Jessica C. Levenson

The Pathophysiology of Insomnia

Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. The aims of this report are (1) to summarize current knowledge on the pathophysiology of insomnia and (2) to present a model of the pathophysiology of insomnia that considers evidence from various domains of research. Working within several models of insomnia, evidence for the pathophysiology of the disorder is presented across levels of analysis, from genetic to molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and self-report. We discuss the role of hyperarousal as an overarching theme that guides our conceptualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that integrates the various types of evidence presented.

The association between social media use and sleep disturbance among young adults

INTRODUCTION Many factors contribute to sleep disturbance among young adults. Social media (SM) use is increasing rapidly, and little is known regarding its association with sleep disturbance. METHODS In 2014 we assessed a nationally representative sample of 1788 U.S. young adults ages 19-32. SM volume and frequency were assessed by self-reported minutes per day spent on SM (volume) and visits per week (frequency) using items adapted from the Pew Internet Research Questionnaire. We assessed sleep disturbance using the brief Patient-Reported Outcomes Measurement Information System (PROMIS®) sleep disturbance measure. Analyses performed in Pittsburgh utilized chi-square tests and ordered logistic regression using sample weights in order to estimate effects for the total U.S. RESULTS In models that adjusted for all sociodemographic covariates, participants with higher SM use volume and frequency had significantly greater odds of having sleep disturbance. For example, compared with those in the lowest quartile of SM use per day, those in the highest quartile had an AOR of 1.95 (95% CI=1.37-2.79) for sleep disturbance. Similarly, compared with those in the lowest quartile of SM use frequency per week, those in the highest quartile had an AOR of 2.92 (95% CI=1.97-4.32) for sleep disturbance. All associations demonstrated a significant linear trend. DISCUSSION The strong association between SM use and sleep disturbance has important clinical implications for the health and well-being of young adults. Future work should aim to assess directionality and to better understand the influence of contextual factors associated with SM use.

Sleep apnea risk and clinical correlates in patients with bipolar disorder

OBJECTIVE Despite the high prevalence of risk factors for obstructive sleep apnea (OSA) among individuals with bipolar disorder, the presence of sleep-disordered breathing has not been systematically assessed in this population. In this study, we sought to determine the level of risk for OSA in a population of remitted individuals with a diagnosis of bipolar I disorder. METHODS A total of 72 individuals with a diagnosis of bipolar I disorder, all of whom were overweight by the World Health Organization criteria, completed the Berlin Questionnaire, a self-assessment tool to establish risk for OSA. RESULTS Over half of this study population (54.1%) was found to be in the high-risk category for OSA. Participants at high risk for OSA scored significantly higher on measures of both depression and mania, even when sleep items were not counted in the total scores. CONCLUSIONS Sleep apnea may be prevalent in patients with bipolar I disorder. Considering the substantial overlap of symptoms between OSA and depression and the potentially harmful effects of sleep disruption in patients with mood disorders, a systematic screening to assess prevalence and associated features of OSA in patients with bipolar disorder is warranted.

Sleep duration is associated with dyslipidemia in patients with bipolar disorder in clinical remission

BACKGROUND The pathways to increased cardiovascular risk in bipolar disorder include health behaviors, psychosocial stress and long-term medication exposure. However, the evidence that the association between cardiovascular risk factors and bipolar disorder remains significant after controlling for these co-factors suggests that additional important risk factors have yet to be identified. Our hypothesis is that disturbances in the sleep-wake cycle are an important and under-recognized pathway through which affective disorders lead to increased cardiovascular risk. METHODS In patients with bipolar disorder type 1 in clinical remission, we: 1) explored whether sleep disturbance predicted the endorsement of NCEP ATP-III criteria for dyslipidemia, independent of other lifestyle factors and 2) tested the association between low HDL (NCEP-ATP III) and sleep duration measured with actigraphy over an eight-day period. RESULTS Median sleep duration is significantly associated with low HDL. The risk of having low HDL increases by 1.23 with every 30 minutes of reduced sleep time. LIMITATIONS Since sleep patterns in patients with bipolar disorder are variable and irregular, it is possible that other sleep characteristics, not present during the span of our study, or the variability itself may be what drives the increased cardiovascular risk. CONCLUSIONS Sleep characteristics of patients with bipolar disorder in clinical remission are associated with cardiovascular risk. More specifically, sleep duration was associated with low HDL. Clinicians should pay special attention to sleep hygiene in treating individuals with bipolar disorder, even when they are in clinical remission.

Differences in sleep disturbances among offspring of parents with and without bipolar disorder: association with conversion to bipolar disorder

Disruptions in sleep and dysregulation in circadian functioning may represent core abnormalities in the pathophysiology of bipolar disorder (BP). However, it is not clear whether these dysfunctions are state or trait markers of BP. This report compared sleep and circadian phenotypes among three groups: offspring of parents with BP diagnosed with BP at intake (BP/OB; n = 47), offspring of parents with BP without BP at intake (non‐BP/OB; n = 386), and offspring of matched control parents who did not have BP (controls; n = 301). We also examined the association of baseline sleep parameters with subsequent development of BP among the non‐BP/OB group.

