"Start to stop": results of a randomised controlled trial of a smoking cessation programme for teens.

OBJECTIVE: To examine the feasibility, acceptability, and effectiveness of a school based smoking cessation programme among students caught smoking at school. DESIGN: A randomised controlled trial comparing cessation rates among students in a behavioural cessation programme and those receiving self help materials only. SETTING: Eighteen schools in the Memphis, Tennessee area. SUBJECTS: Two hundred and sixty one adolescent cigarette smokers (166 male, 95 female) averaging 15.8 years of age. INTERVENTION: Students assigned to the intervention received a four session behavioural treatment programme administered individually by a health educator. In addition, these students received stage matched intervention in brief phone calls monthly until the one year follow up. MAIN OUTCOME MEASURE: Self reported and biochemically verified smoking cessation at post-test and 12 month follow up. RESULTS: Recruiting students who were caught smoking at school proved to be highly successful. Participants rated the programme favourably, and retention rates were high. Although treated participants improved more in tobacco related knowledge relative to controls (p = 0.002), there were no group differences in changes in attitudes toward smoking. In addition, treated and control participants demonstrated no significant differences in cessation rates both at post-test and follow up. Comparisons between self reported cessation rates and those obtained under bogus pipeline conditions or with biochemical verification suggested significant falsification of cessation among participants. CONCLUSIONS: Our results failed to demonstrate any significant effect of the cessation programme on smoking rates for treated adolescents compared with controls. Our findings also highlight the importance of utilising strong methodology in research on adolescent smoking cessation, including control groups and biochemical verification of smoking status.

Quantitative criteria for insomnia.

Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (> or =3 nights a week) and duration (> or =6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity-specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) > or =31 min; (b) occurring > or =3 nights a week; (c) for > or =6 months are the most defensible quantitative criteria for insomnia.

Primary versus secondary insomnia in older adults: subjective sleep and daytime functioning.

Most psychological research on insomnia has centered on primary insomnia (PI). Secondary insomnia (SI), though more common than PI, has received little attention because of its presumed unresponsiveness to treatment. The present study recruited older adults with PI, SI, and a comparison group of older adults with no insomnia (NI). Self-report assessments of sleep revealed no significant difference between the 2 insomnia groups. Daytime functioning measures found significant differences in impairment between the 3 groups with SI having the worst daytime functioning, followed by PI, which was worse than NI. Further analyses found substantial independence between sleep and daytime functioning. Implications of these findings for the clinical management of SI are discussed.

Relaxation and sleep compression for late-life insomnia: a placebo-controlled trial.

Older adults with insomnia were recruited from the community and randomized to treatments: relaxation, sleep compression, and placebo desensitization. Questionnaire data collected at baseline, posttreatment, and 1-year follow-up and polysomnography data collected at baseline and follow-up yielded the following conclusions: All treatments improved self-reported sleep, but objective sleep was unchanged. Clinical significance analyses yielded the strongest findings supporting the active treatments and suggested that sleep compression was most effective. Results partially supported the conclusion that individuals with high daytime impairment (i.e., fatigue) respond best to treatments that extend sleep, as in relaxation, and individuals with low daytime impairment respond best to treatments that consolidate sleep, as in sleep compression. Strong methodological features including a placebo condition and a treatment implementation scheme elevate the confidence due these findings.

First night effect and reverse first night effect in older adults with primary insomnia: does anxiety play a role?

Objective: The main objective was to examine first night effect (FNE) and reverse first night effect (RFNE) in older insomniacs and the role played by anxiety in these processes.Background: RFNE has been documented in a middle-aged sample of insomniacs, but little research has been done on RFNE or FNE in older insomniacs. Also, a relationship between anxiety and FNE has not been established.Methods: Participants were 77 older adults with primary insomnia (57 females, 20 males). Two consecutive nights of polysomnography (PSG) were conducted, and the state form of the State-Trait Anxiety Inventory was completed each night. Sleep diaries were completed the morning after each (PSG) and for 2 weeks at home.Results: Most participants exhibited a FNE (57%) rather than a RFNE (26%). State anxiety was elevated on PSG night 1 relative to PSG night 2 in the FNE group but not the RFNE group, and the FNE group reported greater home total sleep time. Among FNE participants, self-reported total sleep and sleep efficiency were significantly higher on PSG night 2 than at home.Conclusions: Most older insomniacs show a FNE, but a portion exhibit a RFNE. Elevated anxiety on PSG night 1 may play a role in FNE.

Strategies for evaluating adherence to sleep restriction treatment for insomnia.

The methodology of assessing adherence to sleep restriction therapy for insomnia has received little attention in the empirical literature. The present study proposes and evaluates several approaches to assessing adherence to sleep restriction. We investigated multiple methods of measuring adherence and tested their utility by determining the strength of their association with treatment outcome in a sample of 22 older adults with insomnia (16 women, six men). As a group, the measures indicated reasonably good adherence to treatment recommendations. Time spent in bed was significantly reduced at post-treatment, and the night to night consistency of time spent in bed and arising time was significantly greater at post-treatment. However, time spent in bed per night at post-treatment still exceeded therapist recommendations by a mean of 27.89 min (SD=31.72). Greater consistency of time spent in bed per night and a more consistent arising time predicted a better treatment outcome. Measures of degree of bedtime reduction did not predict treatment outcome.

