Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study.

BACKGROUND: Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls. OBJECTIVE: This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults. METHODS: Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point. RESULTS: Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes. CONCLUSION: These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

Insomnia Treatment Preferences Among Primary Care Patients.

PURPOSE: Sleep disturbance is common in primary care. The main treatment options include medication and cognitive behavioral therapy for insomnia. Best practice guidelines recommend a collaborative decision-making approach to treatment. This study examined differences in insomnia treatment preferences based on demographic and clinical characteristics among primary care patients. METHODS: A total of 200 patients (mean [SD] age, 54.92 [12.48] years) at a university medical center and community health clinic participated in brief screenings for insomnia, depression, anxiety, and insomnia treatment preference. Insomnia symptoms were measured with the Insomnia Severity Index, whereas depressive and anxiety symptoms were measured with the Patient Health Questionnaire 2 and Generalized Anxiety Disorder 2. χ2 analyses were performed to detect significant differences in preference between groups. FINDINGS: A total of 46.5% of participants preferred medication and 56.0% preferred behavioral treatment (ratings not exclusionary). Preference for behavioral treatment was highest among severe insomnia presentations (15.2% preferred to 4.5% disliked; P = 0.002). Medication preference was higher among patients with elevated anxiety (57.3% preferred to 42.7% disliked; P = 0.017). Preference for behavioral treatment (66.7% preferred to 33.3% disliked; P = 0.012) and medication (56.8% preferred to 43.2% disliked; P = 0.016) was highest among those with elevated depression. Treatment preference only differed by age for behavioral treatment (P = 0.008). Preference was highest among patients ≤51 years of age (67.2% preferred to 32.8% disliked). IMPLICATIONS: Primary care patients preferred behavioral and medication strategies for insomnia treatment. In addition, as mental health and sleep worsen, patients were more likely to prefer behavioral treatment. Knowledge of patient treatment preference may facilitate shared decision making, which increases patient satisfaction with care and engagement with treatment.

Pilot randomized clinical trial targeting anxiety sensitivity: effects on physical activity.

Anxiety sensitivity (AS)-the tendency to interpret anxiety as an aversive state-is associated with low rates of physical activity. Previous interventions targeting AS via exercise-based interoceptive exposure have not assessed physical activity as an outcome and are limited by brief follow-up periods. This study replicated and extended previous work by including a 6-week follow-up and assessing physical activity. Participants were 44 sedentary young adults with elevated AS randomized to intervention (six 20-minute sessions of moderate-intensity walking) or assessment-only control. Assessments of AS and physical activity were conducted at baseline and weeks 2 (post-treatment), 4, and 8. Between-group change in AS and physical activity over time was assessed using hierarchical linear modeling. The intervention condition demonstrated a marginally significant reduction in AS compared to control at week 4, which eroded by week 8. There were no significant between-group differences for change in physical activity. Findings indicate that a brief intervention might not be sufficient to produce lasting changes in AS or related exercise avoidance without additional treatment. Intervention effects were weaker than previous reports, which may be due to the greater racial/ethnic diversity of the current sample. Future research should objectively measure physical activity and explore individual variability in response.ClinicalTrials.gov identifier: NCT03128437.

Changes in Physician Telemedicine Use during COVID-19: Effects of Practice Setting, Demographics, Training, and Organizational Policies.

Telemedicine use increased during the COVID-19 pandemic, but uptake was uneven and future use is uncertain. This study, then, examined the ability of personal and environmental variables to predict telemedicine adoption during the COVID-19 pandemic. A total of 230 physicians practicing in the U.S. completed questions concerning personal and environmental characteristics, as well as telemedicine use at three time points: pre-pandemic, during the pandemic, and anticipated future use. Associations between use and characteristics were determined to identify factors important for telemedicine use. Physicians reported that telemedicine accounted for 3.72% of clinical work prior to the pandemic, 46.03% during the pandemic, and predicted 25.44% after the pandemic ends. Physicians within hospitals reported less increase in telemedicine use during the pandemic than within group practice (p = 0.016) and less increase in use at hospitals compared to academic medical centers (p = 0.027) and group practice (p = 0.008). Greater telemedicine use was associated with more years in practice (p = 0.009), supportive organizational policies (p = 0.001), organizational encouragement (p = 0.003), expectations of greater patient volume (p = 0.003), and perceived higher quality of patient care (p = 0.032). Characteristics such as gender, number of physicians, and level of telemedicine training were not significant predictors. Organizations interested in supporting physicians to adopt telemedicine should encourage its use and create policies supporting its use. More senior physicians had a greater degree of telemedicine uptake, while training programs did not predict use, suggesting that efforts to develop telemedicine competency in younger physicians may be ineffective and should be re-examined.

