Does Daylength Affect Sleep and Mental Health Symptoms during Behavioral Interventions for Insomnia?

BACKGROUND: Approximately 11-33% of Australian adults experience Insomnia Disorder, which is associated with higher rates of psychiatric comorbidities, and lower quality of life. Non-pharmacological interventions are the front-line treatments for insomnia. Despite the known impact of light on the sleep/wake cycle via the circadian system, it is not yet known whether seasonal variations in environmental light levels (i.e., daylength) influence treatment outcome. We aimed to determine whether seasonal differences in daylength influenced baseline symptoms of Insomnia Disorder or treatment outcome. PARTICIPANTS: One hundred treatment-seeking individuals with Insomnia Disorder (age: 49.3 ± 14.4y, range: 18-82 years; 58 F) enrolled in a Randomized Control Trial in Australia over a 29-month period. METHODS: Clients completed a seven-session behavioral intervention for insomnia over a maximum of 12 weeks. Individuals completed questionnaires assessing insomnia symptoms, diurnal preference, depression and anxiety symptoms, and daily sleep diaries. Objective rest/activity patterns were monitored using wrist actigraphy for the duration of the treatment period. RESULTS: Baseline daylength, sunset and sunrise times, and change in daylength over treatment, were not related to baseline insomnia severity or mental health symptoms. However, longer daylength at baseline predicted greater improvements in insomnia symptoms and anxiety, but not depression, symptoms. These improvements were also associated with later sunset and/or earlier sunrise at baseline. CONCLUSIONS: Our results show, greater treatment-related improvements in subjective sleep and mental health symptoms during spring and summer months. This suggests that daylength could have a role to play in the outcomes of a behavioral insomnia treatment. Future research is needed to provide recommendations.

The ability to self-monitor cognitive performance during 60 h total sleep deprivation and following 2 nights recovery sleep.

We aimed to investigate whether self-monitoring of performance is altered during 60 h of total sleep deprivation, following 2 nights of recovery sleep, and by task difficulty and/or subjective sleepiness. Forty adults (22 females, aged 19-39 years) underwent a 5-day protocol, with a well-rested day, 66 h total sleep deprivation (last test session at 60 h), and 2 nights of 8 h recovery sleep. An arithmetic task (MATH) with three difficulty levels assessed working memory. The Psychomotor Vigilance Task assessed sustained attention. Arithmetic accuracy and Psychomotor Vigilance Task median reaction time measured objective performance. Subjective performance was measured with self-reported accuracy and speed. Objective-subjective differences assessed self-monitoring ability. The performance on both tasks declined during total sleep deprivation and improved following recovery. During total sleep deprivation, participants accurately self-monitored performance on the Psychomotor Vigilance Task; however, they overestimated cognitive deficits on MATH, self-reporting performance as worse than actually observed. Following recovery, participants overestimated the extent of performance improvement on the Psychomotor Vigilance Task. Task difficulty influenced self-monitoring ability, with greater overestimation of performance deficits during total sleep deprivation as difficulty increased. Subjective sleepiness predicted subjective performance ratings at several time points, only for the Psychomotor Vigilance Task. The ability to self-monitor performance was impaired during total sleep deprivation for working memory and after recovery sleep for the Psychomotor Vigilance Task, but was otherwise accurate. The development of self-monitoring strategies, assessing both subjective perceptions of performance and subjective sleepiness, within operational contexts may help reduce the consequences of sleep-related impairments.

Sleep and aging: examining the effect of psychological symptoms and risk of sleep-disordered breathing.

Controversy exists as to whether self-reported sleep quality declines with age, despite changes in sleep being accepted as part of normal aging. This study sought to investigate age-related differences in self-reported sleep quality, after controlling for conditions that are common with age, such as psychological symptoms and increased risk of sleep-disordered breathing (SDB). The Pittsburgh Sleep Quality Index (PSQI) was administered to a sample of 582 community adults (aged 18-89 years), and the association between age and 3 factors of the PSQI (sleep efficiency, perceived sleep quality, and daily disturbance), and global scores, was examined controlling for depression, anxiety, stress, gender, and SDB risk. Results indicate that (a) before controlling for covariates, there was no significant relation between age and all indexes of self-reported sleep quality, with the exception of sleep efficiency. However, once depression, gender, and SDB risk were controlled for, a significant, yet small, relation was revealed between older age and poorer global sleep quality; (b) there was no association between age and perceived sleep quality or daily disturbances before or after controlling for relevant covariates; and (c) depression, gender, and SDB risk were significant predictors of poorer sleep quality across the indexes but, in general, did not have a marked impact on the relation between age and sleep quality. In conclusion, results suggest that sleep problems are common across the lifespan, and that there were modest age-related differences in self-reported sleep quality, which were not due to depressed mood, gender, or risk of SDB.

Protocol for a randomized controlled study examining the role of rapid eye movement sleep in fear-related mechanisms: rapid eye movement fragmentation and fear inhibition in adults with insomnia disorders before and after cognitive behavioral therapy for insomnia.

