcome the different challenges of the NBA schedule. CITATION: Charest J, Samuels CH, Bastien CH, Lawson D, Grandner MA. Impacts of travel distance and travel direction on back-to-back games in the National Basketball Association. J Clin Sleep Med. 2021;17(11):2269-2274.

Sleep, health, and well-being in elite athletes from different sports, before, during, and after international competition.

Objectives: Limited research has been conducted on sleep problems in elite athletes at international competition, and how this relates to their general health and well-being. Methods: Sixty-five elite international athletes (37 males, 28 females, 21.8 ± 2.1 years) from different sports completed validated sleep (Athlete Sleep Screening Questionnaire), health (Subjective Health Complaints Inventory) and well-being (Sports Profile of Mood States) questionnaires; 1 month pre-competition, at the end of international competition, and 1 month post-competition. Results: Twenty-three percent of the elite athletes were identified as having a moderate or severe clinically significant sleep problem during competition, with 82% reporting less than 8 h of sleep per night. Athletes with a moderate or severe clinically significant sleep problem during competition had significantly greater general health complaints (p = 0.002), mood disturbance (p = 0.001) and poorer sleep hygiene (p = 0.002). Swimmers had more sleep difficulty pre and during competition compared to athletics and soccer (p = 0.009). Conclusion: Sleep disturbance during international competition is common and associated with poorer health and lower mood. Swimmers may be more at risk of sleep difficulty pre and during competition compared to those competing in athletics and soccer. Sleep services may be required to support elite athletes at international competition.

Sleep and the athlete: narrative review and 2021 expert consensus recommendations.

Elite athletes are particularly susceptible to sleep inadequacies, characterised by habitual short sleep (<7 hours/night) and poor sleep quality (eg, sleep fragmentation). Athletic performance is reduced by a night or more without sleep, but the influence on performance of partial sleep restriction over 1-3 nights, a more real-world scenario, remains unclear. Studies investigating sleep in athletes often suffer from inadequate experimental control, a lack of females and questions concerning the validity of the chosen sleep assessment tools. Research only scratches the surface on how sleep influences athlete health. Studies in the wider population show that habitually sleeping <7 hours/night increases susceptibility to respiratory infection. Fortunately, much is known about the salient risk factors for sleep inadequacy in athletes, enabling targeted interventions. For example, athlete sleep is influenced by sport-specific factors (relating to training, travel and competition) and non-sport factors (eg, female gender, stress and anxiety). This expert consensus culminates with a sleep toolbox for practitioners (eg, covering sleep education and screening) to mitigate these risk factors and optimise athlete sleep. A one-size-fits-all approach to athlete sleep recommendations (eg, 7-9 hours/night) is unlikely ideal for health and performance. We recommend an individualised approach that should consider the athlete's perceived sleep needs. Research is needed into the benefits of napping and sleep extension (eg, banking sleep).

Sleep in elite multi-sport athletes: Implications for athlete health and wellbeing.

OBJECTIVES: To investigate the prevalence of clinically relevant sleep problems in elite multi-sport athletes and their associations with sleep hygiene, general health, mood, chronotype, and injury. DESIGN: Cross-sectional study. SETTING: During the competitive season in athletes' home environment. PARTICIPANTS: Elite multi-sport Irish athletes (n = 58) competing at the 2017 World University Games. MAIN OUTCOME MEASURES: Category of clinical sleep problem (Athlete-Sleep-Screening-Questionnaire), sleep hygiene (Sleep Hygiene Index), general health (Subjective Health Complaints), mood (Sports Profile of Mood States), chronotype (Morningness-Eveningness Questionnaire), and injury (self-reported injury). RESULTS: 43% had no clinical sleep problem, 41% had a mild clinical sleep problem, 16% had a moderate clinical sleep problem, none had a severe clinical sleep problem. Therefore, 84% of athletes did not have a clinically significant sleep problem while 16% had a clinically significant sleep problem. One-way-ANOVA revealed significantly worse sleep hygiene (p = 0.002), more general health complaints (p = 0.001) and greater mood disturbance (p = 0.001) among those with clinically significant sleep disturbances compared to those without. No association was found between having a clinically significant sleep problem and either chronotype or previous recent injury. CONCLUSIONS: Athletes with a clinically significant sleep problem were more likely to report worse sleep hygiene, more general health complaints, and mood disturbance.

