Deirdre A. Conroy

Cognitive-behavioral therapy for insomnia in alcohol dependent patients: a randomized controlled pilot trial.

In a randomized controlled trial, we evaluated the efficacy of cognitive-behavioral treatment for insomnia to improve sleep and daytime symptoms, and to reduce relapse in recovering alcohol dependent (AD) participants. Seventeen abstinent AD patients with insomnia (6 women, mean age 46.2 ± 10.1 years) were randomized to 8 sessions of cognitive-behavioral treatment for insomnia for AD (CBTI-AD, n=9) or to a behavioral placebo treatment (BPT, n=8). Subjective measures of sleep, daytime consequences of insomnia and AD, alcohol use, and treatment fidelity were collected at baseline and post-treatment. Diary-rated sleep efficiency and wake after sleep onset, and daytime ratings of General Fatigue on the Multidimensional Fatigue Inventory improved more in the CBTI-AD compared to the BPT group. In addition, more subjects were classified as treatment responders following CBTI-AD. No group differences were found in the number of participants who relapsed to any drinking or who relapsed to heavy drinking. The findings suggest that cognitive-behavioral insomnia therapy benefits subjective sleep and daytime symptoms in recovering AD participants with insomnia more than placebo. The benefits of treating insomnia on drinking outcomes are less apparent.

Treatment options for sleep disturbances during alcohol recovery

Abstract Sleep disturbances are extremely common in the early stages of recovery from alcohol dependence and may persist for several months despite continued abstinence. Studies indicate that sleep disturbances independently increase the risk for relapse to alcohol, suggesting that targeting these problems during recovery may support continued abstinence. However, there is limited information in the addiction literature about available and effective treatments for sleep disturbances in recovering alcoholic patients. The primary goals of this article are to describe the phenomenology of sleep disturbances during recovery from alcohol dependence, to outline the evidence linking sleep problems with alcohol relapse, and to describe available pharmacological and nonpharmacological treatment options, including the evidence regarding their efficacy in recovering alcoholic patients. Recommendations for future research are provided along with special considerations for treating insomnia in this population, includinxg avoiding cross-dependent sedatives, such as benzodiazepines and benzodiazepine receptor agonists (BzRAs).

Sleep and Substance Use Disorders: An Update

Substance use disorders (SUD) are common and individuals who suffer from them are prone to relapse. One of the most common consequences of the use of and withdrawal from substances of abuse is sleep disturbance. Substances of abuse affect sleep physiology, including the neurotransmitter systems that regulate the sleep-wake system. Emerging research now highlights an interactive effect between sleep disorders and substance use. New findings in alcohol and sleep research have utilized sophisticated research designs and expanded the scope of EEG and circadian rhythm analyses. Research on marijuana and sleep has progressed with findings on the effects of marijuana withdrawal on objective and subjective measures of sleep. Treatment studies have focused primarily on sleep in alcohol use disorders. Therapies for insomnia in cannabis disorders are needed. Future research is poised to further address mechanisms of sleep disturbance in alcoholics and the effect of medical marijuana on sleep and daytime functioning.

Dim Light Melatonin Onset in Alcohol-Dependent Men and Women Compared with Healthy Controls

Sleep disturbances in alcohol-dependent (AD) individuals may persist despite abstinence from alcohol and can influence the course of the disorder. Although the mechanisms of sleep disturbances of AD are not well understood and some evidence suggests dysregulation of circadian rhythms, dim light melatonin onset (DLMO) has not previously been assessed in AD versus healthy control (HC) individuals in a sample that varied by sex and race. The authors assessed 52 AD participants (mean ± SD age: 36.0 ± 11.0 yrs of age, 10 women) who were 3–12 wks since their last drink (abstinence: 57.9 ± 19.3 d) and 19 age- and sex-matched HCs (34.4 ± 10.6 yrs, 5 women). Following a 23:00–06:00 h at-home sleep schedule for at least 5 d and screening/baseline nights in the sleep laboratory, participants underwent a 3-h extension of wakefulness (02:00 h bedtime) during which salivary melatonin samples were collected every 30 min beginning at 19:30 h. The time of DLMO was the primary measure of circadian physiology and was assessed with two commonly used methodologies. There was a slower rate of rise and lower maximal amplitude of the melatonin rhythm in the AD group. DLMO varied by the method used to derive it. Using 3 pg/mL as threshold, no significant differences were found between the AD and HC groups. Using 2 standard deviations above the mean of the first three samples, the DLMO in AD occurred significantly later, 21:02 ± 00:41 h, than in HC, 20:44 ± 00:21 h (t = −2.4, p = .02). Although melatonin in the AD group appears to have a slower rate of rise, using well-established criteria to assess the salivary DLMO did not reveal differences between AD and HC participants. Only when capturing melatonin when it is already rising was DLMO found to be significantly delayed by a mean 18 min in AD participants. Future circadian analyses on alcoholics should account for these methodological caveats. (Author correspondence: daconroy@med.umich.edu)

Ramelteon and Improved Insomnia in Alcohol-Dependent Patients: A Case Series

In this case series of 5 alcohol-dependent patients with insomnia who had initiated abstinence, a 4-week course of ramelteon 8 mg nightly was associated with markedly improved insomnia scores, increased total sleep time, and decreased time to fall asleep. Given its lack of abuse potential and evidence of low melatonin levels in alcoholism, ramelteon deserves further study as a treatment for insomnia in this group of patients.