The Mackworth Clock Test: a computerized version.

The Mackworth Clock Test (MCT; N. H. Mackworth, 1948) was developed to evaluate vigilance in British Air Force radar technicians during World War II. Homemade versions of the MCT have since varied with respect to both the characteristics of the device and the procedures of its administration. This article is a report on a computerized version of the MCT developed by the authors to closely emulate Mackworth's test. MCT data were collected from 25 undergraduate students; their performance was found to be equivalent to Mackworth's participants' data. This is the first MCT version that has been validated against the original.

Relaxation to assist sleep medication withdrawal.

This study explores the usefulness of relaxation and gradual medication withdrawal in weaning insomniacs from sleep (hypnotic) medication. We recruited 40 volunteers from the community who had insomnia, half of whom were chronic users of hypnotics while the other half were nonmedicated. Half of all participants (10 medicated and 10 nonmedicated) received progressive relaxation. All medicated participants received a standard gradual drug withdrawal program. Medicated participants reduced sleep medication consumption by nearly 80%. Participants who received relaxation obtained additional benefits in sleep efficiency, rated quality of sleep, and reduced withdrawal symptoms. Medicated and nonmedicated participants attained comparable, improved sleep by posttreatment and follow-up. Hypnotic withdrawal was accompanied by serious worsening of insomnia, but this dissipated by the end of the withdrawal period. The psychological treatment of hypnotic-dependent insomnia has high potential for making an important clinical contribution.

Occult sleep apnea in a recruited sample of older adults with insomnia.

Although costly polysomnography (PSG) is not routinely performed with people with insomnia, it may be more necessary with recruited older adults with insomnia because this population may pose a greater risk of veiled sleep disorders compared with younger age groups and with referred samples. The present PSG screening of a recruited sample of older adults with insomnia found a 29%-43% rate of undiagnosed sleep apnea (SA), depending on whether an apnea-hypopnea index of 15 or 5 was used, after interviews had already screened out obvious cases of SA. Also, PSGs revealed a 4% rate of occult periodic limb movements. A discriminant analysis identified overweight men reporting dry mouth at highest risk for occult SA, with an apnea-versus-insomnia classification success rate of 78%. Using PSG evaluations in research on insomnia in recruited older adults is requisite to preclude substantial representation of occult SA.

Objective sleep measures and subjective sleep satisfaction: how do older adults with insomnia define a good night's sleep?

The relationship between objective sleep measures and subjective sleep satisfaction was explored in a sample of 47 older adults (59 years and older; 35 women, 12 men) with primary insomnia. Participants submitted to all-night sleep evaluations (polysomnography) for 2 nights. After each night, participants provided subjective sleep-satisfaction ratings. Depth of sleep (decreased Stage 1 sleep and increased Stages 3 and 4 sleep) and sleep latency were the best predictors of subjective sleep satisfaction. For other sleep variables such as sleep efficiency and wake time after sleep onset, no value predicted satisfaction on a particular night. However, for these sleep variables, relative improvement from Night 1 to Night 2 predicted greater subjective satisfaction.

Daytime functioning in obstructive sleep apnea patients: exercise tolerance, subjective fatigue, and sleepiness.

A sample of 32 obstructive sleep apnea patients (27 males, 5 females) was assessed with overnight polysomnography and the Multiple Sleep Latency Test (MSLT), an objective measure of daytime sleepiness. Patients also participated in a maximal exercise test, which served as an objective indicator of physical fatigue. The Fatigue Severity Scale (FSS) was used as a subjective measure of fatigue. Subjective fatigue ratings were significantly correlated with percent of predicted maximum heart rate achieved during exercise testing, suggesting that self-reported fatigue in apnea patients may refer to reduced physical fitness. FSS scores and exercise testing results were not significantly correlated with the MSLT, indicating that daytime fatigue and daytime sleepiness are independent problems in apnea patients. Participants self-reported a high level of fatigue, and exercise testing revealed decreased physical work capacity among apnea patients, but objective and subjective indicators of fatigue were not significantly correlated with apnea severity. A higher percentage of REM sleep predicted greater work capacity.

Sleep compression and sleep education for older insomniacs: self-help versus therapist guidance.

A treatment package consisting of a bed-time restriction strategy and education was administered to 50 insomniacs and 50 noninsomniacs 60 years or older. Half of the insomniacs and noninsomniacs received treatment through a self-help video only, whereas the remaining treated participants received therapist guidance to supplement the video. A waiting-list control group of 25 senior insomniacs was also included. Sleep knowledge was equivalent for senior insomniacs and noninsomniacs. The self-help insomniac group exhibited improvement on multiple sleep variables, but the addition of therapist guidance appeared to enhance treatment outcome for sleep latency, wake time after sleep onset, and sleep satisfaction. Control participants also improved across time but were generally outperformed by treated insomniacs.