Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial.

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.

Internal consistency reliability of mental health questionnaires in college student athletes.

OBJECTIVES: To examine the internal consistency reliability and measurement invariance of a questionnaire battery designed to identify college student athletes at risk for mental health symptoms and disorders. METHODS: College student athletes (N=993) completed questionnaires assessing 13 mental health domains: strain, anxiety, depression, suicide and self-harm ideation, sleep, alcohol use, drug use, eating disorders, attention deficit hyperactivity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD), gambling and psychosis. Internal consistency reliability of each measure was assessed and compared between sexes as well as to previous results in elite athletes. Discriminative ability analyses were used to examine how well the cut-off score on the strain measure (Athlete Psychological Strain Questionnaire) predicted cut-offs on other screening questionnaires. RESULTS: Strain, anxiety, depression, suicide and self-harm ideation, ADHD, PTSD and bipolar questionnaires all had acceptable or better internal consistency reliability. Sleep, gambling and psychosis questionnaires had questionable internal consistency reliability, although approaching acceptable for certain sex by measure values. The athlete disordered eating measure (Brief Eating Disorder in Athletes Questionnaire) had poor internal consistency reliability in males and questionable internal consistency reliability in females. CONCLUSIONS: The recommended mental health questionnaires were generally reliable for use with college student athletes. To truly determine the validity of the cut-off scores on these self-report questionnaires, future studies need to compare the questionnaires to a structured clinical interview to determine the discriminative abilities.

Shift Work Disorder Index: initial validation and psychosocial associations in a sample of nurses.

STUDY OBJECTIVES: Shift work is common yet does not always result in Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)-defined shift work sleep disorder (SWD). This study reports on the reliability and validity of the DSM-5 informed Shift Work Disorder Index (SWDI), the presence of probable SWD in nurses, and demographic, sleep, and psychosocial correlates. METHODS: Nurses (n = 454) completed the SWDI, psychosocial, and demographic questionnaires. Of the sample, n = 400 completed 14 days of sleep diaries, actigraphy, and additional questionnaires. RESULTS: The global SWDI demonstrated excellent internal consistency (α = .94), as well as good convergent and divergent validity in the nurse sample. Thirty-one percent of nurses were past-month shift workers, with 14% (ie, 44% of shift workers) having probable SWD based on SWDI. Nurses who worked shift work and/or met SWD criteria were more likely to be younger and unmarried and less likely to have children than day workers and reported greater evening chronotype, insomnia, nightmares, and sleep-related impairment, greater depression, anxiety, posttraumatic stress, and perceived stress symptoms, as well as later and more variable sleep midpoint (actigraphy), shorter sleep duration (actigraphy, diaries), and lower sleep efficiency (diaries). CONCLUSIONS: The SWDI is an efficient and valid self-report assessment of DSM-5-defined SWD. Shift work and/or SWD were prevalent and associated with worse sleep and psychosocial health, particularly among nurses with probable SWD. CITATION: Taylor DJ, Dietch JR, Wardle-Pinkston S, et al. Shift Work Disorder Index: initial validation and psychosocial associations in a sample of nurses. J Clin Sleep Med. 2022;18(10):2339-2351.

Sleep disorder symptoms are associated with greater posttraumatic stress and anger symptoms in US Army service members seeking treatment for posttraumatic stress disorder.

