BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
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Behavioral Sleep Medicine
2018 Update
Donna Arand, PhD, DABSM, FAASM
Society of Behavioral Sleep Medicine
September 16-17, 2018
Conflict of Interest Disclosures
Speaker:
1. I do not have any potential conflicts of interest to disclose, OR
2. I wish to disclose the following potential conflicts of interest
Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective
references are provided as support for this lecture:
1.
2.
3.
Outline I. Guidelines, Recommendations and Legislation II. Infants, adolescents and college students III. Treatment of Insomnia IV. Understanding Insomnia
Guidelines Recommendations and Legislation
AASM Position Paper for
Treatment of Nightmare Disorder
• Recommended for PTSD-associated nightmares and nightmare disorder: image
rehearsal therapy.
• May be used for PTSD-associated nightmares: cognitive behavioral therapy;
cognitive behavioral therapy for insomnia; eye movement desensitization and
reprocessing; exposure, relaxation, and rescripting therapy;
the atypical antipsychotics olanzapine, risperidone and aripiprazole; clonidine;
cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin;
topiramate; trazodone; and tricyclic antidepressants.
• May be used for nightmare disorder: cognitive behavioral therapy; exposure,
relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive
deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic
desensitization; testimony method; nitrazepam;
prazosin; and triazolam.
• Not recommended for treatment of nightmare disorder: clonazepam and
venlafaxine.
Morgenthaler TI, Auerbach S, Casey KR, Kristo D, Maganti R, Ramar K, Zak R, Kartje R. Position paper for the treatment of nightmare disorder in
adults: an American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018;14(6):1041–1055.
AASM Clinical Practice Guidelines for use of
Actigraphy in Insomnia
No recommendations only Conditional suggestions for clinician use (lower degree of certainty)
• Use actigraphy to estimate sleep parameters in adult patients with insomnia disorder (Conditional)
• Significant large mean differences between sleep logs and actigraphy in TST, SL and SE
• Small differences between actigraphy and PSG in TST, SL
• Use actigraphy in the assessment of pediatric patients with insomnia disorder. (Conditional)
• Significant large mean differences between sleep logs and actigraphy for TST and WASO
• Use actigraphy in assessment of adult patients with circadian rhythm sleep-wake disorder (Conditional)
• Significant large mean differences between sleep logs and actigraphy for sleep onset and termination
• Use actigraphy in assessment of pediatric patients with circadian rhythm sleep-wake disorder (Conditional)
• Significant large mean sleep difference between sleep logs and actigraphy in TST
Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, Carden KA. Use of actigraphy for the evaluation of sleep disorders and
circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2018;14(7):1231–
1237.
CDC reports insufficient sleep is common in
middle school and high school students
Anonymous, voluntary, school-based paper and pencil questionnaire (Youth Risk Behavior Survey)
during regular class period
• Nationally about 58% of middle school students and 73% of high school students get insufficient
sleep on school nights
• 50-64% of middle school students (n=52,000; 9 states) get < 9 hrs (KY -64%)
• 61-82% of high school students in grades 9-12 (n=14,000; 30 states) get
California law would require middle school and
high school to start no earlier than 8:30 am
• Law was passed by legislature and waiting for Governor’s signature
• Start time law SB 328 would be effective July 1, 2021
8:30
8
Economic Cost of Inadequate Sleep
• Estimated cost of inadequate sleep in Australia for 2016-17 and related
to costs in similar economies using national surveys and databases.
• Overall cost of inadequate sleep is $45.21 billion
• Direct cost was $17.88B and indirect was $27.33B
• $160 million for sleep disorders
• David Hillman, Scott Mitchell, Jared Streatfeild, Chloe Burns, Dorothy Bruck, Lynne Pezzullo; The economic cost of inadequate sleep, Sleep,
Volume 41, Issue 8, 1 August 2018,
Infants, adolescents and college students
Early Nighttime Parental Interventions and Infant
Sleep Regulation Across the First Year
• Objective: To investigate how sleeping arrangement and 2 types of
nighttime interventions(non distress and distress) at 1 and 3 months are
associated with infants’ sleep development across the first 9 months.