Insomnia confers a 2.5-to-3-fold risk of developing posttraumatic stress disorder (PTSD) after a traumatic event. The mechanism underlying this increased risk, however, remains unknown. We postulate insomnia may contribute to PTSD by disrupting rapid eye movement (REM) sleep, as REM sleep disruption has been shown to impair fear inhibitory processes, which are central to the natural recovery from trauma. To test this hypothesis, the following protocol aims to: (1) examine the relationship between REM sleep and fear inhibition in insomnia, and (2) examine whether reducing REM fragmentation by treating insomnia, in turn, improves fear inhibition. Ninety-two adults with Insomnia Disorder will be block randomized (1:1; stratified by sex) to an active treatment (7 weekly sessions of Cognitive Behavioral Therapy for Insomnia (CBT-I) via telehealth) or waitlist control condition. REM sleep (latent variable derived from REM %, REM efficiency, and REM latency) and fear inhibition (i.e. safety signal and extinction recall) will be assessed pre- and post-treatment in a 4 night/3 day testing protocol via at-home polysomnography and the fear-potentiated startle paradigm, respectively. Fear extinction recall will serve as the primary outcome, while safety signal recall will serve as the secondary outcome. In summary, this study aims to test an underlying mechanism potentially explaining why insomnia greatly increases PTSD risk, while demonstrating an existing clinical intervention (CBT-I) can be used to improve this mechanism. Findings will have potential clinical implications for novel approaches in the prevention, early intervention, and treatment of PTSD.

Approaches to the assessment of adherence to CBT-I, predictors of adherence, and the association of adherence to outcomes: A systematic review.

This systematic review (PROSPERO registration CRD42020158010) aimed to: 1) assess how adherence to cognitive behavioural therapy for insomnia (CBT-I) has been measured; 2) evaluate predictors of adherence; and 3) determine whether treatment outcome is associated with adherence. Inclusion criteria included: adults with insomnia; an intervention of CBT-I, including sleep restriction and/or stimulus control; a reported measure of adherence; and written in English. Searches of eight databases returned 2038 publications as of April 2021. The final sample included 102 papers. Publication quality and risk of bias were assessed using Joanna Briggs institute tools. Studies assessed either global adherence or adherence to specific components of CBT-I via questionnaires, sleep diaries, interviews or actigraphy. Twenty-eight papers examined predictors of adherence. Better pre- and post-session sleep, greater psychosocial support, increased self-efficacy, and fewer dysfunctional beliefs about sleep predicted greater adherence. Twenty-eight papers examined whether adherence predicted treatment outcomes. Only insomnia severity index scores post-treatment were consistently predicted by adherence, and only by a few measures of adherence. Overall, there was very little consistency in how adherence was measured, and in predictors and outcome variables assessed. A standardised method for assessing specific adherence constructs is indicated, to fully understand the role of adherence in CBT-I.

Sleep and wake are shared and transmitted between individuals with insomnia and their bed-sharing partners.

Patients with insomnia frequently report disturbing, or being disturbed by, their bedpartner. We aimed to (1) characterize how individuals with insomnia and their bedpartners influence each other's sleep and (2) identify characteristics predicting vulnerability to wake transmission. Fifty-two couples (aged 19-82 years), where one individual was diagnosed with insomnia, participated. Sleep/wake patterns were monitored via actigraphy and sleep diaries for seven nights. Minute-by-minute sleep and wake concordance (simultaneous sleep/wake epochs), number of wake transmissions received (awakenings immediately preceded by wakefulness in the bedpartner), percent wake transmissions received (percentage of total awakenings that were transmitted), and percent of bedpartner's wake minutes resistant to transmission (ability to sleep through bedpartner wakefulness) were calculated. Mixed-effects modeling assessed within-couple bedtime and chronotype differences as predictors of dyadic sleep. We described rates of sleep concordance (MPatient = 63.8%, MPartner = 65.6%), wake concordance (MPatient = 6.6%, MPartner = 6.6%), total transmissions received (MPatient = 5.5, MPartner = 6.9 per night), percent transmissions received (MPatient = 18.5%, MPartner = 23.4% of total awakenings), and percent minutes resistant (MPatient = 56.4%, MPartner = 58.6% of bedpartner's wake time). Partners received wake transmissions at 1.25 times the rate of patients. Percent transmissions received was increased in couples with concordant bedtimes and individuals with later chronotype than their bedpartner. Patterns of chronotype and bedtime order predicting percent minutes resistant to transmission differed across the length of the rest interval. Transmission provides a novel characterization of how bedpartners influence sleep and provide insight into mechanisms of insomnia generation and maintenance. Understanding modifiable risk factors may provide ways to personalize insomnia treatments. Clinical Trial Researching Effective Sleep Treatments (Project REST), ANZCTR Registration: ACTRN12616000586415.

Prevalence of sleep disturbance and its relationships with mental health and psychosocial issues in refugees and asylum seekers attending psychological services in Australia.