STUDY OBJECTIVES: Characterize associations between sleep impairments and posttraumatic stress disorder (PTSD) symptoms, including anger, in service members seeking treatment for PTSD. METHODS: Ninety-three US Army personnel recruited into a PTSD treatment study completed the baseline assessment. State-of-the-science sleep measurements included 1) retrospective, self-reported insomnia, 2) prospective sleep diaries assessing sleep patterns and nightmares, and 3) polysomnography measured sleep architecture and obstructive sleep apnea-hypopnea severity. Dependent variables included self-report measures of PTSD severity and anger severity. Pearson correlations and multiple linear regression analyses examined if sleep symptoms, not generally measured in PTSD populations, were associated with PTSD and anger severity. RESULTS: All participants met PTSD, insomnia, and nightmare diagnostic criteria. Mean sleep efficiency = 70%, total sleep time = 5.5 hours, obstructive sleep apnea/hypopnea (obstructive sleep apnea-hypopnea index ≥ 5 events/h) = 53%, and clinically significant anger = 85%. PTSD severity was associated with insomnia severity (ß = .58), nightmare severity (ß = .24), nightmare frequency (ß = .31), and time spent in Stage 1 sleep (ß = .27, all P < .05). Anger severity was associated with insomnia severity (ß = .37), nightmare severity (ß = .28), and obstructive sleep apnea-hypopnea during rapid eye movement sleep (ß = .31, all P < .05). CONCLUSIONS: Insomnia and nightmares were related to PTSD and anger severity, and obstructive sleep apnea-hypopnea was related to anger. Better assessment and evidence-based treatment of these comorbid sleep impairments in service members with PTSD and significant anger should result in better PTSD, anger, and quality-of-life outcomes. CLINICAL TRIALS REGISTRATION: Registry: ClinicalTrials.gov; Name: Treatment of Comorbid Sleep Disorders and Post Traumatic Stress Disorder; Identifier: NCT02773693; URL: https://clinicaltrials.gov/ct2/show/NCT02773693. CITATION: Miles SR, Pruiksma KE, Slavis D, et al. Sleep disorder symptoms are associated with greater posttraumatic stress and anger symptoms in US Army service members seeking treatment for posttraumatic stress disorder. J Clin Sleep Med. 2022;18(6):1617-1627.

Web-based provider training of cognitive behavioral therapy of insomnia: engagement rates, knowledge acquisition, and provider acceptability.

Insomnia is common but severely underreported and undertreated. One possible reason for this problem is the lack of providers in cognitive behavioral therapy for insomnia (CBT-I). To address this we created CBTIweb.org, an online training platform for providers to learn the basics of sleep, assessing insomnia, and CBT-I. The present study assessed the reach of CBTIweb by examining engagement, knowledge acquisition, and perceived acceptability. Participants who registered for CBTIweb self-reported their practice setting and personal characteristics (i.e. degree, profession, licensure status). Knowledge acquisition was assessed with pre- and post-tests, and provider acceptability was assessed via a survey. In the first three months after launching CBTIweb, 2586 providers registered and 624 of these completed the training within three months of registering. Chi-square tests of independence revealed no differences in completion rates by education or profession, though trainees were more likely to initiate and complete treatment than licensed providers. Paired t tests revealed significant knowledge acquisition, and most providers positively rated the website navigation, content, aesthetics, and understanding of core CBT-I skills. This study demonstrated CBTIweb is an effective platform for training health professionals to be minimally proficient in the gold standard treatment for insomnia disorder.

Developing and Testing a Web-Based Provider Training for Cognitive Behavioral Therapy of Insomnia.

INTRODUCTION: Chronic insomnia is a common and debilitating disease that increases risk for significant morbidity and workplace difficulties. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment, but there is a critical lack of behavioral health providers trained in CBT-I because, in part, of a bottleneck in training availability and costs. The current project developed and evaluated a web-based provider training course for CBT-I: CBTIweb.org. MATERIALS AND METHODS: Subject matter experts developed the content for CBTIweb.org. Then, trainees completed alpha testing (n = 24) and focus groups, and the site was improved. Next, licensed behavioral health providers and trainees completed beta testing (n = 41) and the site underwent another round of modifications. Finally, to compare CBTIweb.org to an in-person workshop, licensed behavioral health providers were randomly assigned to CBTIweb.org (n = 21) or an in-person workshop (n = 23). All participants were CBT-I naïve and completed the following assessments: Computer System Usability Questionnaire, Website Usability Satisfaction Questionnaire, Website Content Satisfaction Questionnaire, and Continuing Education knowledge acquisition questionnaires. RESULTS: Alpha and beta testers of CBTIweb.org reported high levels of usability and satisfaction with the site and showed significant within-group knowledge acquisition. In the pilot comparison study, linear fixed-effects modeling on the pre-/postquestionnaires revealed a significant main effect for time, indicating a significant increase in knowledge acquisition from 69% correct at baseline to 92% correct at posttraining collapsed across in-person and CBTIweb.org groups. The interaction effect of Time by Condition was nonsignificant, indicating equivalence in knowledge gains across both groups. CONCLUSION: CBTIweb.org appears to be an engaging, interactive, and concise provider training that can be easily navigated by its users and produce significant knowledge gains that are equivalent to traditional in-person workshops. CBTIweb.org will allow for worldwide dissemination of CBT-I to any English-speaking behavioral health providers. Future research will work on translating this training to other languages and extending this web-based platform to the treatment of other sleep disorders (e.g., nightmares) and populations (e.g., pediatric populations with insomnia).

