Charles Samuels

Mindfulness-Based Stress Reduction Compared With Cognitive Behavioral Therapy for the Treatment of Insomnia Comorbid With Cancer: A Randomized, Partially Blinded, Noninferiority Trial

PURPOSE Our study examined whether mindfulness-based stress reduction (MBSR) is noninferior to cognitive behavioral therapy for insomnia (CBT-I) for the treatment of insomnia in patients with cancer. PATIENTS AND METHODS This was a randomized, partially blinded, noninferiority trial involving patients with cancer with insomnia recruited from a tertiary cancer center in Calgary, Alberta, Canada, from September 2008 to March 2011. Assessments were conducted at baseline, after the program, and after 3 months of follow-up. The noninferiority margin was 4 points measured by the Insomnia Severity Index. Sleep diaries and actigraphy measured sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency. Secondary outcomes included sleep quality, sleep beliefs, mood, and stress. RESULTS Of 327 patients screened, 111 were randomly assigned (CBT-I, n = 47; MBSR, n = 64). MBSR was inferior to CBT-I for improving insomnia severity immediately after the program (P = .35), but MBSR demonstrated noninferiority at follow-up (P = .02). Sleep diary-measured SOL was reduced by 22 minutes in the CBT-I group and by 14 minutes in the MBSR group at follow-up. Similar reductions in WASO were observed for both groups. TST increased by 0.60 hours for CBT-I and 0.75 hours for MBSR. CBT-I improved sleep quality (P < .001) and dysfunctional sleep beliefs (P < .001), whereas both groups experienced reduced stress (P < .001) and mood disturbance (P < .001). CONCLUSION Although MBSR produced a clinically significant change in sleep and psychological outcomes, CBT-I was associated with rapid and durable improvement and remains the best choice for the nonpharmacologic treatment of insomnia.

Sleep, Recovery, and Performance: The New Frontier in High-Performance Athletics

The relationship of sleep to post-exercise recovery (PER) and athletic performance is a topic of great interest because of the growing body of scientific evidence confirming a link between critical sleep factors, cognitive processes, and metabolic function. Sleep restriction (sleep deprivation), sleep disturbance (poor sleep quality), and circadian rhythm disturbance (jet lag) are the key sleep factors that affect the overall restorative quality of the sleep state. This article discusses these theoretic concepts, presents relevant clinical cases, and reviews pilot data exploring the prevalence of sleep disturbance in two groups of high-performance athletes.

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

I-CAN SLEEP: Rationale and design of a non-inferiority RCT of Mindfulness-based Stress Reduction and Cognitive Behavioral Therapy for the treatment of Insomnia in CANcer survivors

UNLABELLED Individuals with cancer are disproportionately affected by sleep disturbances, relative to the general population. These problems can be a consequence of the psychological, behavioral and physical effects of a cancer diagnosis and treatment. Sleep disturbances often persist for years and, when combined with already high levels of cancer-related distress, may place cancer survivors at a higher risk of future psychopathology, health problems and poorer quality of life. It is important to develop and evaluate treatments that comprehensively address the common symptom profiles experienced by cancer survivors. METHODS This study is a randomized controlled non-inferiority trial comparing Cognitive Behavior Therapy for Insomnia (CBT-I; a known efficacious treatment) to Mindfulness-Based Stress Reduction (MBSR; a treatment with demonstrated potential). This design can efficiently compare these two treatments directly and determine whether MBSR performs to the same standard as CBT-I for the treatment of insomnia with additional benefits of reducing cancer-related distress. Participants are randomly assigned to an 8-week CBT-I or MBSR group. Sleep indices are measured using subjective (sleep diaries) and objective (actigraphy) assessment tools. The primary outcome is insomnia severity. Secondary outcomes include sleep quality, symptoms of stress, mood disturbance, mindfulness, and dysfunctional beliefs and attitudes toward sleep. Assessments are completed at three time periods: pre-treatment, post-treatment and at 3month follow up. CONCLUSIONS Considering the high prevalence of distress and sleep disturbances in the cancer population, should MBSR produce sleep effects comparable to CBT-I, it may be more comprehensive - making it the treatment of choice for addressing cancer-related psychological sequelae.

