Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the front-line treatment for insomnia. Despite the demonstrated effectiveness of CBT-I, it is necessary to consider how CBT-I may be tailored to different individuals. The purpose of the present review is to provide a summary of literature on tailoring CBT-I to different individuals and provide directions for future research. This review focused on the following domains of adaptation: (i) tailoring CBT-I components to individuals with comorbid mental or physical health conditions such as comorbid depression and pain; (ii) adapting CBT-I delivery for different contexts in which individuals exist, such as inpatient, educational, and different social/cultural settings, (iii) adapting CBT-I to specific individuals via case-formulation in clinical settings. We highlight current gaps in the exploration of tailored CBT-I, including a lack of research methodology to evaluate tailored interventions, a need for the integration of ongoing individualised assessment to inform treatment, and the necessary involvement of consumers and stakeholders throughout the research and treatment development process. Together, this review showed abundant adaptations in CBT-I already exist in the literature. Future research is needed in understanding when and how to apply adaptations in CBT-I and evaluate the benefits of these adaptations.

The Development and Validation of the Health Belief Model for Shift Workers (HBM-SW) Scale.

OBJECTIVE: Shift work is associated with circadian misalignment, sleep loss, and suboptimal health behaviors, which may contribute to longer term negative health outcomes. To inform future interventions for shift workers, the present study aimed to develop and evaluate the Health Belief Model for Shift Workers (HBM-SW) scale. METHODS: The HBM-SW development involved a seven-step process, including a literature review, expert panel analysis, cognitive interviews with shift workers, and a trial with a pilot sample of shift workers (n = 153). Utilizing exploratory factor analysis for factor identification and item reduction, the developed scale loaded on seven factors in line with the theoretical framework of the Health Belief Model: Perceived Threat, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action, Self-efficacy, and Health Motivation. Validation of the scale was conducted utilizing Pittsburgh Sleep Quality Index, International Physical Activity Questionnaire, and Food Frequency Questionnaire. RESULTS: The pilot sample had an average age of 34.0 (18.0) years, was majority female (54.2%), with an average of 8.0 (11.0) years shift work experience. The HBM-SW showed good - excellent (α = 0.74-0.93) internal consistency and moderate - good (ICC = 0.64-0.89) test re-test reliability. Using health behavior outcome measures, the HBM-SW scale showed meaningful correlations with sleep quality, sleep duration, diet quality and leisure time physical activity, and acceptable validity and reliability. Further testing should be conducted in a larger sample to facilitate confirmatory factor analysis. CONCLUSIONS: The developed Health Belief Model for Shift Workers scale is likely beneficial for use in future studies of interventions for shift workers.

Sleep disorder risk, perceived control over sleep, and mental health symptoms in paramedicine students.

Paramedics commonly experience both poor sleep and mental health symptoms. Clarifying whether sleep or mental health symptoms are a challenge prior to commencement of employment is important, as early prevention and intervention initiatives during training could support these workers. Paramedicine students (n=53) were included, with sleep disorder screening (obstructive sleep apnea, insomnia and restless legs syndrome), and mental health outcomes (depressive symptoms: Patient Health Questionnaire-9, and anxiety symptoms: General Anxiety Disorder-7). Data were analysed using robust regression models, adjusted for age, sex, and shift work status. Meeting criteria for a sleep disorder (n=21) was associated with higher scores for anxiety (8.2 [95% CI: 5.9-10.5] v 4.6, [3.4-5.8]) and depressive symptoms (11.1 [8.6-13.6] v 4.4 [3.1-5.7)] compared to those who did not meet the criteria for a sleep disorder (n=32). Depressive symptoms were lower in those with perceived control over sleep (5.2 [3.2-7.2] v 9.8 [7.7-11.8]). There was no interaction between sleep disorder risk and perceived control over sleep on mental health symptoms. Investigation and management of factors contributing to low perceived control over sleep, together with early screening and management of sleep disorders, are likely to be important priorities to support paramedic student wellbeing prior to commencing shift work.