Age-dependent associations among insomnia, depression, and inflammation in nurses.

OBJECTIVE: Insomnia and depression have been inconsistently associated with inflammation. Age may be one important moderator of these associations. This study examined associations between insomnia and depression with inflammatory biomarkers in nurses and how these associations varied by age. Design: Participants were 392 nurses ages 18-65 (Mage = 39.54 years ± 11.15, 92% female) recruited from two hospitals. Main outcome measures: Participants completed surveys to assess insomnia and depression symptoms. Serum samples were obtained and analysed for inflammatory biomarkers interleukin-6 (IL-6), C-reactive protein (CRP), interleukin-1 beta (IL-1ß), and tumour necrosis factor alpha (TNF-α). Results: Neither insomnia nor depression symptoms were associated with inflammatory biomarkers. Older age was associated with higher IL-1ß, and age moderated the effects of depression symptoms on CRP and TNF-α: Greater depression symptoms were associated with higher CRP (b = .14, p = .017) and TNF-α (b = .008, p = .165) among older nurses only. Conclusion: Results suggest older nurses with higher depression symptoms may be at increased risk for elevated inflammation. Interventions should consider the role of age-related processes in modifying health and well-being. Given relatively low levels of depression in the current sample, future studies should replicate results in clinical and non-nurse samples.

The Nightmare Disorder Index: development and initial validation in a sample of nurses.

STUDY OBJECTIVES: Nurses are a group at high risk for nightmares, yet little is known about the rate of nightmare disorder and associated psychosocial factors in this group in part attributable to the lack of a self-report questionnaire to assess DSM-5 criteria for nightmare disorder. Aims of the current study were to (1) report on development and initial validity of a self-report measure of DSM-5 nightmare disorder, and (2) examine the rate and associated factors of nightmare disorder among nurses. METHODS: Nurses (N = 460) completed baseline measures online including Nightmare Disorder Index (NDI), psychosocial and demographic questionnaires. A subset (n = 400) completed 14 days of sleep diaries and actigraphy. RESULTS: NDI demonstrated satisfactory psychometric characteristics as indicated by good internal consistency (α = 0.80), medium inter-item correlations (r = 0.50), medium to large item-total (r = 0.55-0.85) and convergent correlations (0.32-0.45), and small to medium discriminant correlations (-0.12-0.33). Per NDI, 48.7% of nurses reported no nightmares in the past month, 43.9% met partial/subthreshold criteria and 7.4% met full criteria for probable nightmare disorder. Nurses with nightmare disorder demonstrated significantly poorer psychosocial functioning (i.e. posttraumatic stress, depression, anxiety, stress) than those with subthreshold nightmare symptoms, who had poorer functioning than those with no nightmares. CONCLUSIONS: NDI is an efficient and valid self-report assessment of nightmare disorder. Nurses have high rates of nightmares and nightmare disorder which are associated with poorer psychosocial functioning. We recommend increased nightmare screening particularly for high-risk populations such as healthcare workers.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in active duty military: Design and methodology of a randomized clinical trial.