Posttraumatic stress in NICU mothers: modeling the roles of childhood trauma and infant health.

OBJECTIVE: To evaluate acute stress disorder (ASD) symptoms and their predictors in Neonatal Intensive Care Unit (NICU) mothers. STUDY DESIGN: In this cross-sectional study, 119 mothers (~72% Medicaid) completed surveys during the first month of their infants' hospitalizations. Correlations and structural equation models (SEMs) evaluated relations among mothers' childhood trauma history, infant health appraisals, objective infant health, and ASD. RESULT: ASD symptoms (~55%) and childhood trauma (~33%) were prevalent. ASD was correlated with childhood trauma, infant health, and infant health appraisals. All SEMs had good fit, indicating that (a) infant health appraisals partially mediated relations between childhood trauma and ASD, and (b) infant health appraisals fully mediated relations between objective infant health and ASD. CONCLUSION: ASD symptoms are prevalent among NICU mothers regardless of infant health severity. Recognition of childhood trauma history and appraisals of infant health is critical for trauma-informed care.

Models of Trauma Exposure, Depression, and Suicidality in Safety-Net Primary Care.

Suicidality is a major public health concern, particularly for low-income, trauma-exposed patients with limited access to mental health providers. However, limited research has modeled pathways of suicidality in safety-net primary care samples. Patients (N = 207) in a safety-net primary care clinic completed measures of childhood and adult trauma exposure, depression, and suicidality. Participants (M age = 44.8 years, SD = 11.6), were 60.4% male, 63.8% Black/African American, and predominantly low-income (i.e., 69.1% reported an annual income less than $5,000 USD). Half of the sample reported at least four childhood traumatic events (M = 3.9 events, SD = 3.0) and approximately three adult traumatic events (M = 3.0 events, SD = 2.1). Most participants (82.1%) reported significant depressive symptoms, and 43.5% endorsed recent suicidality. Models showing the mediational effect of depression on the association between trauma exposure and suicidality, ß = .20, B = 0.23, SE = 0.05, 95% CI [0.16, 0.32], and the moderational effect of trauma exposure on the association between depression and suicidality, ß = .16, B = 0.20, SE = 0.08, p = .007, were both supported. These results underscore the high prevalence of trauma exposure, depression, and suicidality in a safety-net primary care sample. They also highlight the pervasiveness and complexity of suicidality in low-income primary care patients, emphasize the importance of trauma-informed suicide assessment, and identify trauma sequelae and depression as potential treatment targets to reduce suicidality.

Racism, Mental Health, Healthcare Provider Trust, and Medication Adherence Among Black Patients in Safety-Net Primary Care.

There has been a growing research focus on social determinants to health disparities in general and medication adherence more specifically in low-income Black populations. The purpose of this study was to examine whether prior experiences of racism among Black patients in safety-net primary care indirectly predicts poor medication adherence through increased mental health symptoms and low healthcare provider trust. Two competing models were run whereby mental health leads to provider trust or provider trust leads to mental health in this multiple mediational chain. A group of 134 Black patients (76 men, average age 45.39 years) in a safety-net primary care clinic completed measures of these constructs. Results revealed that in the first model, mental health mediated the relationship between racism and provider trust, and provider trust mediated the relationship between mental health and medication adherence. All paths within this model were statistically significant, except the path between provider trust and medication adherence which approached significance. In the second model, provider trust and mental health significantly mediated the relationship between racism and medication adherence, and all direct and indirect paths were statistically significant, though the path between provider trust and medication adherence was omitted. These results may serve as catalysts to assess and attempt to mitigate specific minority-based stressors and associated outcomes within safety-net primary care settings.

Sleep Disturbance Mediates the Association Between Loneliness and Health in Older Americans.

BACKGROUND: As the research documenting loneliness as a risk factor for morbidity and mortality continues to grow, it becomes increasingly critical to understand the mechanics of this relationship. This study assessed whether sleep disturbance mediates the relationship between loneliness and health. METHOD: Data came from the 2006, 2010, and 2014 waves of the Health and Retirement Study, a longitudinal study of older Americans; participants ≥ 65 who completed the Psychosocial and Lifestyle Questionnaire in 2006 were included (n = 5067). Measures include the Hughes loneliness scales, a modified version of the Jenkins sleep scale, and self-reported health. Cross-lagged mediation models (i.e., path analysis) were used to model the relationships between loneliness, sleep disturbance, and self-reported health over the 8-year span. RESULTS: Loneliness predicted subsequent sleep disturbance, which in turn predicted subsequent self-reported health. Moreover, there was evidence of both direct and indirect effects (via sleep disturbance) of loneliness on self-reported health. These effects remained after controlling for demographics, isolation, and depression. CONCLUSION: Sleep disturbance partially mediates the relationship between loneliness and self-reported health over 8 years. These findings are not attributable to isolation or depression. Further research is necessary to develop and assess a more comprehensive model of how loneliness shapes health. This study indicates that targeting sleep disturbance may mitigate the health risks of loneliness in older Americans.