Differences in sleep patterns, sleepiness, and physical activity levels between young adults with autism spectrum disorder and typically developing controls.

OBJECTIVE: To investigate the differences in sleep, sleepiness, and physical activity (PA) between young adults with autism spectrum disorder (ASD) and typically developing controls (TDC). METHOD: Actigraphic data and questionnaires on sleep, sleepiness, and PA were compared between fifteen adults with ASD (ADOS range 7-19; ages 22.8 ± 4.5 years) and TDC. RESULTS: In comparison to the TDC group, the ASD group slept longer on average per night but took longer to fall asleep. In relationship to PA levels, the objective PA levels were lower in the ASD group than the TDC group. Fewer wake minutes during the sleep period in the ASD sample were associated with more PA the following day. CONCLUSION: The findings support previous research that demonstrates differences in sleep parameters and PA between ASD and TDC. Interventions aimed at increasing PA in an ASD population may be beneficial for improved sleep.

Sleep Quality and Chronotype Differences between Elite Athletes and Non-Athlete Controls.

Previous research has found that elite athletes have insufficient sleep, yet the specific kinds of sleep disturbances occurring as compared to a control group are limited. Here we compare the subjective sleep quality and chronotype of elite athletes to a control group of non-athlete good sleepers. Sixty-three winter Canadian National Team athletes (mean age 26.0 ± 0.0; 32% females) completed the Pittsburgh Sleep Quality Index (PSQI) and the Athlete Morningness Eveningness Scale. They were compared to 83 healthy, non-athlete, good-sleeper controls (aged 27.3 ± 3.7; 51% females) who completed the PSQI and the Composite Scale of Morningness. The elite athletes reported poorer sleep quality (PSQI global score 5.0 ± 2.6) relative to the controls (PSQI global score 2.6 ± 1.3), despite there being no group difference in self-reported sleep duration (athletes 8.1 ± 1.0 h; controls 8.0 ± 0.7 h). Further, athletes' chronotype distribution showed a greater skew toward morningness, despite there being no group differences in self-reported usual bedtime and wake time. These results suggest that a misalignment of sleep times with circadian preference could contribute to poorer sleep quality in elite athletes.

Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review.

OBJECTIVES: For physicians in independent practice, we synthesised evidence on the (1) impacts of insufficient sleep and fatigue on health and performance, and patient safety and (2) effectiveness of interventions targeting insufficient sleep and fatigue. DESIGN: We systematically reviewed online literature. After piloting, one reviewer selected studies by title and abstract; full texts were then reviewed in duplicate. One reviewer extracted data; another verified a random 10% sample. Two reviewers assessed risk of bias. We pooled findings via meta-analysis when appropriate or narratively. DATA SOURCES: We searched Medline, Embase, PsycINFO, CINAHL and PubMed for published studies in April 2016; Medline was updated in November 2017. We searched Embase for conference proceedings, and hand-searched meeting abstracts, association and foundation websites. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English or French language primary research studies published from 2000 to 2017 examining the effect of fatigue-related or sleep-related exposures or interventions on any outcome among physicians in independent practice and their patients. RESULTS: Of 16 154 records identified, we included 47 quantitative studies of variable quality. 28 studies showed associations between fatigue or insufficient sleep and physician health and well-being outcomes. 21 studies showed no association with surgical performance, and mixed findings for psychomotor performance, work performance and medical errors. We pooled data from six cohort studies for patient outcomes. For sleep deprived versus non-sleep deprived surgeons, we found no difference in patient mortality (n=60 436, relative risk (RR) 0.98, 95% CI 0.84 to 1.15, I2=0% (p=0.87)) nor postoperative complications (n=60 201, RR 0.99, 95% CI 0.95 to 1.03, I2=0% (p=0.45)). The findings for intraoperative complications and length of stay were considerably heterogeneous. CONCLUSIONS: Fatigue and insufficient sleep may be associated with negative physician health outcomes. Current evidence is inadequate to inform practice recommendations.

The Clinical Validation of the Athlete Sleep Screening Questionnaire: an Instrument to Identify Athletes that Need Further Sleep Assessment.

