Effect of cognitive behavioural therapy and yoga for generalised anxiety disorder on sleep quality in a randomised controlled trial: the role of worry, mindfulness, and perceived stress as mediators.

Sleep disturbances are present in ~65% of individuals with generalised anxiety disorder (GAD). Although both Kundalini yoga (KY) and cognitive behavioural therapy (CBT) are effective treatment options for GAD, little is known about how these treatments compare in improving sleep for GAD and what drives these changes. Accordingly, we examined the effects of CBT, KY, and stress education (SEdu; an attention control condition) on subjective sleep quality (as measured by the Pittsburgh Sleep Quality Index [PSQI] and Insomnia Severity Index [ISI]) in a randomised controlled trial of 226 adults with GAD (mean age 33.37 years; 70% female; 79% White). We hypothesised that both CBT and KY would outperform SEdu in improving sleep disturbances. Three potential mediators of sleep improvement (worry, mindfulness, perceived stress) were also examined. In line with hypotheses, PSQI and ISI scores significantly improved from pre- to post-treatment for all three treatment groups (all p < 0.001, all d > 0.97). However, contrary to predictions, sleep changes were not significantly greater for CBT or KY compared to SEdu. In mediation analyses, within-person deviations in worry, mindfulness, and stress each significantly mediated the effect of time on sleep outcomes. Degree of change in sleep attributable to worry (CBT > KY > SEdu) and perceived stress (CBT, KY > SEdu) was moderated by treatment group. Personalised medicine as well as combined treatment approaches should be studied to help reduce sleep difficulties for patients with GAD who do not respond.

In natura heart rate variability predicts subsequent alcohol use in individuals in early recovery from alcohol use disorder.

Impairment in autonomic self-regulatory functioning reflected by reduced heart rate variability (HRV) is a common feature of alcohol use disorder (AUD) and is believed to heighten AUD relapse risk. However, to date, no study has explored associations between in natura HRV and subsequent alcohol use among individuals seeking AUD recovery. In this study, 42 adults in the first year of a current AUD recovery attempt were monitored for 4 days using ambulatory electrocardiogram, followed by 90 days of alcohol use monitoring using timeline follow-back. HRV indices (independent variables) reflecting autonomic neurocardiac engagement were calculated from electrocardiogram recordings. Alcohol use (dependent variable) was calculated from timeline follow-back and expressed as per cent days abstinent (PDA). The sample was 73.81% White/European American, 19.05% Black/African American, 4.76% Asian, and 2.38% Other race/Mixed race. As predicted, higher parasympathetically mediated HRV and lower heart rate were associated with greater PDA over 90-day follow-up. Additionally, interactions between these measures and baseline PDA indicated higher parasympathetically mediated HRV and lower heart rate mitigated the deleterious positive association between baseline and follow-up alcohol use. Including factors known to influence alcohol use and/or HRV in the models did not meaningfully alter their results. Findings are consistent with psychophysiological theories implicating autonomic self-regulatory functioning in AUD treatment outcomes and suggest that select HRV indices may have utility as indicants of risk for alcohol use lapse in individuals in early AUD recovery. Findings provide theoretical support for HRV Biofeedback for this population, which exercises the psychophysiological systems that support self-regulation.

Treatment-related changes in insomnia, anticipatory pleasure, and depression symptoms: A proof-of-concept study with cancer survivors.

OBJECTIVE/BACKGROUND: Cancer survivors have elevated rates of insomnia and depression. Insomnia increases risk for depression onset, and the Integrated Sleep and Reward (ISR) Model suggests that impairments in reward responding (e.g., ability to anticipate and/or experience pleasure) plays a central role in this relationship. Cognitive behavioral therapy for insomnia (CBT-I) is efficacious for treating chronic insomnia and reducing depression in cancer survivor populations. The effects of CBT-I on anticipatory and consummatory pleasure are theoretically and clinically meaningful, yet remain unexamined. PATIENTS/METHODS: This secondary analysis of a pilot RCT (N = 40 cancer survivors with insomnia) explicated changes in anticipatory and consummatory pleasure and depression symptoms following a 4-session, synchronous, virtual CBT-I program versus enhanced usual care (referral to a behavioral sleep medicine clinic + sleep hygiene handout). Linear mixed models examined changes in anticipatory and consummatory pleasure and depression symptoms as predictors of changes in insomnia severity from baseline to post-intervention and 1-month follow-up. RESULTS: CBT-I buffered against deterioration in anticipatory pleasure but not consummatory pleasure or depression symptoms. Across conditions, increased anticipatory pleasure was associated with insomnia reduction through 1-month follow-up, even after adjusting for changes in depression symptoms. CONCLUSION: CBT-I may improve reward processing deficits in cancer survivors with insomnia. Findings provide support for the ISR Model and implicate pleasure as an important target for insomnia and depression.