Many individuals with posttraumatic stress disorder (PTSD) also suffer from insomnia and nightmares, which may be symptoms of PTSD or constitute partially independent comorbid disorders. Sleep disturbances are resistant to current treatments for PTSD, and those suffering from PTSD, insomnia, and nightmares have worse PTSD treatment outcomes. In addition, insomnia and nightmares are risk factors for depression, substance abuse, anxiety, and suicide. Cognitive-Behavioral Therapy for Insomnia and Nightmares (CBT-I&N) and Cognitive Processing Therapy (CPT) for PTSD are first line treatments of these conditions. CPT does not typically address insomnia or nightmares, and CBT-I&N does not typically address other symptoms of PTSD. There are limited scientific data on how best to provide these therapies to individuals suffering with all three disorders. This project aims to inform the most effective way to treat individuals suffering from PTSD, insomnia, and nightmares, potentially changing the standard of care. U.S. military personnel and recently discharged Veterans who served in support of combat operations following 9/11 aged 18-65 with PTSD, insomnia, and nightmares (N = 222) will be randomly assigned to one of the following 18-session individual treatment conditions delivered over 12-weeks: (1) 6 sessions of CBT-I&N followed by 12 sessions of CPT; (2) 12 sessions of CPT followed by 6 sessions of CBT-I&N; or (3) 12 sessions of CPT followed by an additional 6 sessions of CPT. All participants will be assessed at baseline, during treatment, and at 1-week, 1-month, 3-months, and 6-months posttreatment. The primary outcome will be PTSD symptom severity.

Intraindividual Variability in Sleep and Levels of Systemic Inflammation in Nurses.

OBJECTIVE: Disturbed sleep is common among nurses and is associated with morbidity and mortality. Inflammation may be one mechanism linking sleep and disease. However, most studies rely on retrospective questionnaires to assess sleep, which fail to account for night-to-night fluctuations in sleep across time (i.e., intraindividual variability [IIV]). We examined prospective associations between mean and IIV in sleep with inflammation markers in nurses. METHODS: Participants were 392 nurses (mean age = 39.54 years, 92% female, 23% night-shift working) who completed 7 days of sleep diaries and actigraphy to assess mean and IIV in total sleep time and sleep efficiency. Blood was drawn on day 7 to assess inflammation markers C-reactive protein, interleukin (IL)-6, tumor necrosis factor α, and IL-1ß. RESULTS: Greater IIV in total sleep time-measured via both actigraphy and sleep diary-was associated with higher IL-6 (actigraphy: b = 0.05, p = .046, sr = 0.01; diary: b = 0.04, p = .030, sr = 0.01) and IL-1ß (actigraphy: b = 0.12, p = .008, sr = 0.02; diary: b = 0.09, p = .025, sr = 0.01), but not C-reactive protein or tumor necrosis factor α. IIV in actigraphy- and sleep diary-determined sleep efficiency was not associated with inflammation biomarkers, nor were any mean sleep variables. Shift work did not moderate any associations. CONCLUSIONS: Nurses with more variable sleep durations had elevated levels of inflammation, which may increase risk for development of inflammatory-related diseases. Research should investigate how sleep regularization may change levels of inflammation and improve health.

A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel.

STUDY OBJECTIVES: The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares. METHODS: Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up. RESULTS: Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians. CONCLUSIONS: ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.

Insomnia and cognitive performance: A systematic review and meta-analysis.

Cognitive performance has been extensively investigated in relation to insomnia, yet review of the literature reveals discrepant findings. The current study aimed to synthesize this literature with a systematic review and meta-analysis. 48 studies (k = 50 independent samples, n = 4539 total participants) met inclusion criteria. Omnibus meta-analysis revealed insomnia was associated with poorer overall cognitive performance (Hedge's g = -0.24, p < 0.001). Analyses by cognitive domain revealed insomnia was specifically associated with impairments in subjective cognitive performance (g = -0.35), and objective measures of perceptual function (g = -0.24), manipulation (g = -0.52) and retention/capacity in working memory (g = -0.30), complex attention (g = -0.36), alertness (g = -0.14), episodic memory (g = -0.29), and problem solving in executive functions (g = -0.39). Age, percent female, publication year, and insomnia measure did not consistently moderate findings. Approximately 44% of studies failed to use diagnostic criteria when categorizing insomnia and cognitive measures varied widely. This indicates a need for standardization of methods assessing insomnia and cognitive performance in research. Overall, findings from this meta-analysis indicate insomnia is associated with impairment in objective and subjective cognitive performance, highlighting the utility of treating insomnia to potentially improve cognitive outcomes.