Geneviève Belleville

Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety

INTRODUCTION Concomitant anxiety and insomnia is a frequent problem encountered by mental health professionals. PRIMARY OBJECTIVE To assess the impact of cognitive-behavior therapy for insomnia (CBT-I) on associated anxiety. METHOD Systematic search for clinical trials of CBT-I in PsycInfo, Medline, and Proquest Dissertations and Theses. RESULTS Of the 216 CBT-I trials reviewed, 72 (33.3%) reported data on anxiety. The combined effect size (ES) of CBT-I on anxiety was 0.406 [95% CI 0.318-0.493], indicating a small to moderate effect of CBT-I on concomitant anxiety. Anxiety and anxiety-related constructs were measured with 31 different questionnaires or questionnaire subscales, the majority of which were used only once in the sample of studies. CONCLUSIONS CBT-I has only a moderate impact on anxiety in individuals who present insomnia with or without a comorbid anxiety disorder. A careful evaluation of residual anxiety should be conducted subsequent to CBT-I. Further research should focus on standardizing the assessment of anxiety in insomnia research.

Persistence of sleep disturbances following cognitive-behavior therapy for posttraumatic stress disorder.

OBJECTIVES The objectives of the present study were (1) to assess the impact of cognitive-behavior therapy (CBT) for posttraumatic stress disorder (PTSD) on associated sleep disturbances and (2) to explore the correlates of persistent sleep difficulties in terms of anxiety and depression symptoms and perceived health. METHOD Fifty-five individuals with PTSD were administered a series of assessments designed to evaluate sleep, PTSD symptoms, symptoms of anxiety and depression, and perceived health before and after individual CBT for PTSD and at 6-month follow-up. RESULTS Significant improvements were observed on sleep quality, sleep onset latency, sleep efficiency, and sleep disturbances. These changes were not fully maintained after 6 months, and 70% of people who reported baseline sleep difficulties (Pittsburgh Sleep Quality Index >5) still reported significant problems with sleep after treatment. Persistent sleep difficulties were associated with more severe posttraumatic, anxious, and depressive symptoms as well as poorer health. CONCLUSION Although CBT for PTSD had a favorable impact on sleep, the majority of participants suffered from residual sleep difficulties. Individuals with persistent sleep difficulties posttreatment may experience more residual posttraumatic, depression, and anxiety symptoms and poorer mental and physical health than those who do not report sleep problems posttreatment. Further research in this area will allow clinicians to treat sleep problems in these individuals more effectively.

Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey.

Objective: Although widely used in the general population, sleeping pills and minor tranquilizers, also known as antianxiety agents, have been associated with undesirable outcomes. Reports about the association of these drugs with an elevated mortality rate are inconsistent and controversial. This study was designed to assess the mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey in Canada. It was hypothesized that anxiolytic and hypnotic drug use would be associated with an elevated mortality hazard. Method: A population-based sample of 14 117 people aged 18 to 102 years participated in a longitudinal panel survey, with data collected every second year from 1994 to 2007. The primary outcome measures reported in this study are self-report use of anxiolytic and hypnotic drugs, and death. Results: For respondents who reported anxiolytic or hypnotic drug use in the past month the odds of mortality were 3.22 times more (95% CI 2.70 to 3.84) than for those who did not use anxiolytic or hypnotic drugs in the past month. After controlling for confounding sociodemographic, lifestyle, and health factors (including depression), the odds ratio was reduced to 1.36 (95% CI 1.09 to 1.70) but remained significant. Conclusion: Sedative drug use is associated with a small but significant increase in mortality risk. Further research is required to confirm the mechanisms by which sedative drug use increases mortality risk. Where possible, physicians should systematically consider possibilities for nonpharmacological treatment of sleep disturbances and anxiety.

Impact of sleep disturbances on PTSD symptoms and perceived health.

More than two-thirds of individuals with PTSD report significant sleep difficulties that correlate positively with PTSD symptom severity. The aim of the study was to assess the impact of sleep disturbances on PTSD symptom severity and perceived health. Ninety-two volunteer treatment-seeking adults with PTSD were administered a Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon and William, 1996), and a series of questionnaires assessing PTSD symptom severity, perceived health, sleep, and alcohol use. Results from regression analyses revealed that sleep quality has an impact on PTSD symptom severity and perceived mental health, even when the effect of other potential confounding variables (sociodemographic data, trauma-related characteristics, psychiatric comorbidities, alcohol, and psychotropic medication use) is controlled for. The present study highlights the important influence sleep has on the severity of PTSD symptoms. Future studies could explore whether the addition of interventions focusing on sleep help optimize PTSD treatment.

Subjective sleep characteristics associated with anxiety and depression in older adults: a population-based study

Sleep complaints are often associated with anxiety and depression, but the specific complaints related to each syndrome are poorly characterized, especially in older adults. The objective was to identify subjective sleep characteristics specific to anxiety and depression in this population.

Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management.

OBJECTIVE The aim was to assess the efficacy of two brief cognitive-behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes. METHOD A 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n=71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences. RESULTS The seven-session CBT (n=19), one-session panic management (n=24) and pharmacotherapy (n=13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n=15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED. CONCLUSIONS These results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP.