Predictors of Alcohol Use in Safety-Net Primary Care: Classism, Religiosity, and Race.

Class-based discrimination may impact problematic drinking in low-income populations, which may be buffered by personal religiosity. However, little is known how race may impact this association. The purpose of this study was to examine racial differences in the effect of class-based discrimination on problematic drinking as moderated by comfort with God and determine if there were conditional direct effects of class-based discrimination on problematic drinking by race. In this cross-sectional study, participants (N = 189) were patients of an urban, safety-net primary care clinic who completed questionnaires assessing experiences of class-based discrimination, attitudes toward God, and alcohol use. Data were collected from 2015 to 2016 and analyzed using the Hayes PROCESS macro. There was a significant main effect for class-based discrimination predicting problematic drinking. Two-way interaction analyses identified a significant comfort with God by race interaction with greater comfort with God associated with less problematic drinking among white but not black respondents. Conditional direct effects showed that experiences of class-based discrimination were associated with problematic drinking at low and moderate but not high levels of comfort with God in black participants, whereas none were observed for white participants. This study provides insight on how personal religiosity, class-based discrimination, and race may intertwine to shape problematic alcohol use in primarily low-income, urban patients. Clinicians' awareness of risk and protective factors, as well as how race tempers the effects of such factors, is vital in providing better care for this population.

Mindfulness training for healthcare professional students: A waitlist controlled pilot study on psychological and work-relevant outcomes.

OBJECTIVES: To fill gaps in the literature on the effects of mindfulness for healthcare professionals (HCPs), the current pragmatic trial investigated feasibility, acceptability, and effectiveness of Mindfulness for Interdisciplinary Healthcare Professional (MIHP) students on stress and work-relevant outcomes in the absence of offering school-based incentives. DESIGN: A partially randomized waitlist-controlled design (intention-to-treat sample: 22 in the mindfulness group, 26 in the control group) was employed. INTERVENTION: MIHP is an eight-week intervention that incorporates meditation training, yoga, and discussion on the application of mindfulness principles to stressors commonly faced by HCPs and students. MAIN OUTCOME MEASURES: Domains of feasibility and acceptability; Maslach Burnout Inventory and other validated measures of psychological functioning; cognitive task performance on the Trail Making Test A & B; and the Work Productivity and Activity Impairment plus Classroom Impairment Questionnaire. RESULTS: Results supported the feasibility and acceptability of MIHP but found randomization to be unacceptable. Small to large effects were found for MIHP, relative to the control group, on outcomes of burnout, perceived stress, mindfulness, and activity impairment. No effect of MIHP was found on cognitive performance or work productivity outcomes. CONCLUSIONS: Preferential group allocation improved retention relative to randomization in the absence of school-based incentives. Results suggest that MIHP is feasible and acceptable and may have benefit for improving mindfulness and reducing burnout, stress, and activity impairment. Cognitive performance, work absenteeism, and work impairment did not change following MIHP. Results support future investigations into the effects of participant compensation on MIHP's dissemination and effectiveness.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial.

BACKGROUND: Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. METHODS: We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. DISCUSSION: This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Rapid telepsychology deployment during the COVID-19 pandemic: A special issue commentary and lessons from primary care psychology training.

OBJECTIVE: This article positions the special issue on telepsychology amidst the COVID-19 pandemic, which has dramatically accelerated the adoption and dissemination of telepsychology. METHOD: The article makes general observations about the themes emerging in the special issue with considerations for application, training, theory-driven research, and policy. It then presents as a case example the rapid deployment during the pandemic of telepsychology doctoral training and services at the Virginia Commonwealth University (VCU) Primary Care Psychology Collaborative. RESULTS: Facilitators to VCU telepsychology deployment included trainee and supervisor resources, strong telepsychology training, and prior experience. Barriers to overcome included limited clinic capacity, scheduling, technology, and accessibility and diversity issues. Lessons learned involved presenting clinical issues, supervision, and working with children and adolescents. CONCLUSIONS: Telepsychology is crucial for psychological service provision, during the COVID-19 pandemic more than ever, and that is unlikely to change as psychologists and patients increasingly continue to appreciate its value.