The Athlete Sleep Screening Questionnaire: a new tool for assessing and managing sleep in elite athletes

Background/aim The purpose of this study was to develop a subjective, self-report, sleep-screening questionnaire for elite athletes. This paper describes the development of the Athlete Sleep Screening Questionnaire (ASSQ). Methods A convenience sample of 60 elite athletes was randomly distributed into two groups; 30 athletes completed a survey composed of current psychometric tools, and 30 athletes completed a revised survey and a sleep specialist structured clinical interview. An item analysis was performed on the revised survey with comparison to clinical decisions regarding appropriate intervention based on a sleep specialist assessment. Results A comparison of existing sleep-screening tools with determination of clinical need from a sleep specialist showed low consistency, indicating that current sleep-screening tools are unsuitable for assessing athlete sleep. A new 15-item tool was developed (ASSQ) by selecting items from existing tools that more closely associated with the sleep specialists reviews. Based on test-retest percentage agreement and the κ-statistic, we found good internal consistency and reliability of the ASSQ. To date, 349 athletes have been screened, and 46 (13.2%) identified as requiring follow-up consultation with a sleep specialist. Results from the follow-up consultations demonstrated that those athletes identified by the ASSQ as abnormal sleepers have required intervention. Conclusions The research developed a new athlete-specific sleep-screening questionnaire. Our findings suggest that existing sleep-screening tools are unsuitable for assessing sleep in elite athletes. The ASSQ appears to be more accurate in assessing athlete sleep (based on comparison with expert clinical assessment). The ASSQ can be deployed online and provides clinical cut-off scores associated with specific clinical interventions to guide management of athletes’ sleep disturbance. The next phase of the research is to conduct a series of studies comparing results from the ASSQ to blinded clinical reviews and to data from objective sleep monitoring to further establish the validity of the ASSQ as a reliable sleep screening tool for elite athletes.

THE COMPARATIVE IMPACT OF MINDFULNESS-BASED CANCER RECOVERY (MBCR) AND COGNITIVE BEHAVIOR THERAPY FOR INSOMNIA (CBT-I) ON SLEEP AND MINDFULNESS IN CANCER PATIENTS

BACKGROUND Insomnia is an important but often overlooked side effect of cancer. Dysfunctional sleep beliefs have been identified as an important perpetuating factor for insomnia. Mindfulness practice has been demonstrated to improve sleep quality but it is unknown whether these effects relate to changes in dysfunctional sleep beliefs. PURPOSE This study is a secondary analysis of a randomized controlled trial comparing mindfulness-based cancer recovery (MBCR) to cognitive behavior therapy for insomnia (CBT-I) in cancer patients with insomnia. This present analysis compares program impact on mindfulness, dysfunctional sleep beliefs, and insomnia severity clinical cutoffs. METHODS Patients (MBCR, n = 32; CBT-I, n = 40) were assessed at baseline, post-program, and 3-month follow-up. RESULTS Across both groups, patients showed improvements over time in acting with awareness (P = .021) and not judging experiences (P = .023). Changes in dysfunctional sleep beliefs produced by the CBT-I group exceeded those produced by MBCR at post-program and follow-up (P < .001). Acting with awareness, non-judging, and non-reacting were the facets of mindfulness associated with an overall reduction in dysfunctional sleep beliefs. There were no significant differences between the MBCR and CBT-I groups in the percentage of patients exceeding insomnia severity clinical cutoffs at post-program or follow-up. CONCLUSIONS This study supports the use of both CBT-I and MBCR to reduce insomnia severity and suggests the development of mindfulness facets as a method of reducing dysfunctional sleep beliefs.

Comment on: “Does Elite Sport Degrade Sleep Quality? A Systematic Review”