A quantitative approach to distinguishing older adults with insomnia from good sleeper controls.

STUDY OBJECTIVE Establishing quantitative criteria to distinguish individuals with and without insomnia is important for clinical and research applications, but consensus has not yet been reached for specific values. The purpose of this study was to identify the optimal quantitative thresholds for actigraphy and sleep diary that differentiate older adults (> 60 years) with insomnia from good sleeper controls. METHODS A total of 119 participants (79 insomnia [35% male], 40 control [31.7% male]; mean age = 71.7 [7.2] years) completed at least 7 nights of sleep diary and actigraphy. Receiver operating characteristic curve analyses and the Youden index were used to identify optimal threshold values. Outcomes for each measurement method included sleep onset latency (SOL), wake time after sleep onset (WASO), sleep efficiency (SE), and total sleep time (TST). RESULTS Sleep diary measures produced areas under the curves (AUC) in the high range (0.84-0.97), whereas actigraphy performed poorly at discriminating the two groups (AUC 0.58-0.61). The Youden index identified SOL = 18 minutes, WASO = 21 minutes, SE = 92%, and TST = 388 minutes as the sleep diary measures that yielded the highest sensitivity and specificity values for insomnia-control discrimination. Accounting for hypnotic medication and sleep apnea use did not change the findings. CONCLUSION Sleep diary parameters discriminated individuals with insomnia from good sleepers more accurately than actigraphy. These quantitative criteria are similar to those reported by other investigators using different methods and samples, including younger adults. The results suggest that the sleep diary, an inexpensive self-report sleep measure, may be used in clinical and research settings to help distinguish older adults with and without insomnia.

An Integrated Risk Reduction Intervention can reduce body mass index in individuals being treated for bipolar I disorder: results from a randomized trial.

We conducted a randomized, controlled trial comparing the efficacy of an Integrated Risk Reduction Intervention (IRRI) to a control condition with the objective of improving mood stability and psychosocial functioning by reducing cardiometabolic risk factors in overweight/obese patients with bipolar I disorder.

Implementation of Sleep and Circadian Science: Recommendations from the Sleep Research Society and National Institutes of Health Workshop.

Sairam Parthasarathy, MD1; Mary A. Carskadon, PhD2,3; Girardin Jean-Louis, PhD4; Judith Owens, MD, MPH5; Adam Bramoweth, PhD6; Daniel Combs, MD1; Lauren Hale, PhD7; Elizabeth Harrison, PhD8; Chantelle N. Hart, PhD9; Brant P. Hasler, PhD10; Sarah M. Honaker, PhD, CBSM11; Elisabeth Hertenstein, PhD12; Samuel Kuna, MD13; Clete Kushida, MD, PhD14; Jessica C. Levenson, PhD10; Caitlin Murray, MA15; Allan I. Pack, MD, PhD13; Vivek Pillai, PhD16; Kristi Pruiksma, PhD17; Azizi Seixas, PhD4; Patrick Strollo, MD18; Saurabh S. Thosar, PhD19; Natasha Williams, MD4; Daniel Buysse, MD6

COMPARATIVE OUTCOMES AMONG THE PROBLEM AREAS OF INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSION

Background: Although interpersonal psychotherapy (IPT) is an efficacious treatment for acute depression, the relative efficacy of treatment in each of the four IPT problem areas (grief, role transitions, role disputes, interpersonal deficits) has received little attention. We evaluated the specificity of IPT by comparing treatment success among patients whose psychotherapy focused on each problem area. Moreover, we sought to understand how the patient characteristics and interpersonal problems most closely linked to the onset of a patients current depression contributed to IPT success. Methods: Patients meeting DSM‐IV criteria for an episode of major depressive disorder (n=182) were treated with weekly IPT. Remission was defined as an average Hamilton Rating Scale for Depression 17‐item score of 7 or below over 3 weeks. Personality disorders were diagnosed using the Structured Clinical Interview for DSM‐IV Personality Disorders. Results: Contrary to our prediction that patients whose treatment was focused on interpersonal deficits would take longer to remit, survival analyses indicated that patients receiving treatment focused on each of the four problem areas did not differ in their times to remission. Nor were patients in the interpersonal deficits group more likely to have an Axis II diagnosis. Patients whose treatment focused on role transitions remitted faster than those whose treatment focused on role disputes, after controlling for covariates. Conclusion: With skillful use of IPT strategies and tactics and with careful medication management where appropriate, patients in this study whose treatment focused on each problem area were treated with equal success by trained IPT clinicians. Depression and Anxiety, 2010.

Social rhythm disrupting events increase the risk of recurrence among individuals with bipolar disorder

As outlined in the social zeitgeber hypothesis, social rhythm disrupting (SRD) life events begin a cascade of social and biological rhythm disruption that may lead to the onset of affective episodes in those vulnerable to bipolar disorder. Thus, the study of SRD events is particularly important in individuals with this chronic condition. The purpose of the current study was to evaluate (i) the extent to which SRD life events increased the risk of recurrence of a bipolar mood episode, and (ii) whether the social rhythm disruption associated with the event conferred an increased risk of recurrence, after accounting for the level of threat associated with the life event.