BACKGROUND: Previous research has established that general sleep screening questionnaires are not valid and reliable in an athlete population. The Athlete Sleep Screening Questionnaire (ASSQ) was developed to address this need. While the initial validation of the ASSQ has been established, the clinical validity of the ASSQ has yet to be determined. The main objective of the current study was to evaluate the clinical validity of the ASSQ. METHODS: Canadian National Team athletes (N = 199; mean age 24.0 ± 4.2 years, 62% females; from 23 sports) completed the ASSQ. A subset of athletes (N = 46) were randomized to the clinical validation sub-study which required subjects to complete an ASSQ at times 2 and 3 and to have a clinical sleep interview by a sleep medicine physician (SMP) who rated each subjects' category of clinical sleep problem and provided recommendations to improve sleep. To assess clinical validity, the SMP category of clinical sleep problem was compared to the ASSQ. RESULTS: The internal consistency (Cronbach's alpha = 0.74) and test-retest reliability (r = 0.86) of the ASSQ were acceptable. The ASSQ demonstrated good agreement with the SMP (Cohen's kappa = 0.84) which yielded a diagnostic sensitivity of 81%, specificity of 93%, positive predictive value of 87%, and negative predictive value of 90%. There were 25.1% of athletes identified to have clinically relevant sleep disturbances that required further clinical sleep assessment. Sleep improved from time 1 at baseline to after the recommendations at time 3. CONCLUSIONS: Sleep screening athletes with the ASSQ provides a method of accurately determining which athletes would benefit from preventative measures and which athletes suffer from clinically significant sleep problems. The process of sleep screening athletes and providing recommendations improves sleep and offers a clinical intervention output that is simple and efficient for teams and athletes to implement.

Evaluating the Effectiveness of Fatigue Management Training to Improve Police Sleep Health and Wellness: A Pilot Study.

OBJECTIVES: To evaluate the effectiveness of an intervention for improving sleep health in a sample of employees from the Royal Canadian Mounted Police (RCMP). METHODS: Using a pre- and post-design we exposed 61 RCMP members to a fatigue-management training program. Pre- and post-intervention surveys included the Pittsburg Sleep Quality Index (PSQI), the World Health Organization Quality of Life (WHOQOL) instrument, and the six item index of psychological distress (Symptom Checklist-90). RESULTS: We found the training improved member satisfaction with sleep (Wald = 2.58; df = 1; P = 0.03) and reduced symptoms of insomnia (Wald = 5.5; df = 1; P = 0.02). Furthermore, the training reduced the incidence of headaches (Wald = 6.5; df = 1; P = 0.01). CONCLUSIONS: Our findings suggest that a fatigue management training program resulted in positive sleep health benefits for police. We stress the importance of continued evaluation to inform the large-scale implementation of fatigue-management programs.

Insomnia symptoms and heart rate recovery among patients in cardiac rehabilitation.

Insomnia symptoms (i.e., difficulty falling asleep, difficulty staying asleep, and early morning awakenings) are common among people with cardiovascular disease, and have been linked to adverse cardiovascular health outcomes. Reduced parasympathetic tone is one pathway through which risk may be conferred. The purpose of this study was to evaluate whether insomnia symptoms are associated with lower parasympathetic tone in cardiac rehabilitation patients with suspected insomnia. Participants (N = 121) completed a self-report measure of insomnia severity. 1-min heart rate recovery (HRR), an index of parasympathetic tone, was obtained during a maximal exercise test. Difficulty falling asleep, but not difficulty staying asleep or early awakenings, was associated with attenuated 1-min HRR. When analyses were restricted to participants with moderate and severe insomnia severity (n = 51), the strength of this association increased. In a sample of cardiac rehabilitation patients with insomnia, only the symptom of difficulty falling asleep was associated with lower parasympathetic tone, suggesting that individual insomnia symptoms may show specificity in their associations with physiological mechanisms.

The Athlete Sleep Screening Questionnaire: a new tool for assessing and managing sleep in elite athletes.