How Tired is Too Tired to Drive? A Systematic Review Assessing the Use of Prior Sleep Duration to Detect Driving Impairment.

Driver fatigue is a contributory factor in approximately 20% of vehicle crashes. While other causal factors (eg, drink-driving) have decreased in recent decades due to increased public education strategies and punitive measures, similar decreases have not been seen in fatigue-related crashes. Fatigued driving could be managed in a similar way to drink-driving, with an established point (ie, amount of prior sleep) after which drivers are "deemed impaired". This systematic review aimed to provide an evidence-base for the concept of deemed impairment and to identify how much prior sleep may be required to drive safely. Four online databases were searched (PubMed, Web of Science, Scopus, Embase). Eligibility requirements included a) measurement of prior sleep duration and b) driving performance indicators (eg, lane deviation) and/or outcomes (eg, crash likelihood). After screening 1940 unique records, a total of 61 studies were included. Included studies were categorised as having experimental/quasi-experimental (n = 21), naturalistic (n = 3), longitudinal (n = 1), case-control (n = 11), or cross-sectional (n = 25) designs. Findings suggest that after either 6 or 7 hours of prior sleep, a modest level of impairment is generally seen compared with after ≥ 8 hours of prior sleep (ie, well rested), depending on the test used. Crash likelihood appears to be ~30% greater after 6 or 7 hours of prior sleep, as compared to individuals who are well rested. After one night of either 4 or 5 hours of sleep, there are large decrements to driving performance and approximately double the likelihood of a crash when compared with well-rested individuals. When considering the scientific evidence, it appears that there is a notable decrease in driving performance (and associated increase in crash likelihood) when less than 5h prior sleep is obtained. This is a critical first step in establishing community standards regarding the amount of sleep required to drive safely.

Is cognitive behavioral therapy for insomnia (CBTi) efficacious for treating insomnia symptoms in shift workers? A systematic review and meta-analysis.

Shift workers commonly report insomnia symptoms. Cognitive behavioral therapy for insomnia (CBTi) is the first line treatment for insomnia, however efficacy in shift workers is not well understood. This systematic review and meta-analysis evaluates existing trials of CBTi in shift working populations. A systematic literature search was conducted across seven electronic databases (n = 2120). Fifty-two full-text articles were reviewed and of these, nine studies (across ten publications with a total of 363 participants) were deemed suitable for inclusion. Heterogeneity was considerable between studies, with variability in study design, style and delivery of intervention, and follow-up times. Small sample sizes were common and attrition was high. Some studies modified aspects of CBTi for use in shift workers, while others were limited to psycho-education as part of larger intervention studies. Mean differences (MD) pre and post CBTi were modest for both the insomnia severity index (ISI; MD: -3.08, 95% CI: -4.39, -1.76) and the Pittsburgh sleep quality index (PSQI; MD: -2.38, 95% CI: -3.55, -1.21). Neither difference was of a magnitude considered to reflect a clinically significant improvement. Tailored approaches to CBTi are needed for shift workers to improve efficacy, ideally including co-production with workers to ensure interventions meet this population's needs.

Longitudinal studies of sleep, physical activity and nutritional intake in shift workers: A scoping review.

Shift work is known to be associated with poor health outcomes, however our understanding of health behaviours (sleep, physical activity and nutritional intake) longitudinally in shift workers is currently limited. Systematic searches of four data bases were conducted. Using PRISMA-ScR guidelines we report a scoping review of 15 eligible studies. Of the included studies, 11 studies examined sleep outcomes, three examined physical activity and two examined nutritional intake. The number of follow ups conducted in each study varied from one to six, with the majority of studies reporting one follow up. Study length varied from six months to 16 years. Findings suggest that shift workers have stable but largely insufficient sleep longitudinally. Many shift workers, particularly inexperienced shift workers, are additionally experiencing poor sleep quality. There is limited data longitudinally on physical inactivity and nutrition intake, but included studies indicate that shift workers may also be physical inactive and with some poor nutritional intake (i.e., high levels of saturated fat intake). Longitudinal studies of shift work with multiple follow-ups are needed to address the current gaps in literature. The evidence that shift workers may be susceptible to poor health behaviours longitudinally is important as it provides a means by which strategies and interventions can be targeted, at both individual and organisational levels, to assist in better long term health outcomes.