Mental health and sleep disparities in an urban college sample: A longitudinal examination of White and Black students.

OBJECTIVE: Racial disparities in sleep may be consequential among college students given high rates of dysfunctional sleep among this population. The present study sought to investigate whether disparities in sleep explain existing mental health disparities. METHOD: Data included secondary analysis of a college risk behaviors and health study (n = 1242, mean age = 18.5). Race was dichotomized as White or Black, excluding all others, with participants completing measures of sleep at baseline and measures of depression and anxiety at follow-up 1 to 2 years later. RESULTS: Compared to White students, Black students were more likely to report lower rates of depression and anxiety, but poorer sleep outcomes. Mediation analyses revealed that sleep partially mediated (suppressed) the association between race and depressive and anxiety symptoms. CONCLUSIONS: Results indicate that disparities in sleep may play an important role in the association between race and mental health symptoms among college students. Future health disparity research would benefit from exploring the potentially bidirectional relationship between sleep and mental health symptoms among college students.

Psychosocial Underpinnings of Pain and Sleep Disturbance in Safety-Net Primary Care Patients.

Objective: The aim of this study was to uncover possible psychosocial underpinnings of pain and sleep disturbance in a safety-net primary care sample. Methods: Patients (n = 210) awaiting care in a safety-net primary care clinic waiting room completed measures of cynical hostility, social support, mental health, sleep disturbance, and pain. This study was cross-sectional and observational. Results: A structural equation model suggested that higher cynical hostility was associated with lower social support, which in turn was associated with poorer mental health, which then corresponded with higher pain and sleep disturbance. All possible indirect (mediational) effects within this model were statistically significant, suggesting a possible route through which cynical hostility may shape pain and sleep, two common presenting problems in primary care. Conclusions: These findings illustrate the interplay of psychosocial factors with chronic pain and sleep disturbance in a sample of low-income, predominantly African-American patients seeking care at a safety-net primary care clinic. The findings support integrated primary care as a way to target not only behavioral health issues but also the psychosocial factors entangled with physical health.

Loneliness and sleep: A systematic review and meta-analysis.

Despite the mounting evidence linking loneliness with health, the mechanisms underlying this relationship remain obscure. This systematic review and meta-analysis on the association between loneliness and one potential mechanism-sleep-identified 27 relevant articles. Loneliness correlated with self-reported sleep disturbance (r = .28, 95% confidence interval (.24, .33)) but not duration, across a diverse set of samples and measures. There was no evidence supporting age or gender as moderators or suggesting publication bias. The longitudinal relationship between loneliness and sleep remains unclear. Loneliness is related to sleep disturbance, but research is necessary to determine directionality, examine the influence of other factors, and speak to causality.

Night-to-night fluctuations in sleep apnea severity: diagnostic and treatment implications.

STUDY OBJECTIVES: Sleep apnea is a common disorder with serious consequences; however, effective treatments are available. Successful implementation of treatment strategies relies on accurate diagnosis, which may be hampered by the presence of substantial nightly fluctuation in sleep apnea severity. We examined the amount of nightly fluctuation in the severity of sleep apnea around commonly used diagnostic and treatment cut points in individuals who underwent two nights of home sleep apnea testing (HSAT). METHODS: A nationwide retrospective cohort study of adults thought to have sleep apnea underwent two nights of HSAT between 2005 and 2017. RESULTS: The study included 47,423 adults (mean age, 55.2 [14.6] years; 53.7% male). The average apnea-hypopnea index (AHI) for the sample was 26.9. The average amount of nightly fluctuation in AHI was 5.5. More than a third of the sample, 16,115 individuals, had fluctuations between diagnostic cut points across the two nights of HSAT. The negative predictive value of the HSAT in the first night was 47.42%, 73.57%, and 88.65% for detecting an AHI ≥ 5, AHI ≥ 15, and AHI ≥ 30, respectively. CONCLUSIONS: The addition of a second night of HSAT has the potential to reduce the likelihood of missed diagnoses that could result from nightly fluctuation in the severity of sleep apnea.

Isolation, Not Loneliness or Cynical Hostility, Predicts Cognitive Decline in Older Americans.