Alcohol, toxins, and medications as a cause of sleep dysfunction

Publisher Summary Numerous substances can result in sleep dysfunction by directly altering brain systems that regulate sleep. Substances can also cause sleep dysfunction indirectly by exacerbating an illness or disorder associated with sleep impairment (for example, caffeine can exacerbate reflux disease causing pain and discomfort that disturb sleep). Substances included in this chapter are drugs of abuse, prescription medications, substances obtained over the counter and off the shelf in stores, and toxic heavy metals. The chapter focuses on the clinical studies and observations. Substance-related, population related, and methodology-related factors influence the observed effects of a substance on sleep in clinical research. Substance related factors include dose, timing of dose, acute versus chronic use, withdrawal from use, pharmacokinetics, mechanism of action, and interactions with other drugs. Population-related factors include age, gender, weight, genetics, psychological traits and states, and health status. Methodological factors include sample size, study design, and type of outcome measures (e.g., nocturnal sleep versus daytime sleepiness; self-report versus polysomnography (PSG))

A Pilot Study on Adolescents With Depression and Insomnia: Qualitative Findings From Focus Groups.

Nonpharmacological treatments for insomnia in adolescents with depression are lacking. This qualitative study was a thematic analysis of the unique characteristics of and preferences for an insomnia treatment in a group of depressed adolescents. Fourteen adolescents with insomnia (age range = 14–19, mean = 17, SD ± 1.7; 71% female) and depression completed a 90-min focus group. Information was elicited about sleep disruptions, insomnia’s impact on mood, and preferences for insomnia treatments. Themes included poor daytime functioning affecting sleep, lack of benefit from sleep medication, and bedtime rumination. Most identified sleep diaries as a barrier to treatment regardless of mode of delivery. Participants also preferred an in-person therapy. Insomnia therapy in adolescents should consider the unique characteristics of depression. Larger studies are warranted.

Marijuana use patterns and sleep among community-based young adults

ABSTRACT Marijuana is the most commonly used recreational drug in the United States. Research on the relationship between marijuana and sleep is still in its infancy. The study examined differences in sleep characteristics between a community sample of daily users, non-daily marijuana users, and non-users. A total of 98 subjects (45 M; 53 F) participated. The mean age was 22.3 (standard deviation = 3.0). There were 53 females and 55% of the sample was Caucasian. Recruitment was done online and via print advertisements in the community. Groups were categorized as non-daily users (n = 29), daily users (n = 49), and non-user controls (n = 20). Sleep was characterized by the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, and the Morningness Eveningness Questionnaire. A standard cut off score of >10 for the Insomnia Severity Index was found in 38.8% of daily users, 10.3% of non-daily users, and 20% of non-users. Pittsburgh Sleep Quality Index scores in daily users (7.0+/–3.8) were higher than non-daily (4.9+/–3.2) and non-user controls (5.0+/–3.7), p = .02. Insomnia Severity Index scores in daily users (7.9+/–6.1) were higher than non-daily (5.1+/–4.3) and non-user controls (4.3+/–4.8), p = .01. Covariate adjusted regression analyses revealed mean Pittsburgh Sleep Quality Index and Insomnia Severity Index scores were significantly lower for non-daily users and controls relative to the daily users. When adjusting for depression and anxiety, these unique associations were not significant. There were no differences in the Epworth Sleepiness Scale or Morningness Eveningness Questionnaire. Daily marijuana users endorsed more sleep disturbance than non-daily users. Future studies should consider mood in the relationship between marijuana use and sleep.

Referral Practices for Cognitive Behavioral Therapy for Insomnia: A Survey Study

This study examined referring practices for cognitive behavioral therapy for insomnia (CBTI) by physicians at University of Michigan Hospitals and Weill Cornell Medical College of Cornell University. A five-item questionnaire was sent via email that inquired about the physicians patient load, number of patients complaining of insomnia, percent referred for CBTI, and impressions of what is the most effective method for improving sleep quality in their patients with insomnia. The questionnaire was completed by 239 physicians. More physicians believed a treatment other than CBTI and/or medication was most effective (N = 83). “Sleep hygiene” was recommended by a third of the sample. The smallest number of physicians felt that CBTI alone was the most effective treatment (N = 22). Additional physician education is needed.

Substance Use as a Risk Factor for Sleep Problems Among Adolescents Presenting to the Emergency Department

Objectives:To determine correlates of sleep problems among adolescents. Specifically, to assess the relative strength of associations between sleep problems and dating victimization, reasons for emergency department (ED) visit, depression, unhealthy alcohol use, and other drug use (marijuana, nonmedical use of prescription opioids, stimulants, and tranquilizers). Methods:A total of 1852 adolescents aged 14 to 20 years presenting for care to the University of Michigan Emergency Department, Ann Arbor, Michigan, during 2011–2012, self-administered a computerized health survey. Sleep problems were identified if any of the 4 items on the Sleep Problems Questionnaire were rated by a patient as greater than 3 on a 0 to 5 scale. Adolescents who were too sick to be screened in the ED were eligible to participate in the study during their inpatient stay. Exclusion criteria for baseline included insufficient cognitive orientation precluding informed consent, not having parent/guardian present if younger than 18 years, medical severity precluding participation, active suicidal/homicidal ideation, non-English-speaking, deaf/visually impaired, or already participated in this study on a prior visit. Results:23.5% of adolescents reported clinically significant sleep problems. Female gender, depression, dating victimization, tobacco use, nonmedical use of prescription medication, and an ED visit for medical reasons were each associated with sleep problems among adolescents, even while controlling for age, other types of drug use, receiving public assistance, and dropping out of school. Conclusions:These exploratory findings indicate that ED-based screening and brief intervention approaches addressing substance use and/or dating victimization may need to account for previously undiagnosed sleep problems.