Effects of the COVID-19 pandemic on anhedonia, reward exposure and responsiveness, and sleep in college students.

Objective: The COVID-19 pandemic's effects on college student mental health and its underlying mechanisms are not fully understood. Although necessary, physical distancing abruptly restricts interaction with environmental rewards and disrupts sleep patterns, both of which may contribute to psychological symptoms (eg, depression and anhedonia). This study explored differences in psychological symptoms, reward exposure and responsiveness, and sleep before versus during the pandemic. Methods: Eighty-seven college students completed baseline questionnaires and a one-week daily diary paradigm. The sample was divided into two groups based on data collection before (pre-) or after (post-COVID-19) implementation of state-wide COVID-19 physical distancing measures. Results: Findings highlight higher anhedonia, decrements in exposure to social, professional, and exercise related rewards, lower aniticipatory reward responsiveness, and lower sleep efficiency among college students during the initial months of the pandemic. Conclusions: Findings suggest anhedonia, reward system functioning, and sleep may be important targets to mitigate against college student mental health sequelae during COVID-19.

Relationships Among Sleep Disturbance, Reward System Functioning, Anhedonia, and Depressive Symptoms.

Recent models propose reward system dysfunction as a key mediator of the relationship between sleep and depression and anhedonia. This study explored interrelationships among sleep disturbance, depressive symptoms, anhedonia, and reward responsiveness. Two-hundred and sixty undergraduate students completed questionnaires and a daily diary paradigm assessing sleep, reward responsiveness, depression, anhedonia, and positive affect over 1 week. Baseline sleep disturbance was associated with depressive symptoms, anhedonia, and reward responsiveness. Daily diary sleep parameters showed differential associations with anticipatory versus consummatory reward responsiveness and positive affect. Poorer sleep quality, shorter sleep duration, and longer awakening after sleep onset predicted blunted anticipatory and consummatory reward responsiveness, while increased sleep onset latency and lower sleep efficiency predicted only decreased consummatory reward responsiveness. All sleep indices, except sleep onset latency, were associated with positive affect. Findings demonstrate unique associations between disparate sleep disturbance and reward responsiveness elements, highlighting new treatment mechanisms for anhedonia and depression.

The Survivorship Sleep Program (SSP): A synchronous, virtual cognitive behavioral therapy for insomnia pilot program among cancer survivors.

BACKGROUND: For cancer survivors, insomnia is prevalent, distressing, and persists for years if unmanaged. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment yet can be difficult to access and may require modification to address survivorship-specific barriers to sleep. In this 2-phase study, the authors adapted and assessed the feasibility, acceptability, and preliminary effects of synchronous, virtual CBT-I adapted for cancer survivors (the Survivorship Sleep Program [SSP]). METHODS: From April to August 2020, cancer survivors with insomnia (N = 10) were interviewed to refine SSP content and delivery. From October 2020 to March 2021, 40 survivors were recruited for a randomized controlled trial comparing 4 weekly SSP sessions with enhanced usual care (EUC) (CBT-I referral plus a sleep hygiene handout). Feasibility and acceptability were assessed by enrollment, retention, attendance, fidelity, survey ratings, and exit interviews. Insomnia severity (secondary outcome), sleep quality, sleep diaries, and fatigue were assessed at baseline, postintervention, and at 1-month follow-up using linear mixed models. RESULTS: The SSP included targeted content and clinician-led, virtual delivery to enhance patient centeredness and access. Benchmarks were met for enrollment (56% enrolled/eligible), retention (SSP, 90%; EUC, 95%), attendance (100%), and fidelity (95%). Compared with EUC, the SSP resulted in large, clinically significant improvements in insomnia severity (Cohen d = 1.19) that were sustained at 1-month follow-up (Cohen d = 1.27). Improvements were observed for all other sleep metrics except sleep diary total sleep time and fatigue. CONCLUSIONS: Synchronous, virtually delivered CBT-I targeted to cancer survivors is feasible, acceptable, and seems to be efficacious for reducing insomnia severity. Further testing in larger and more diverse samples is warranted.

Associations between insomnia and reward learning in clinical depression.