The review article by Gupta et al. in a recent issue of Sports Medicine has provided the sleep and sport science community with a methodologically sound systematic review of the literature on sleep in elite athletes [1]. The review included research studies with multiple methods for assessing sleep including objective measures of polysomnography (PSG) and actigraphy, as well as subjective measures using questionnaires. The authors acknowledge the quality of evidence was low with poorly designed research studies and few studies with comparisons to non-athlete controls. Based on the evidence available, the authors conclude that ‘‘elite athletes generally show a high overall prevalence of insomnia symptoms characterized by longer sleep latencies, greater sleep fragmentation, non-restorative sleep, and excessive daytime fatigue.’’ The focus of the review was on insomnia symptomatology with pre-sleep cognitive hyperarousal as a main cause. However, we should also consider another potential cause rarely assessed in the sleep and sport literature thus far. Circadian misalignment is not only present after transmeridian travel, but could also potentially be present in athletes who have delayed or advanced sleep phase syndrome. Athletes who are morning types would not likely suffer from insomnia, but those who are evening types may have difficulties falling asleep within the ideal 30-min window. The standard advice to ‘‘go to bed at a reasonable hour’’ may not align with the athlete’s endogenous sleep phase and could exacerbate insomnia symptoms in those athletes. Future research and sleep screening tools must assess chronotype to identify athletes who are misaligned with the imposed training or competition schedule. It is also important to understand that insomnia is only one of many clinically relevant sleep and circadian disorders that contribute to poor sleep quality in elite athletes. One of the studies cited in the review found that 50% of 175 elite rugby and cricket athletes [2] were identified as being poor sleepers according to the Pittsburgh Sleep Quality Index (PSQI) [3]. If we assumed this was only due to insomnia, we would miss the fact that 38% of the sample identified themselves as being snorers and 8% were reported to have apneic episodes, both indicative of obstructive sleep apnea. In addition, 28% of the sample also had clinically significant levels of excessive daytime sleepiness, a symptom not present in those suffering from insomnia. While the prevalence of clinically significant sleep and circadian disorders is low, the diagnosis and management of these disorders is critical to the performance and well-being of the athlete and the team. Although the sleep duration of elite athletes was similar to non-athlete controls [1], we cannot discount it as a potential contributor to poor sleep in elite athletes. Recommendations for a normal adult are between 7 and 9 h of sleep per day [4], with athletes needing more. The average sleep duration across the 23 studies in Table 2 [1] is only 7.3 h of sleep. It is likely that this lack of sufficient sleep is also contributing to the high prevalence of sleep complaints in athletes. Another important point to consider is that the most widely used questionnaire by studies in this review was the & Amy M. Bender abender@centreforsleep.com

Differences in sleep patterns, sleepiness, and physical activity levels between young adults with autism spectrum disorder and typically developing controls

ABSTRACT Objective: To investigate the differences in sleep, sleepiness, and physical activity (PA) between young adults with autism spectrum disorder (ASD) and typically developing controls (TDC). Method: Actigraphic data and questionnaires on sleep, sleepiness, and PA were compared between fifteen adults with ASD (ADOS range 7–19; ages 22.8 ± 4.5 years) and TDC. Results: In comparison to the TDC group, the ASD group slept longer on average per night but took longer to fall asleep. In relationship to PA levels, the objective PA levels were lower in the ASD group than the TDC group. Fewer wake minutes during the sleep period in the ASD sample were associated with more PA the following day. Conclusion: The findings support previous research that demonstrates differences in sleep parameters and PA between ASD and TDC. Interventions aimed at increasing PA in an ASD population may be beneficial for improved sleep.

Sleep Quality and Chronotype Differences between Elite Athletes and Non-Athlete Controls

Previous research has found that elite athletes have insufficient sleep, yet the specific kinds of sleep disturbances occurring as compared to a control group are limited. Here we compare the subjective sleep quality and chronotype of elite athletes to a control group of non-athlete good sleepers. Sixty-three winter Canadian National Team athletes (mean age 26.0 ± 0.0; 32% females) completed the Pittsburgh Sleep Quality Index (PSQI) and the Athlete Morningness Eveningness Scale. They were compared to 83 healthy, non-athlete, good-sleeper controls (aged 27.3 ± 3.7; 51% females) who completed the PSQI and the Composite Scale of Morningness. The elite athletes reported poorer sleep quality (PSQI global score 5.0 ± 2.6) relative to the controls (PSQI global score 2.6 ± 1.3), despite there being no group difference in self-reported sleep duration (athletes 8.1 ± 1.0 h; controls 8.0 ± 0.7 h). Further, athletes’ chronotype distribution showed a greater skew toward morningness, despite there being no group differences in self-reported usual bedtime and wake time. These results suggest that a misalignment of sleep times with circadian preference could contribute to poorer sleep quality in elite athletes.