• Method:
• Participants: 107 families with solitary or cosleeping infants
• Design: observation and survey at 1, 3, and 9 months
• Measures:
• Solitary and cosleeping infants
• # distress-initiated wakings (DIW)
• # non-distress initiated wakings (NDIW) (parents’ behaviors to non-distressed vocalizations or
while infants were asleep)
Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year. Sleep 2018, July13.Parental Interventions and Infant Sleep
Regulation
• Results
• Infant night wakings decreased over time
• Non-distress initiated interventions moderated by sleep arrangement
• Solitary sleeping infants with higher levels of NDIW showed less steep decline in wakings
compared to solitary infants with low NDIW
• Higher DIW at 1 and 3 months resulted in steeper decrease in night wakings for both
solitary and cosleeping infants.
• Conclusion
• Responding to nighttime distress before 3 months predicts better infant sleep
• Not responding to non-distress before 3 months predicts better sleep
• Parental interventions after 3 month does not have similar impact
• Very early patterns of nighttime parenting may organize infant sleep sleep
regulation
Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year.
Sleep 2018, July13Midday Napping and Neurocognitive Function
in Early Adolescents
• Participants: 363 chinese adolescents (12 + 0.38 years)
• Method: self-reported midday napping, nighttime sleep duration and sleep
quality, computerized neurocognitive battery (accuracy and reaction time)
• Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early Adolescents,
Behavioral Sleep MedicineNapping and Neurocognitive in Early
Adolescents
• Results
• 64% took >3 naps per week
• 70% took naps over 30 minutes
• Ss with frequent or longer naps reported significantly better night sleep quality
• Frequent nappers (5-7d/week) had significantly better accuracy on sustained attention and
nonverbal reasoning, faster reaction times on spatial memory
• Naps of any length resulted in faster reaction time compared to non-nappers
• Moderate duration nappers (31-60 min) had both faster speeds and greater accuracy
Conclusion: There is an association between habitual napping and
neurocognitive function in early adolescents. Naps 31-60 min seemed best
for speed and accuracy.
Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early
Adolescents, Behavioral Sleep Medicine, DOI:Sleep Hygiene Index as a Screening Tool in Nigerian
Students
• Purpose: To determine characteristics and usefulness of the sleep
hygiene index in Nigerian undergraduate students
• Methods
• Participants: 348 students randomly divided in two prior to factor analysis
• Measures: SHI, PSQI, ESS, Morningness Eveningness Questionnaire (MEQ)
Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening tool in a
sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292Sleep Hygiene Index
• Results of SHI:
• SHI Internal consistency was .64
• Significant negative correlation with MEQ (r=-0.17)
• Significant positive correlation with PSQI (r=0.89)
• Significant positive correlation with ESS (r=0.29)
• Exploratory factor analysis in group 1 yielded 3 factors
• Corroborative factor analysis in group 2
• Cutoff score of 16 on SHI had sensitivity of .77 and specificity of 0.47 to identify
students experiencing poor sleep quality
• Conclusion: SHI has satisfactory psychometric properties for evaluating
sleep hygiene and as a screening instrument for poor sleep quality among
Nigerian undergraduate students.
Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening
tool in a sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292Acceptability of Smartphone Applications for Improving Sleep
Behavior in Low Income and Minority Adolescents
• Purpose: to determine acceptability and components to motivate
engagement
• Participants: N=27 (age 14-18) low income and ethnically diverse group
• Method:
• Three focus groups
• Specific feedback on two commercial sleep promoting apps from 10 participants
who had used one on their smart phone prior to interview, thematic analysis
Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the
Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine,
DOI: 10.1080/15402002.2018.1432483Acceptability of Smartphone Sleep Apps
• Results:
• Barriers identified
• reluctance to follow schedule on weekends
• concern about parting with electronics at bedtime
• Intrigued by idea but skeptically they could adopt sleep hygiene practices
• More interested in making changes on weekdays than on weekends
• Feedback on 2 sleep apps not targeting adolescents was positive with good
adherence and engagement and perceived health benefits
• Conclusion
• Need to adapt sleep hygiene apps to targeted populations and consider social and
cultural factors
• Importance of platform, setting and messenger to deliver info to adolescents
Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the
Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine,
DOI: 10.1080/15402002.2018.1432483Insomnia Treatment
Exposure, Relaxation and Rescripting Therapy
(ERRT) for trauma-related nightmares
• Objective: To conduct a dismantling study of exposure, relaxation and
rescripting therapy for nightmares
• Method
• Participants (n=70) reported mean of 6 traumatic events,
mean 30 nightmares/mos, mean nights with nightmares was 4
• Design:
• Randomized to 2 conditions
• ERRT with nightmare exposure and rescripting (EX) n=37, Exposure 30 min in 1 session
• ERRT without nightmare exposure and rescripting (NEX) n=33
• follow-up at 1 week, 3 months and 6 months post treatment
• Measures: nights with nightmares, nightmares per week and nightmare severity
• Secondary measures: insomnia, depression, fear of sleep, PTSD, sleep quality
• Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for
trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.ERRT for Trauma for Nightmares
Insomnia Nightmare Severity
18
4.5
16
4
Insomnia Severity Scale
14
3.5
Nigtmare Severity
12
3
10
2.5
8
2
6
1.5
4 No exposure No exposure
1
2
Exposure 0.5 Exposure
0
0
baseline 1-month 3-month 6-month
baseline 1-month 3-month 6-month
# Nights with Nightmares Nightmare Frequency
4 4.5
3.5 4
3 3.5
Nightmares/week
Number of nights
3
2.5
2.5
2
2
1.5
1.5
1 No exposure 1 No exposure
0.5 0.5
Exposure Exposure
0 0
baseline 1-month 3-month 6-month baseline 1-month 3-month 6-month
ruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama:
Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.ERRT for Trauma Related Nightmares
PTSD Severity Depression
60 30
50 25
Depression Scale
40 20
PTSD
30 15
20 10
No exposure No exposure
10 5
Exposure Exposure
0 0
baseline 1-month 3-month 6-month baseline 1-month 3-month 6-month
Fear of Sleep Sleep Quality
40 16
35 14
30 12
Quality of Sleep
25 10
20 8
15 6
10 No exposure 4 No exposure
5 2 Exposure
Exposure
0 0
baseline 1-month 3-month 6-month baseline 1-month 3-month 6-month
Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related
nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.ERRT for Trauma Related Nightmares
• Results:
• ERRT with and without nightmare exposure significantly improved outcomes (nights
with nightmares, nightmares per week, nightmare severity)
• Both conditions significantly improved on fear of sleep, sleep quality, insomnia
severity, daytime sleepiness, PTSD symptom severity and depression severity.
• Significant main effect for time for all variables
• No difference between groups at any point
Conclusions: ERRT with and without nightmare exposure and rescripting can
significantly alleviate nightmare and related distress.
Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting
therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75Aerobic Exercise vs CBT-I in Cancer Patients
• Objective: Access the efficacy of 6-week home based aerobic exercise program
(EX) compared to 6-week self-administered CBT-I
• Method:
• Participants: 41 patients (78% F, mean age 57) with various types of Cancer and insomnia
(ISI>8)
• Design: randomized controlled trial, repeated measures
• Groups: Exercise (EX) (n-20) and CBT (n=21)
• Testing: pre- and post-treatment, 3 and 6 month follow-up
• Measures:
• ISI
• PSQI
• sleep diaries (SOL, WASO, TWT and SE)
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25Exercise vs CBT-I in Cancer Patients
Insomnia Severity Index Score
PSQI
18
14
16
Insomnia Severity Index Score
14 12
12 10
10
PSQI Score
8
8
6 6
4 CBT-I 4
CBT-I
2 Exercise 2 Exercise
0
Pre Post 3-month FU 6-month FU 0
Pre Post 3 month FF 6 month FU
Sleep Onset Latency WASO
45 70
40 60
35
50
Minutes Awake
30
Minutes
25 40
20 30
15
20
10 CBT-I
CBT-I
5 10
Exercise
Exercise
0 0
Pre Post 3-month FU 6-month FU Pre Post 3-month FU 6-month FU
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self administered CBT-I in cancer patients. Sleep 2018, Jul 25Exercise vs CBT-I in Cancer Patients
Total Sleep Time Sleep Efficiency
460 90
440 85
% Sleep Efficiencyy
420 80
Minutes of Sleep
400 75
380 70
CBT-I
CBT-I
360 65
Exercise
Exercise
340 60
Pre Post 3-month FU 6-month FU Pre Post 3-month FU 6-month FU
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25Exercise vs CBT-I in Cancer Patients by Patient
Preference
ISI Sleep Efficiency PSQI
18
90 16
16 80 14
14 70
12
% Sleep Efficiency
12 60
10
PSQI score
ISI Score
10 50
8
8 40
CBT-I matched 6
6 CBT-I matched 30 CBT-I matched
EX-matched 4 EX-matched
4 EX-matched 20
CBT-I mismatch CBT-I mismatch CBT-I mismatch
2 10 2
EX mismatch EX mismatch EX mismatch
0 0 0
Pre Post Pre Post Pre Post
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25Exercise vs CBT-I in Cancer Patients
• Results
• Exercise and CBT-I significantly improved ISI, PSQI and most sleep diary parameters at FU
(significant main effect of time)
• Exercise was statistically inferior to CBT-I at post treatment based on ISI
• Exercise was non-inferior at follow-up
• Objective actigraphy data did not significantly differ between groups
• General persistence of sleep difficulties in CBT-I and EX with remission rates of 30% and 35%
respectively post treatment and at follow-up
• Conclusions:
• Exercise and CBT-I significantly improved sleep
• CBT-I remains treatment of choice in CA-related insomnia, although exercise has some
beneficial effects
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25Zero-time exercise on inactive adults with
Insomnia Disorder: pilot RCT
• Objective: To evaluate the effects of lifestyle-integrated zero-time
exercise on insomnia in inactive adults with insomnia disorder
• Method:
• Participants- 37 physically inactive adults (49.9 +13.6 years, 91.9%F)
with insomnia disorder from community
• Design: Random controlled trial
• ZTEx (n-18) attended two 2-hr training lesson on ZTEx & practiced daily for 8 weeks
• Sleep hygiene education (SHE) (n=19) attended two 2-hr lessons on same schedule
• Measures: ISI, actigraphy, sleep dairy
• Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-
Man Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized
controlled trial. SleepMedicine, 2018.Zero-time Exercise in Insomnia
• Results:
• ZTEx had lower ISI scores than SHE with large between group effect size of 0.94-
1.10 at weeks 2,4,6,8 but difference was non-significant at 8 weeks.
• No difference in sleep diary or actigraphy
• 83% finished ZTEx training and
• 78% did ZTEx >5 days per week for 8 weeks
Conclusion: Simple and brief ZTEx training has high acceptability and
compliance and effectively reduced ISI in inactive adults with Insomnia.
Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-Man
Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized controlled trial.
SleepMedicine, 2018.Comparative Treatments for Insomnia and
Sleep Quality in Hot Flashes
• Purpose: Assess interventions for insomnia in women with
vasomotor symptoms (VMS)
• Method:
• Design: Pooled data from 4 RCT n=546 peri and
postmenopausal F with ISI >12, >14 VMS/week.