BACKGROUND: Worldwide, 68.5 million individuals are refugees, asylum seekers, or internally displaced. Although many studies have examined mental health concerns in this population, few studies have assessed sleep or examined the relationship between sleep and mental health or psychosocial functioning. OBJECTIVES: The objectives were to (1) examine the prevalence of sleep disturbance within refugees and asylum seekers from diverse backgrounds, (2) examine mental health and psychosocial factors associated with sleep disturbance, and (3) explore whether symptoms cluster together in unique subsets of individuals. METHODS: Clinician-administered interview data (N = 2703) were obtained from a large mental health service in greater Melbourne, Australia. Data included patient demographics, sleep disturbance, mental health (anxiety, depression, traumatic stress symptoms), and psychosocial concerns (family dysfunctions, interpersonal difficulties, social isolation). RESULTS: A total of 75.5% of the sample reported moderate or severe sleep disturbance. Severity of sleep disturbance was positively correlated with severity of mental health symptoms, psychosocial concerns, age, and migration status. This was true in both refugee and asylum seeker populations and in both adults and children. Cluster analyses revealed 3 subsets of individuals: those with "severe sleep and anxiety symptoms," "mild to moderate symptoms," and "mild symptoms." Using "mild symptoms" as the comparator, being a refugee and increasing age were associated with a 1.57- and 1.02-fold increase, respectively, in the likelihood of classification as "severe sleep and anxiety problems" and 1.70- and 1.02-fold increase, respectively, in the likelihood of classification as "mild to moderate symptoms." CONCLUSION: These findings suggest that systematic screening of sleep disturbance among refugees and asylum seekers during health-related visits is needed.

Partner-assisted cognitive behavioural therapy for insomnia versus cognitive behavioural therapy for insomnia: a randomised controlled trial.

BACKGROUND: Insomnia is a prevalent sleep disorder associated with significant economic and personal burdens. Cognitive behavioural therapy for insomnia (CBTI) is considered the gold standard intervention for insomnia and its efficacy has been well demonstrated. However, the core treatment strategies of CBTI require significant behavioural change, which many individuals find challenging. As a result, although CBTI is efficacious, its effectiveness is reduced by modest levels of adherence in typical clinical settings. This is problematic as adherence is essential to attain desired treatment outcomes. Sleep is often a dyadic process, with approximately 60% of Australian adults sharing a bed. Hence, the present study aims to determine whether incorporating bed partners into treatment for insomnia increases treatment adherence and completion. The impact of adherence on symptoms of insomnia will also be examined. METHODS: This study is a mixed-effects randomised effectiveness trial of partner-assisted CBTI (PA-CBTI). It is an "effectiveness" (as opposed to "efficacy") trial, due to the focus on "real world" clinic-based clients and adherence/attrition as outcomes. Participants will include 120 clients with insomnia who are randomly assigned, in equal numbers, to PA-CBTI, traditional individual CBTI (i-CBTI), or partner-assisted sleep management therapy (PA-SMT; which serves as the control group). All interventions consist of seven weekly 1-h sessions. Treatment outcome is evaluated using clinician-rated treatment adherence, and diary-based adherence to stimulus control and sleep restriction. Clients and partners complete major assessments at pre- and post-treatment, and at 6-month follow-up. Secondary outcome variables include actigraphy, self-report measures related to sleep, comorbid psychopathology, and relationship functioning. DISCUSSION: This is the first randomised clinical trial to examine the impact of incorporating the bed partner in the treatment of insomnia. Results will provide new information about the role partners play in clients' insomnia presentation and treatment response, and better define the role of adherence in CBTI. This trial has the potential to optimise treatment outcomes for insomnia by improving adherence and reducing attrition. Results could have far-reaching impacts. Improvements in insomnia have been linked to improvements in mental and physical health and, given the high financial costs of insomnia, this study could have a positive economic impact. TRIAL REGISTRATION: ACTRN, ACTRN12616000586415 . Registered on 5 May 2016.

Effects of sleep deprivation on component processes of working memory in younger and older adults.

Study Objectives: Working memory (WM) has been described as a multicomponent process, comprised of the following: attention-driven encoding, maintenance and rehearsal of information, and encoding to and retrieval from episodic memory. Impairments can affect higher-order cognitive processes and many everyday functions. The impact of sleep changes on these cognitive processes across the life span needs to be investigated. The aim of the current study is to examine the effects of sleep deprivation on component processes of WM, comparing younger and older adults across verbal and visuospatial modalities. Methods: Thirty-one younger adults (19-38 years) and 33 older adults (59-82 years) attended two counterbalanced sleep protocols: a regular night of sleep followed by testing the next day (normally rested condition), and 36 hr of total sleep deprivation (TSD), followed by testing (TSD condition). Participants completed matched versions of verbal and visuospatial WM tasks across conditions. Results: Younger adults significantly outperformed older adults on encoding and displacement component processes, for both verbal and visuospatial WM. Following TSD, younger adults showed a significantly larger drop compared with older adults in verbal encoding and in visuospatial displacement. A main effect of condition was observed for verbal displacement. Conclusions: Differences were observed in the performance of younger and older adults on component processes of WM following TSD. This suggests that TSD can have differential effects on each component process when younger and older adults are compared, in both verbal and visuospatial tasks. Understanding this profile of changes is important for the development of possible compensatory strategies or interventions and the differentiation of clinical and healthy populations.