Shift work disorder and the prevalence of help seeking behaviors for sleep concerns in Australia: A descriptive study.

Shift work disorder (SWD) is a circadian rhythm sleep-wake disorder, defined by symptoms of insomnia and excessive levels of sleepiness resulting from work that occurs during non-standard hours. Sleep problems are common in shift workers, yet our understanding of help seeking behaviours for sleep in shift workers is limited. The primary aim of this study was to examine the help seeking behaviours of Australian workers who meet criteria for SWD. Of the 448 (46% of sample, n = 964 total) Australian workers reporting non-standard work hours, 10.5% (n = 41) met the criteria for probable shift work disorder (pSWD). Non-standard workers with pSWD did not seek help for sleep problems at higher rates than workers without SWD. Of the small proportion of workers with pSWD who sought help, general practitioners were the most common healthcare professionals for sleep problems. Self-management was common in workers with pSWD, with a high self-reported prevalence of alcohol use (31.7%) as a sleep management strategy, and caffeine consumption (76.9%) as a sleepiness management strategy. The majority of individuals with pSWD reported the mentality of 'accept it and keep going' as a sleepiness management strategy, highlighting a potential barrier to help seeking behaviour in workers with pSWD. These findings provide novel insight into the help seeking behaviours of those with pSWD. There is a need for further research to understand why individuals at risk for SWD are not actively seeking help, and to develop health promotion and intervention strategies to improve help seeking when needed.

Sleep disturbance in caregivers of individuals with Parkinsonism: a systematic review and meta-analysis.

OBJECTIVES: The global prevalence of Parkinsonism continues to rise given ageing populations. Individuals with Parkinsonism who have moderate or severe symptoms typically require a high level of care, including assistance with activities of daily living. This care is often provided across the 24-hour period by a family member or friend. It is likely that providing care significantly impacts the sleep duration and quality of the caregiver given overnight caring responsibilities, in addition to worry and stress associated with the caregiving role. The aim of this systematic review and meta-analysis was to investigate whether providing care to an individual with Parkinsonism was associated with disturbed caregiver sleep, and to identify associated factors that may contribute to disturbed sleep in this population. SETTING: Five databases were electronically searched on 30 June 2021 including CINAHL, PubMed, PsycINFO, CENTRAL and EMBASE. PARTICIPANTS: Eligibility criteria included a population of caregivers whose care recipient has a form of Parkinsonism. PRIMARY AND SECONDARY OUTCOME MEASURES: To be included in this systematic review, outcome measures of caregiver sleep (eg, sleep duration, sleep quality) were required. RESULTS: Eighteen studies (n=1998) were included. Findings indicated that caregivers of individuals with Parkinsonism typically experience poor sleep quality (mean (95% CI): 5.6 (4.8 to 6.4) points on the Pittsburgh Sleep Quality Index), increased sleep latency and poor sleep efficiency. CONCLUSIONS: The degree of poor sleep quality was clinically significant. However, further investigation of sleep outcomes is required using sleep measurement tools tailored for this population (eg, measures that capture overnight sleep disruption by care recipient/s). Additionally, there is a need for appropriate individual and societal-level interventions to improve caregiver sleep. PROSPERO REGISTRATION NUMBER: CRD42021274529.

How effective are Fatigue Risk Management Systems (FRMS)? A review.