• Interventions: escitalopram 10-20 mg/d, yoga, aerobic exercise, 1.8g/d
omega 3 fatty acids, 17-beta estradiol 0.5mg.d, venlafaxine XR 75mg.d, and
CBT-I
• Outcomes: ISI, PSQI at baseline, 4 weeks, 8 weeks and some at 12 weeks
Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic Interventions on
Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four
MsFLASH TrialsTreatments for Insomnia and Sleep Quality in Hot Flashes
ISI changes compared to control PSQI
1
0
0
-0.5
-1
PSQI Difference form Baseline
ISI Difference from Baseline
Escitalopram
-1
Exercise
-2
Yoga
Omega-3 -1.5
-3
Estradiol
Venlafaxine -2
-4 CBT-i
-2.5
-5
0 4 8
-6 -3 0 4 8
Weeks Weeks
Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic
Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual
Participant Data From Four MsFLASH TrialsTreatments for Insomnia and Sleep Quality in
Hot Flashes
• Results:
• CBT-I produced the greatest reduction in ISI from baseline compared to controls -5.2 points
(95% CI -7.0 to -3.4)
• Exercise and venlafaxine were similar (-2.1 and -2.3)
• CBT-I produced largest reduction in PSQI of -2.7 points (-3.9 to -1.5)
• Yoga, exercise, estradiol, venlafaxine and escitalopram produced significant decrease of 1.2-
1.6 points
• Omega-3 supplements did not improve insomnia symptoms
Conclusion: Results support the recommendation for CBT-I as a first line treatment
in healthy midlife women with insomnia symptoms and moderately bothersome
VMS.
Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic
Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual
Participant Data From Four MsFLASH TrialsCBT-I and Neuropsychological Functioning in Older Adults
with Mild Cognitive Impairment
• Purpose: Determine if CBT-I improves sleep and cognitive function in
older adults with mild cognitive impairment
• Methods:
• 6 session CBT-I
• 2 groups –
• CBT-I (n=14)
• Active control (n=14)
• Neuropsychological battery at baseline, post-treatment and 4 month FU
Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive
Impairment and Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.CBT-I and Neuropsychological Functioning
• Results:
• significant improvement in sleep
• a significant change on a key measure of executive functioning sub task of inhibition
(Condition 3 of D-KEF Color-Word Interference Test),
• a positive trend on the inhibition-switching task (p < .10;) Condition 4 of D-KEF Color-
Word Interference Test),
• no change in a measure of verbal memory (HVLT-R Delayed Recall) compared with
the active control
• Conclusion: CBT-I has potential to improve sleep and cognitive function in
older adults with MCI
Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive Impairment and
Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.CBT for Older Adults with Insomnia and
Depression
• Purpose: To determine if CBT-I is effective for older adults with comorbid insomnia and
depression and compare CBT- I to CBT-I plus mood strategies (CBT-I+)
• Methods:
• Participants: n=72 (56% F, age 75 +7) with comorbid insomnia & depression DX
based on DSM-5, clinical interviews; ISI and GDS >10)
• Exclusions: cognitive impairment, changes in psychotropic meds in 4 wks, high risk, in ECT or
psychotherapy
• Design:
• 8-week RCT within community mental health services
• 3 conditions in group therapy, 60-90min (CBT-I, CBT-I+, Psychoeducation control group)
• No demographic or sleep and mental health characteristics differences between groups
• Measures:
• ISI, Geriatric Depression Scale at pre, post, FU (weeks 0, 8, 30 respectively)
• Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
August 2018CBT-I in Insomnia and Depression
Insomnia Severity Index Depression Severity
20
20
18
18
16
16
Geriatric Depression Scale
14
14
12 CBT-I 12
ISI Score
10 CBT-I+ 10
8 Control 8
6 6
4 4
2 2
0 0
Pre Post Follow-up Pre Post Follow-up
Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
August 2018CBT in Insomnia & Depression
• Results:
• CBT-I and CBT-I+ both showed significantly greater reduction in insomnia and
depression severity compared to PCG control
• Large effects sizes, high retention and strong remission rates
• Results were maintained at follow-up
• Conclusion: CBT-I, and CBTI+ were both effective in reducing
insomnia and depression severity in older adults.
Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
August 2018Music and Sleep Quality in Primary Insomnia-
a Meta-analysis
• Purpose: To determine if music improves sleep quality in adults with
primary insomnia
• Method: Network meta-analysis
• Databases: PubMed, Embase, Cochrane Library,
China National Knowledge Infrastructure Library
• Publications from 1998 to May 2017
• Music interventions for primary insomnia
• Outcome was sleep quality (PSQI and overall sleep quality)
• Secondary outcomes were sleep latency and sleep efficiency
Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review
and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.Music and Sleep Quality
• Results:
• 20 trials, N=1339 insomnia patients; 684 music intervention groups; 655 no music control
• 12 treatment groups: acupuncture, music & language induction, listening to music, music and
acupuncture, music assisted relaxation, music assisted relaxation and stimulus control, music
with exercise, stimulus control, usual care (health info and hypnosis), western medicine,
placebo music
• All interventions significantly better than usual care for improving PSQI
• Only music-associated relaxation was significantly better than usual care for improving
overall sleep quality
• Only music-assisted relaxation and listening to music had significant advantages for sleep
latency
• Listening to music top rated intervention by patients and ranked best for improving SE
• Conclusions:
• Music intervention offers clear advantages for adults with primary insomnia.
• Listening to music and music-associated relaxation are probably the best options to consider
in the application of music intervention.
Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review
and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.Blocking Nocturnal Blue Light for Insomnia
• Purpose: To determine if wearing amber-tinted blue light-blocking lenses before bed improves
sleep in individuals with insomnia
• Method:
• Participants: n=14 (8 F; age 46.6 + 11.5) with insomnia >3 months (ISQ)
• Exclusion: OSA, sleep disorders, >5 on STOP-Bang, shift work, smoker, beta blockers,
psychiatric disorder, antidepressives or anti anxiety meds, pregnant, breastfeeding of caffeine >400mg/day
• Design:
• Randomized placebo controlled crossover design
• Amber or clear lens glasses worn for 2 hrs before bedtime for 1 week with 4 wk washout
• Told to put on glasses during night awakening if light turned on, electronic device used or got out of bed
• Measures:
• Pittsburgh Insomnia Rating Scale and Quality of Life, Distress and Sleep Parameter subscales completed at 1800
after 7-d of intervention
• Post sleep questionnaire completed every day (SOL, TST, WASO, overall evaluation of sleep and soundness)
• Log of when used the glasses
• Actigraphy
Shechter, A, Kim EW, St-Onge, MP, Westwood, AJ. Blocking nocturnal blue light or insomnia: A randomized controlled trial. J Psychi
Res, Jan 2018, 96, 196-202Blocking Nocturnal Blue Light • Results: Compared to clear lenses, amber lenses significantly improved: • PIRS total score (88 vs 72) • QOL (18 vs 14) • Distress (56 vs 46)and Sleep Parameter subscales (13 vs 11) • Overall quality & soundness of sleep significantly higher (3.3 vs 4; 3.3 vs 4.3) • Reported wake up time significantly delayed (6h:47m vs 7h:15m) • Subjective TST increased (347 vs 399 min) • No difference in actigraphy sleep parameters between groups Conclusion: Amber lenses are a safe, affordable and an easily implemented therapeutic intervention for insomnia symptoms.