Impact of seasonal and lunar cycles on psychological symptoms in the ED: an empirical investigation of widely spread beliefs

OBJECTIVES This study evaluates the impacts of seasonal and lunar cycles on anxiety and mood disorders, panic and suicidal ideation in patients consulting the emergency department (ED) with a complaint of unexplained chest pain (UCP). METHODS Patients with UCP were recruited from two EDs. Psychiatric diagnoses were evaluated with the Anxiety Disorders Interview Schedule for DSM-IV. RESULTS Significant seasonal effects were observed on panic and anxiety disorders, with panic more frequently encountered during spring [odds ratio (OR)=1.378, 95% confidence interval (CI)=1.002-1.896] and anxiety disorders during summer (OR=1.586, 95% CI=1.037-2.425). Except for one significant finding, no significant effects of lunar cycles were observed. These findings encourage ED professionals and physicians to abandon their beliefs about the influence of lunar cycles on the mental health of their patients. Such unfounded beliefs are likely to be maintained by self-fulfilling prophecies.

Efficacy of 2 interventions for panic disorder in patients presenting to the ED with chest pain.

BACKGROUND Brief and efficacious interventions for panic disorder (PD) in patients presenting to emergency departments (EDs) for chest pain are essential. This study assessed the effects of 2 interventions for this population: a brief cognitive-behavioral therapy delivered by psychologists, and a 6-month pharmacologic treatment initiated and managed by the ED physician. The relative efficacy of both interventions was also examined. MATERIALS AND METHODS Forty-seven adult patients meeting the diagnostic criteria for PD upon presentation to the ED were assigned to 1 of 3 experimental conditions: a brief cognitive-behavioral therapy (7 sessions), a pharmacologic intervention (paroxetine; 6 months); and a usual care control condition. The primary outcome was severity of PD on Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and secondary outcomes included measures of PD symptoms, depressive symptoms, and cardiac anxiety. Outcome measures were taken at baseline, postintervention, as well as at 3- and 6-month follow-ups. RESULTS Patients receiving either intervention demonstrated significant reductions of PD severity (P = .012), frequency of panic attacks (P = .048), and depressive symptoms (P = .027). CONCLUSION Taken together, these findings suggest that empirically validated interventions for PD initiated in an ED setting can be feasible and efficacious, and future studies should assess their impact on both the direct (ie, health care utilization) and indirect (ie, lost productivity) costs associated with PD morbidity in this population.

Preliminary Investigation of the Panic Screening Score for Emergency Department Patients With Unexplained Chest Pain

OBJECTIVES The objective was to demonstrate the derivation and the preliminary validation of a brief screening score to improve recognition of panic-like anxiety in emergency department (ED) patients with unexplained chest pain. METHODS This cross-sectional study included 507 ED patients with unexplained chest pain randomly assigned to the derivation condition (n = 201) or the validation condition (n = 306). The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) acted as the criterion standard for panic diagnosis. Receiver operating characteristic (ROC) curves were used to determine which of the sociodemographic, medical, and questionnaire response variables best predicted the presence of panic-like anxiety in the derivation condition. The selected predictors were entered in a logistic regression analysis to determine variables to be included in the screening score. The predictive validity of the resulting score was evaluated in both conditions. RESULTS The four-item Panic Screening Score (PSS) identified panic-like anxiety with a sensitivity of 63% (95% confidence interval [CI] = 52% to 73%) and a specificity of 84% (95% CI = 76% to 90%) in the derivation phase. The positive predictive value was 74% (95% CI = 62% to 93%) and the negative predictive value was 76% (95% CI = 68% to 89%). In the validation phase, the sensitivity and specificity were 53% (95% CI = 44% to 62%) and 85% (95% CI = 78% to 89%), respectively. The positive predictive value was 72% (95% CI = 62% to 80%) and the negative predictive value was 71% (95% CI = 65% to 77%). CONCLUSIONS The PSS may be useful to identify patients with unexplained chest pain who could benefit from referral to mental health professionals or their primary care providers for evaluation of panic attack and panic disorder. Prospective studies to improve and validate the PSS, followed by impact analysis, are mandatory before clinical implementation.

Sequential Treatment of Comorbid Insomnia and Generalized Anxiety Disorder

OBJECTIVE To explore the efficacy of cognitive-behavior therapy (CBT) for patients with comorbid generalized anxiety disorder (GAD) and insomnia using 2 sequential treatments. METHOD Using a single-case methodology, 10 women (mean age = 45) with chronic insomnia and GAD were randomly assigned to CBT for GAD followed by CBT for insomnia, or to CBT for insomnia followed by CBT for GAD. Sleep and anxiety were measured via diagnostic interviews, daily diaries, and self-report questionnaires. RESULTS Time series analyses, group effect sizes, and indications of clinically significant change revealed improvements on anxiety, worry, and sleep after CBT for GAD. Following CBT for insomnia, positive changes were observed on sleep and, to a lesser extent, anxiety and worry. CONCLUSIONS In the presence of comorbid GAD and insomnia, initiating treatment for GAD first produced superior clinical benefits in anxiety and sleep. The addition of insomnia-specific treatment led to additional improvements in worry and sleep quality.