OBJECTIVE: Fatigue Risk Management Systems (FRMS) are a data-driven set of management practices for identifying and managing fatigue-related safety risks. This approach also considers sleep and work time, and is based on ongoing risk assessment and monitoring. This narrative review addresses the effectiveness of FRMS, as well as barriers and enablers in the implementation of FRMS. Furthermore, this review draws on the literature to provide evidence-based policy guidance regarding FRMS implementation. METHODS: Seven databases were drawn on to identify relevant peer-reviewed literature. Relevant grey literature was also reviewed based on the authors' experience in the area. In total, 2129 records were screened based on the search strategy, with 231 included in the final review. RESULTS: Few studies provide an evidence-base for the effectiveness of FRMS as a whole. However, FRMS components (e.g., bio-mathematical models, self-report measures, performance monitoring) have improved key safety and fatigue metrics. This suggests FRMS as a whole are likely to have positive safety outcomes. Key enablers of successful implementation of FRMS include organisational and worker commitment, workplace culture, and training. CONCLUSIONS: While FRMS are likely to be effective, in organisations where safety cultures are insufficiently mature and resources are less available, these systems may be challenging to implement successfully. We propose regulatory bodies consider a hybrid model of FRMS, where organisations could choose to align with tight hours of work (compliance) controls. Alternatively, where organisational flexibility is desired, a risk-based approach to fatigue management could be implemented.

Physical and psychological health in intern paramedics commencing shift work: Protocol for an exploratory longitudinal study.

BACKGROUND: Paramedics are routinely exposed to shift work. Existing research shows that shift work exposure is associated with adverse mental and physical health outcomes. However, the current understanding of the impact of commencing shift work in a paramedic role on health is limited. This can be addressed by recruiting new paramedics before they commence shift work, and conducting regular follow-ups of potential biological, psychological and social changes. The present study aimed to examine changes in biological, psychological and social factors relative to pre-shift work baseline in a cohort of paramedics commencing intern employment with an Australian ambulance service. METHOD AND ANALYSIS: This observational, mixed-methods, longitudinal study aims to recruit 40 interns from one Australian ambulance service. Data collection will occur at baseline (standard day schedule for initial training), and subsequently at three months, six months, nine months and twelve months, to measure biological, psychological and social changes relative to baseline measurements. Changes in cardiometabolic markers (cholesterol, triglycerides, fasting glucose), microbiome (self-collected stool samples), sleep and physical activity (actigraphy) will be measured. Interns will also complete a battery of self-report questionnaires, sleep diaries and qualitative interviews to explore various psychological and social variables over time. Statistical analyses will be conducted using mixed effects regression, specifying a random effect of subject on the intercept, allowing participants to vary according to individual baseline levels, as well as tracking progress over time, appropriately accounting for serial correlation. Qualitative study components will be analysed via coding and thematic analysis procedures. DISCUSSION: The present study protocol is a comprehensive outline of the observational study planned. The study will allow for greater knowledge of any changes in biological, psychological and social factors during a 12-month transition to shift work. The findings from the proposed study will have implications for the development of strategies to support early-career shift workers.

Interventions to improve sleep in caregivers: A systematic review and meta-analysis.

Unpaid caregivers often experience sleep impairments as an unintended consequence of providing care. This systematic review and meta-analysis investigated the efficacy of interventions to improve sleep in unpaid caregivers. Six databases were searched from journal inception to 7-Sep-2021 to identify randomised controlled trials. Random-effects meta-analyses estimated mean differences (MD) at end-of-intervention. Twenty-one studies were identified (15 eligible for meta-analysis). Compared to control, interventions improved sleep quality (Pittsburgh Sleep Quality Index; 12 studies, 1153 participants, MD = -1.66, 95% CI [-2.91, -0.41], p = 0.009, I2 = 90.51%, GRADE = low), and total sleep time (hours; two studies, 122 participants, MD = 0.45, 95% CI [0.42, 0.48], p = 0.003, I2 = 0.00%, GRADE = low), but not sleeping problems (sleep item on Symptom Distress Scale of the Omega Screening Questionnaire; two studies, 529 participants, MD = -0.06, 95% CI [-0.69, 0.58], p = 0.458, I2 = 0.01%, GRADE = low). There is low quality evidence that interventions improve sleep quality in unpaid caregivers compared to control. Limitations include the lack of evidence for specific intervention modes and limited use of objective sleep measures. Future research should explore potential effect modifiers such as care recipient condition (CRD42021278670).

Shift work, clinically significant sleep disorders and mental health in a representative, cross-sectional sample of young working adults.