Understanding Insomnia
Explanations Given for Going to Bed Late
• Participants: N=17 (7F) ages 20-62 who were frequent bedtime
procrastinators and without a Dx of sleep disorders or shift work
• Method: in-depth structured interview and thematic analysis
• Results: Three emerging themes
• Deliberate procrastination- willful delay because they deserved time for themselves
• Mindless procrastination- lost track of time
• Strategy delay- need delay in order to fall asleep quickly
• Conclusion: Different causes can direct interventions
• Sanne Nauts, Bart A. Kamphorst, Wim Stut, Denise T. D. De Ridder & Joel H. Anderson (2018) The Explanations People Give for Going to Bed Late: A
Qualitative Study of the Varieties of Bedtime Procrastination, Behavioral Sleep MedicineInsomnia as a Path to Alcoholism
• Objective: To assess the risks of Alcohol as a sleep aid by evaluating tolerance
development to sedative–hypnotic effects and subsequent dose escalation
• Method:
• Participants: volunteers 21-55 (50% F) with insomnia (DSM-4: SEInsomnia a Path to Alcoholism • Exp 1 - comparison between night 2 (N2) of alcohol vs night 6 (N6) • 0.6g/kg dose had higher SE and TST on N2 compared to 0 and 0.3g/kg (p
Insomnia and Alcohol
% Nights Alcohol Chosen Number of Refills
60 8
54 Placebo
7
50 Alcohol
6
% Nights Alcohol Chosen
40 37
Number of Refills
5
30 4
3
20
2
10
1
0 0
Alcohol Placebo Alcohol pre Tx Placebo preTX
Pre Treatment Group
Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep,
Volume 41, Issue 8, 1 August 2018Insomnia a Pathway to Alcohol Results: • 0.6 g/kg ethanol increased TSE and stage 3 on night 2, effects lost by night 6 • After 6 nights of pretreatment, choice nights had more self-administered ethanol refills than placebo Conclusion: • Alcohol is a risk as a sleep aid among individuals with insomnia. • Initially a moderate dose of ethanol improved NPSG sleep but was lost by night 6. • Tolerance was associated with enhanced self-administration Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep, Volume 41, Issue 8, 1 August 2018
Insomnia Patients With Objective Short Sleep Duration
Have a Blunted Response to CBT for Insomnia1
• Purpose: Do insomnia patients with 6 hrs objective sleep time (normal sleep time)
• Participants: n=60, ages 40-75 (51% F)without co-morbid mental health or sleep interfering
conditions. Complaint of SMI, DX insomnia based on DSM-4, WASO>60 on diary, insomnia >6
months with onset after 10 years old, reporting >1 poor sleep hygiene practice. Exclusions:
pregnant, medical condition affecting sleep, major psychiatric disorder, 15 or PLMSA>15, other sleep disorders, PSG TST
>2 hours different from subjective estimate.
• Design: participants randomly assigned waitlist or 1,2,4 or 8 treatment sessions. Initially blind to
number of sessions until after first session to encourage maximum use of first session. Baseline
actigraphy and some actigraphy during treatment, first session 45-60 min and subsequent session
15-30 min)
• Measures: baseline PSG, actigraphy, sleep diary, ISQ, Therapy evaluation questionnaire all done
for 2 weeks baseline, through 8 week treatment period and for 2 weeks at 3 and 6 month follow-
up
Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration have a blunted response to CBT
for insomnia. SLEEP, Vol. 40, (1), 2017.Insomnia Patients with Short Sleep Duration
have Blunted Response to CBT-I
Insomnia Sleep Questionnaire % WASO < 31 min
100 90
90 80
80 70
70
% MWASOInsomnia Patients with Short Sleep Duration
have Blunted Response to CBT-I
Sleep Efficiency >80% % Total Wake Decline
60 90
80
50
70
40
% with SE >80%
60
% participants
short sleeper 6h
40
20 30
20
10
10
0 0
baseline 6-month FU 33%
% of Wake Decline
Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration
have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.Total Sleep Time Measured by Actigraphy and
Diaries in Each Group
TST 6 h
400 420
350 400
Total Sleep Time (min)
300
Total Sleep Time )min)
380
250
200 360
150
Diary 340
100
Actigraphy Diary >6h
320
50
Actigraphy >6h
0 300
Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration have a
blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.Total Sleep Time Measured by Actigraphy and
Diaries in Each Group
Conclusions
• Varying insomnia phenotypes show differential response to CBT
• Insomnia patients with objective short sleep time 6 hours TST
• Suggested that insomnia patients with short objective sleep time may
benefit more from CBT combined with pharmacological treatment
• Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration
have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017PTSD is Associated with Reduced
Parasympathetic Activity in NREM
• Purpose: Examine high frequency HR variability (HF-HRV)in sleep in
PTSD
• Methods:
• Participants: 62 veterans, with PTSD (n=29, age 33+7) and without PTSD
(n=33, age31+8))
• Measures:
• self-reported sleep quality
• insomnia severity index
• Self-reported disruptive nocturnal behaviors
• in-lab PSG
Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated
with Reduced Parasympathetic Activity during Sleep in United States Veterans and Military Service Members of the Iraq and
Afghanistan Wars, Sleep 2018, August 29HF HRV in PTSD
Results:
• PTSD vets had significantly lower HF HRV in NREM compared to those
without PTSD. This was significant in 1st and 4th NREM cycles.