BACKGROUND: Depression and insomnia commonly co-occur. Yet, little is known about the mechanisms through which insomnia influences depression. Recent research and theory highlight reward system dysfunction as a potential mediator of the relationship between insomnia and depression. This study is the first to examine the impact of insomnia on reward learning, a key component of reward system functioning, in clinical depression. METHODS: The sample consisted of 72 veterans with unipolar depression who endorsed sleep disturbance symptoms. Participants completed the Structured Clinical Interview for DSM-IV, self-report measures of insomnia, depression, and reward processing, and a previously validated signal detection task (Pizzagalli et al., 2005, Biological Psychiatry, 57(4), 319-327). Trial-by-trial response bias (RB) estimates calculated for each of the 200 task trials were examined using linear mixed-model analyses to investigate change in reward learning. RESULTS: Findings demonstrated diminished rate and magnitude of reward learning in the Insomnia group relative to the Hypersomnia/Mixed Symptom group across the task. Within the Insomnia group, participants with more severe insomnia evidenced the lowest rates of reward learning, with increased RB across the task with decreasing insomnia severity. CONCLUSIONS: Among individuals with depression, insomnia is associated with decreased ability to learn associations between neutral stimuli and rewarding outcomes and/or modify behavior in response to differential receipt of reward. This attenuated reward learning may contribute to clinically meaningful decreases in motivation and increased withdrawal in this comorbid group. Results extend existing theory by highlighting impairments in reward learning specifically as a potential mediator of the association between insomnia and depression.

Emotion Regulation Flexibility in Generalized Anxiety Disorder.

BACKGROUND: People differ in their affective styles, which refers to habitual use of emotion regulation (ER) strategies. Previous research has shown that mental health is associated with an individual's adaptive flexibility of emotion regulation strategies rather than any one particular ER strategy. METHODS: The present study employed a person-centered approach using latent profile analyses to distinguish patients with generalized anxiety disorder based on their responses on an affective styles measure. RESULTS: Results of the latent profile analysis supported a three-class solution. Class 1 (26% of participants) identified individuals with the lowest scores of each affective style; class 2 (10%) included individuals with the highest scores of each style; and class 3 (64%) consisted of individuals who scored in the mid-range of each affective style. Greater ER flexibility was associated with better emotional functioning and quality of life. CONCLUSIONS: Patients with GAD differ in ER flexibility. The vast majority of patients appear to have only moderate or low ER flexibility. Those individuals with high ER flexibility show a greater quality of life and less emotional distress.

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support.

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory-II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f2 = 0.065; more harassment during deployment, f2 = 0.020; and lower ratings of postdeployment social support, f2 = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.

The Welch Emotional Connection Screen: validation of a brief mother-infant relational health screen.

AIM: The Welch Emotional Connection Screen (WECS), assesses mother-infant Emotional Connection in clinical settings. It includes: Attraction, Vocal Communication, Facial Communication, Sensitivity/Reciprocity and clinical decision of Emotional Connection (yes/no). We tested concurrent and construct validity of the WECS and associations with behavioural and physiological measures in preterm infants. METHODS: Videos from 76 mothers-infants (gestational age 36 weeks) during an in-NICU caregiving paradigm were coded for maternal caregiving behaviour. Videos of mothers-infants were also obtained at 4 months during 10 minutes of face-to-face play (coded with WECS and for maternal positivity and infant social engagement) and the still-face paradigm (coded for infant behavioural approach towards mother; infant electrocardiogram acquired in vivo). RESULTS: WECS maternal scores were positively associated with maternal sensitivity and quality of vocal contact at 36 weeks (caregiving) and maternal positivity at 4 months (face-to-face). WECS infant scores positively correlated with infant social engagement and maternal positivity during face-to-face interactions at 4 months. Infants from emotionally not connected dyads (vs. emotionally connected dyads) displayed autonomic dysregulation and less approach-seeking behaviour towards mother during interactive/play sessions of the still-face paradigm. CONCLUSION: This preliminary evidence supports the WECS as a valid screen for rating mother-preterm infant emotional connection associated with healthier infant biobehavioural stress responding.

Patient and Provider Perspectives on a Mind-Body Program for Grieving Older Adults.

BACKGROUND: Spousal bereavement in older age is a major stressor associated with an increase in both mental and physical problems. The Stress Management and Resiliency Training: Relaxation Response Resiliency Program (SMART-3RP) is an 8-week multimodal mind-body program that targets stress and has been found efficacious in decreasing the mental and physical manifestations of stress in varied populations. This qualitative study sought to investigate the relevance, credibility, and feasibility of the SMART-3RP in the community. METHODS: Focus groups were conducted among both older widowed adults and providers who support them in the community (eg, chaplains, hospice bereavement coordinators). Transcripts were coded independently by coders trained in qualitative research. Codebooks were created based on both general themes and detailed subthemes present in the transcripts. RESULTS: Findings from 4 focus groups revealed a general convergence between the needs of recently widowed older adults reported by widow(er)s and community providers alike and needs identified in the literature. Several components of the SMART-3RP target many of these needs (eg, social support, stress awareness, coping skills), making both community providers and widow(er)s report that the SMART-3RP is logical (89%) and would be helpful (100%) and successful in reducing symptoms (78%). Additionally, all widow(er)s reported a willingness to participate (100%). Feedback from the focus groups was used to adapt the SMART-3RP to improve its relevance to grief-related stress. CONCLUSIONS: Our findings suggest that the SMART-3RP may be helpful in decreasing somatic and psychological distress in older adults who have lost a spouse.