Mental health conditions confer considerable global disease burden in young adults, who are also the highest demographic to work shifts, and of whom 20% meet criteria for a sleep disorder. We aimed to establish the relationship between the combined effect of shift work and sleep disorders, and mental health. The Raine Study is the only longitudinal, population-based birth cohort in the world with gold-standard, Level 1 measurement of sleep (polysomnography, PSG) collected in early adulthood. Participants (aged 22y) underwent in-laboratory PSG and completed detailed sleep questionnaires. Multivariable adjusted robust linear regression models were conducted to explore associations with anxiety (GAD7) and depression (PHQ9), adjusted for sex, health comorbidities, and work hours/week. Data were from 660 employed young adults (27.3% shift workers). At least one clinically significant sleep disorder was present in 18% of shift workers (day, evening and night shifts) and 21% of non-shift workers (p = 0.51); 80% were undiagnosed. Scores for anxiety and depression were not different between shift and non-shift workers (p = 0.29 and p = 0.82); but were higher in those with a sleep disorder than those without (Md(IQR) anxiety: 7.0(4.0-10.0) vs 4.0(1.0-6.0)), and depression: (9.0(5.0-13.0) vs 4.0(2.0-6.0)). Considering evening and night shift workers only (i.e. excluding day shift workers) revealed an interaction between shift work and sleep disorder status for anxiety (p = 0.021), but not depression (p = 0.96), with anxiety scores being highest in those shift workers with a sleep disorder (Md(IQR) 8.5(4.0-12.2). We have shown that clinical sleep disorders are common in young workers and are largely undiagnosed. Measures of mental health do not appear be different between shift and non-shift workers. These findings indicate that the identification and treatment of clinical sleep disorders should be prioritised for young workers as these sleep disorders, rather than shift work per se, are associated with poorer mental health. These negative mental health effects appear to be greatest in those who work evening and/or night shift and have a sleep disorder.

Non-Pharmacological Interventions to Improve Chronic Disease Risk Factors and Sleep in Shift Workers: A Systematic Review and Meta-Analysis.

Shift work is associated with adverse chronic health outcomes. Addressing chronic disease risk factors including biomedical risk factors, behavioural risk factors, as well as sleep and perceived health status, affords an opportunity to improve health outcomes in shift workers. The present study aimed to conduct a systematic review, qualitative synthesis, and meta-analysis of non-pharmacological interventions targeting chronic disease risk factors, including sleep, in shift workers. A total of 8465 records were retrieved; 65 publications were eligible for inclusion in qualitative analysis. Random-effects meta-analysis were conducted for eight eligible health outcomes, including a total of thirty-nine studies. Interventions resulted in increased objective sleep duration (Hedges' g = 0.73; CI: 0.36, 1.10, k = 16), improved objective sleep efficiency (Hedges' g = 0.48; CI: 0.20, 0.76, k = 10) and a small increase in both subjective sleep duration (Hedges' g = 0.11; CI: -0.04, 0.27, k = 19) and sleep quality (Hedges' g = 0.11; CI: -0.11, 0.33, k = 21). Interventions also improved perceived health status (Hedges' g = 0.20; CI: -0.05, 0.46, k = 8), decreased systolic (Hedges' g = 0.26; CI: -0.54, 0.02, k = 7) and diastolic (Hedges' g = 0.06; CI: -0.23, 0.36, k = 7) blood pressure, and reduced body mass index (Hedges' g = -0.04; CI: -0.37, 0.29, k = 9). The current study suggests interventions may improve chronic disease risk factors and sleep in shift workers; however, this could only be objectively assessed for a limited number of risk factor endpoints. Future interventions could explore the impact of non-pharmacological interventions on a broader range of chronic disease risk factors to better characterise targets for improved health outcomes in shift workers.

Sleep and physical activity in university students: A systematic review and meta-analysis.