• Groups did not differ in REM
HF HRV
900
800
700
600
HF HRV
500
Control
400
PTSD
300
200
100
0
NREM REM
Conclusion: There is blunted parasympathetic modulation during NREM in young
veterans with PTSD
Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated with Reduced Parasympathetic
Activity during Sleep in United States Veterans and Military Service Members of the Iraq and Afghanistan Wars, Sleep 2018, August 29Influence of Exercise Time of Day on Salivary
Melatonin Responses
• Purpose: Evaluate the influence of exercise time of day on melatonin
• Methods:
• 12 regularly exercising males (age 20.8+0.6)
• randomized crossover design
• All completed 3 protocols separated by > 5 days:
• morning exercise (AMEX; 09:00)
• afternoon exercise (PMEX, 1400)
• no exercise
• Exercise was 30 min of running at 75% of VO2max
• Saliva collected at 20:00h, 22:00h and 03:00 h following each session
Carlson LA, Pobocik KM, Lawrence MA, Brazeau DA, Koch AJ. Influence of Exercise Time of Day on Salivary Melatonin Responses Int J Sports Physiol
Perform. 2018 Aug 30:1-13Influence of time of Exercise on Melatonin
• Results: Significant time and condition effects
• s-melatonin significantly increased 03:00 compared to 20h and 22h for all
conditions.
• s-melatonin at 22:00 significantly higher after AMEX (16.5 ± 7.5 pg·mL-1)
compared to PMEX (13.7 ± 6.1 pg·mL-1) . Neither differed from control
• Conclusion: Exercising in the afternoon may blunt melatonin
secretion as compared to morning exercise. If sleep is an issue
morning exercise may be preferable to afternoon exercise.Reproducibility of the Epworth Sleepiness Scale
• Objective- to measure reproducibility of ESS in suspected
OSA pts 1
• Method- retrospective comparison of ESS score at referral
and after 1st sleep clinic visit
• Demo: 154 pts (68% M), mean age 51 +13, AHI = 43 + 40
Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep
apnea. J Clin Sleep Med. 2018;14(5):791-5.Changes in ESS Score
• Results –
• No statistically significant difference between mean ESS score at referral and first
visit (13.7 ± 4.9 vs 13.5 ± 4.6) (P = .61)
• Ave ESS change was -0.2 + 3.9
• 7% dropped from above ESS=10 and 7.8% increased over ESS=10
8%
• 8% had an ESS change of 7 or more
• 21% had an ESS change of 5 points or more 7 or more
• 46% had an ESS change of 3 points or more 21% 5 or more
46%
3 or more
• Conclusion: ESS is variable and should not be used as the
sole tool to prioritize patients for OSA assessment
Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep apnea. J Clin Sleep Med. 2018;14(5):791-5.Requiem for Clinical Use of the ESS
Commentary on the ESS reproducibility study
• ESS performed worst with 39% sensitivity compared to STOP
BANG at 87% for identifying OSA risk
• Need to abandon this subjective measure in evaluation of OSA
1Omobomi O, Quan SF. A requiem for the clinical use of the Epworth Sleepiness Scale. J Clin Sleep Med. 2018;14(5):711–712.Behavioral Sleep the Otter Way
Cat Nap
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