Objective: To jointly examine isolation, loneliness, and cynical hostility as risk factors for cognitive decline in older adults. Method: Data came from the 2006 to 2012 waves of the Health and Retirement Study (HRS), a longitudinal study of U.S. older adults (age ⩾ 65 years, n = 6,654). Measures included frequency of contact with social network (objective isolation), the Hughes Loneliness Scale (loneliness), a modified version of the Cook-Medley Hostility Inventory (cynical hostility), and a modified version of the Telephone Interview for Cognitive Status (cognitive function). Multilevel modeling (random slope + intercept) was used to examine the association between these factors and trajectories of cognitive function. Results and Discussion: After controlling for demographic characteristics, self-reported health, and functional limitations, loneliness (ß = -.34, 95% confidence interval [CI] = [-0.56, -0.11), and cynical hostility (ß = -.14, 95% CI = [-0.24, -0.04) correlated with lower cognitive function, but none predicted change in cognitive function. Objective social isolation was associated with lower cognitive function (ß = -.27, 95% CI = [-0.41, -0.12]) and steeper decline in cognitive function (ß = -.09, 95% CI = [-0.16, -0.01]).

Insomnia Disorder and Behaviorally Induced Insufficient Sleep Syndrome: Prevalence and Relationship to Depression in College Students.

Background: College students are at increased risk for sleep disorders, including insomnia disorder and obtaining less than 6.5 hr of sleep per night by choice, or behaviorally induced insufficient sleep syndrome (BIISS). These disorders can have deleterious daytime consequences, including depression. This study aims to establish the prevalence of insomnia and BIISS disorders and examine associations of insomnia and BIISS with other sleep characteristics and depression. Methods: A subset of data from Spit for Science, a college risk behaviors and health study (n = 989) was used. Insomnia and BIISS were defined as mutually exclusive disorders, based on diagnostic criteria. Results: A majority (68%) of students were categorized as normal sleepers, followed by insomnia (22%), and BIISS (10%). Sleep duration was comparable between BIISS and insomnia, while daytime sleepiness was significantly higher in BIISS, and sleep latency was longer in insomnia (m = 44 vs. m = 13 min). Insomnia was associated with the highest depression symptoms, followed by BIISS, and normal sleep, controlling for demographics. Insomnia was associated with twice the risk of moderate or higher depression compared to normal sleep (CI: 1.60, 2.70, p < .001). Conclusion: These findings highlight the sleep difficulties endemic to college populations. Further, this study provides the first prevalence estimation of BIISS in college students and the first comparison of insomnia and BIISS on sleep characteristics and depressive symptoms. This study underscores the importance of targeted screening and intervention to improve both sleep and depression in this vulnerable population.

Social determinants of sleep disturbance in safety-net primary care: unmet needs, classist discrimination, and anxiety.

BACKGROUND: The 3P model proposes that predisposing, precipitating, and perpetuating factors all play a role in sleep disturbance. OBJECTIVE: The purpose of the current study is to investigate social determinants of sleep disturbance by applying the 3P model to a safety-net primary care setting, specifically by evaluating the role of classism and unmet needs as precipitating factors for sleep disturbance, and anxiety as a perpetuating factor for sleep disturbance. METHODS: Participants (N = 210) were a convenience sample of racially/ethnically diverse adults over the age of 18 (age M = 44.7 years) recruited from a safety-net primary care clinic in an urban area. The study employed a cross-sectional design. Participants completed a survey assessing sleep disturbances, anxiety, unmet needs, classism, social support, and a researcher-generated demographic form. RESULTS AND CONCLUSIONS: The unmet need for affordable long-term housing and greater experiences of classism were associated with more sleep disturbance, suggesting that both acted as precipitating factors. In a structural equation model with adequate fit indices, anxiety mediated the relationships with sleep disturbance for both the unmet need for affordable long-term housing and classism, suggesting that it serves as a perpetuating factor. Medical providers are recommended to explore these potential needs in safety-net primary care when patients present with sleep disturbance or anxiety. Assisting with connections to long-term housing and helping patients counteract and cope with classist discrimination may be effective in improving sleep in safety-net primary care.

Reciprocal Effects Between Loneliness and Sleep Disturbance in Older Americans.

Objectives: To model the relationship between loneliness and sleep disturbance over time. Method: Data came from the Health and Retirement Study (2006, 2010, 2014 waves; age ≥ 65 years; n = 5,067). Loneliness was measured via the Hughes Loneliness Scale and sleep disturbance via a four-item scale assessing sleep and restedness. Cross-lagged panel modeling (path analysis) was used to jointly examine reciprocal effects between loneliness and sleep disturbance. Results: Higher loneliness correlated with higher sleep disturbance at baseline. There was evidence of reciprocal effects between loneliness and sleep across timepoints. These associations overall remained when accounting for demographics, objective isolation, and depression. Discussion: Although causality cannot be established, the findings indicate that the relationship between loneliness and sleep disturbance is bidirectional. This requires revision to the current theory on sleep disturbance as a mechanism for the relationship between loneliness and health and indicates that effective treatment of sleep disturbance may reduce loneliness.