University students have low levels of physical activity and report disturbances to sleep, which are independently associated with poor health outcomes. Some research suggests that there is a bi-directional relationship between sleep and physical activity in adults. However, the relationship between sleep and physical activity in university students has not yet been evaluated. Therefore, the aim of this systematic review and meta-analysis was to qualitatively synthesise and quantitatively evaluate the evidence for the association between sleep and physical activity in university students. Twenty-nine eligible studies were included, with a total of 141,035 participants (43% men and 57% women). Only four studies used device-based measures of sleep and/or physical activity, with the remainder including self-report measures. Qualitative synthesis found that the majority of studies did not find any association between sleep and physical activity in university students. However, random-effects meta-analysis showed that moderate-to-high intensity physical activity was associated with lower PSQI scores (e.g., better sleep quality) [r = -0.18, 95% CI (-0.37, 0.03), p = 0.100]. Further, a weak negative association between moderate-to-vigorous physical activity level and sleep duration was also found [r = -0.02, 95% CI (-0.16, 0.12), p = 0.760]. As the findings of this review are predominantly derived from cross-sectional investigations, with limited use of device-based measurement tools, further research is needed to investigate the relationship between sleep and physical activity in university students. Future studies should employ longitudinal designs, with self-report and device-based measures, and consider the intensity and time of physical activity as well as records of napping behaviour.

Protecting the health and safety of the paramedic workforce in Australia: The role of cohort studies with new recruits.

Research related to the paramedic workforce is increasing, particularly given the associations with physical and mental health outcomes. However, it is clear that the evidence base to support future paramedic workforce initiatives lacks longitudinal data in cohorts of paramedics. We identify gaps in the epidemiological evidence base for this workforce, and provide insight into the role that prospective cohorts can, and should, play in future research in the paramedic workforce in order to identify health and safety changes over time, and the associations with job requirements, particularly shift work.

Prevalence of Probable Shift Work Disorder in Non-Standard Work Schedules and Associations with Sleep, Health and Safety Outcomes: A Cross-Sectional Analysis.

PURPOSE: We aimed to estimate the prevalence of probable shift work disorder (pSWD) in a representative sample of Australian workers and identify sleep, health and safety correlates. PATIENTS AND METHODS: In 2019, data were collected from working respondents as part of a cross-sectional national sleep health survey conducted online (n=964 total; n=448 individuals on non-standard work schedules). We established the prevalence of pSWD according to International Classification of Sleep Disorders criteria (ICSD-R, ICSD-2 and ICSD-3). Poisson regression was used to determine crude and adjusted prevalence association (prevalence ratio, PR) of pSWD with sleep, health and safety outcomes. RESULTS: Overall prevalence of pSWD in workers on non-standard work schedules was 10.5%, ranging from 9.6% in early morning workers to 12.7% in rotating shift workers. In adjusted models, workers who met the criteria for pSWD were 1.8 times more likely to report both depression/bipolar disorder, and anxiety/panic disorder, and 1.7 times more likely to report work errors due to a sleep problem. CONCLUSION: The prevalence of pSWD in employees engaged in non-standard work schedules is influenced by selection of factors used to quantify pSWD, including sleep/wake patterns. Higher likelihoods of mental health problems and workplace errors in those with pSWD highlight the importance of intervention and management of this under-recognised sleep disorder.

Perceptions of the impact of non-standard work schedules on health in Australian graduates: an exploratory study.

Non-standard working hours are associated with negative health outcomes. However, little is known about the early years of exposure to non-standard work hours, or whether workers new to these work schedules perceive their work as impacting their health. This limits our ability to develop meaningful intervention strategies for transitioning into non-standard work hour schedules. This exploratory study investigated whether recent Australian graduates in various non-standard workhour schedules perceive that their work schedule negatively impacts their health. The responses of 120 graduates within four years of completing their tertiary qualification collected from an online survey were analysed. Graduates were asked whether they perceived their work arrangements as impacting their health. Significantly more of those who were engaged in non-standard work schedules or worked beyond contracted hours perceived their working arrangements as having an impact on their health. This study highlights the importance of studying workers' perceptions of the impact of work hours on health, particularly when workers may be experiencing good global health but be at risk for negative health outcomes in future.