BACKGROUND/AIM: The purpose of this study was to develop a subjective, self-report, sleep-screening questionnaire for elite athletes. This paper describes the development of the Athlete Sleep Screening Questionnaire (ASSQ). METHODS: A convenience sample of 60 elite athletes was randomly distributed into two groups; 30 athletes completed a survey composed of current psychometric tools, and 30 athletes completed a revised survey and a sleep specialist structured clinical interview. An item analysis was performed on the revised survey with comparison to clinical decisions regarding appropriate intervention based on a sleep specialist assessment. RESULTS: A comparison of existing sleep-screening tools with determination of clinical need from a sleep specialist showed low consistency, indicating that current sleep-screening tools are unsuitable for assessing athlete sleep. A new 15-item tool was developed (ASSQ) by selecting items from existing tools that more closely associated with the sleep specialist's reviews. Based on test-retest percentage agreement and the κ-statistic, we found good internal consistency and reliability of the ASSQ. To date, 349 athletes have been screened, and 46 (13.2%) identified as requiring follow-up consultation with a sleep specialist. Results from the follow-up consultations demonstrated that those athletes identified by the ASSQ as abnormal sleepers have required intervention. CONCLUSIONS: The research developed a new athlete-specific sleep-screening questionnaire. Our findings suggest that existing sleep-screening tools are unsuitable for assessing sleep in elite athletes. The ASSQ appears to be more accurate in assessing athlete sleep (based on comparison with expert clinical assessment). The ASSQ can be deployed online and provides clinical cut-off scores associated with specific clinical interventions to guide management of athletes' sleep disturbance. The next phase of the research is to conduct a series of studies comparing results from the ASSQ to blinded clinical reviews and to data from objective sleep monitoring to further establish the validity of the ASSQ as a reliable sleep screening tool for elite athletes.

The Comparative Impact of Mindfulness-Based Cancer Recovery (MBCR) and Cognitive Behavior Therapy for Insomnia (CBT-I) on Sleep and Mindfulness in Cancer Patients.

BACKGROUND: Insomnia is an important but often overlooked side effect of cancer. Dysfunctional sleep beliefs have been identified as an important perpetuating factor for insomnia. Mindfulness practice has been demonstrated to improve sleep quality but it is unknown whether these effects relate to changes in dysfunctional sleep beliefs. PURPOSE: This study is a secondary analysis of a randomized controlled trial comparing mindfulness-based cancer recovery (MBCR) to cognitive behavior therapy for insomnia (CBT-I) in cancer patients with insomnia. This present analysis compares program impact on mindfulness, dysfunctional sleep beliefs, and insomnia severity clinical cutoffs. METHODS: Patients (MBCR, n = 32; CBT-I, n = 40) were assessed at baseline, post-program, and 3-month follow-up. RESULTS: Across both groups, patients showed improvements over time in acting with awareness (P = .021) and not judging experiences (P = .023). Changes in dysfunctional sleep beliefs produced by the CBT-I group exceeded those produced by MBCR at post-program and follow-up (P < .001). Acting with awareness, non-judging, and non-reacting were the facets of mindfulness associated with an overall reduction in dysfunctional sleep beliefs. There were no significant differences between the MBCR and CBT-I groups in the percentage of patients exceeding insomnia severity clinical cutoffs at post-program or follow-up. CONCLUSIONS: This study supports the use of both CBT-I and MBCR to reduce insomnia severity and suggests the development of mindfulness facets as a method of reducing dysfunctional sleep beliefs.

Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial.

PURPOSE: Our study examined whether mindfulness-based stress reduction (MBSR) is noninferior to cognitive behavioral therapy for insomnia (CBT-I) for the treatment of insomnia in patients with cancer. PATIENTS AND METHODS: This was a randomized, partially blinded, noninferiority trial involving patients with cancer with insomnia recruited from a tertiary cancer center in Calgary, Alberta, Canada, from September 2008 to March 2011. Assessments were conducted at baseline, after the program, and after 3 months of follow-up. The noninferiority margin was 4 points measured by the Insomnia Severity Index. Sleep diaries and actigraphy measured sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency. Secondary outcomes included sleep quality, sleep beliefs, mood, and stress. RESULTS: Of 327 patients screened, 111 were randomly assigned (CBT-I, n = 47; MBSR, n = 64). MBSR was inferior to CBT-I for improving insomnia severity immediately after the program (P = .35), but MBSR demonstrated noninferiority at follow-up (P = .02). Sleep diary-measured SOL was reduced by 22 minutes in the CBT-I group and by 14 minutes in the MBSR group at follow-up. Similar reductions in WASO were observed for both groups. TST increased by 0.60 hours for CBT-I and 0.75 hours for MBSR. CBT-I improved sleep quality (P < .001) and dysfunctional sleep beliefs (P < .001), whereas both groups experienced reduced stress (P < .001) and mood disturbance (P < .001). CONCLUSION: Although MBSR produced a clinically significant change in sleep and psychological outcomes, CBT-I was associated with rapid and durable improvement and remains the best choice for the nonpharmacologic treatment of insomnia.