Patricia L. Haynes

Polysomnographic and subjective profiles of sleep continuity before and after mindfulness-based cognitive therapy in partially remitted depression

Objectives: To examine whether mindfulness meditation (MM) was associated with changes in objectively measured polysomnographic (PSG) sleep profiles and to relate changes in PSG sleep to subjectively reported changes in sleep and depression within the context of a randomized controlled trial. Previous studies have indicated that mindfulness and other forms of meditation training are associated with improvements in sleep quality. However, none of these studies used objective PSG sleep recordings within longitudinal randomized controlled trials of naïve subjects. Methods: Twenty-six individuals with partially remitted depression were randomized into an 8-week Mindfulness-Based Cognitive Therapy (MBCT) course or a waitlist control condition. Pre-post measurements included PSG sleep studies and subjectively reported sleep and depression symptoms. Results: According to PSG sleep, MM practice was associated with several indices of increased cortical arousal, including more awakenings and stage 1 sleep and less slow-wave sleep relative to controls, in proportion to amount of MM practice. According to sleep diaries, subjectively reported sleep improved post MBCT but not above and beyond controls. Beck Depression Inventory scores decreased more in the MBCT group than controls. Improvements in depression were associated with increased subjective sleep continuity and increased PSG arousal. Conclusions: MM is associated with increases in objectively measured arousal during sleep with simultaneous improvements in subjectively reported sleep quality and mood disturbance. This pattern is similar to the profiles of positive responders to common antidepressant medications. BDI = Beck Depression Inventory; EEG = electroencephalogram; EMG = electromyogram; EOG = electrooculogram; HRSD = Hamilton Rating Scale for Depression; MBCT = Mindfulness-Based Cognitive Therapy; MM = mindfulness meditation; NWAK = number of awakenings; PSG = polysomnograph; RCT = randomized controlled trial; REM = rapid eye movement; SE = sleep efficiency; SOL = sleep onset latency; SWS = slow-wave sleep; TIB = time in bed; TST = total sleep time; WASO = wake after sleep onset.

Nightmares, insomnia, and sleep‐disordered breathing in fire evacuees seeking treatment for posttraumatic sleep disturbance

Eight months after the Cerro Grande Fire, 78 evacuees seeking treatment for posttraumatic sleep disturbances were assessed for chronic nightmares, psychophysiological insomnia, and sleep-disordered breathing symptoms. Within this sample, 50% of participants were tested objectively for sleep-disordered breathing; 95% of those tested screened positive for sleep-disordered breathing. Multiple regression analyses demonstrated that these three sleep disorders accounted for 37% of the variance in posttraumatic stress symptoms, and each sleep disorder was significantly and independently associated with posttraumatic stress symptoms severity. The only systematic variable associated with posttraumatic stress symptoms of avoidance was sleep-disordered breathing. The findings suggest that three common sleep disorders relate to posttraumatic stress symptoms in a more complex manner than explained by the prevailing psychiatric paradigm, which conceptualizes sleep disturbances in PTSD merely as secondary symptoms of psychiatric distress.

Nocturia and snoring: predictive symptoms for obstructive sleep apnea

PurposeCurrent screening for obstructive sleep apnea (OSA) emphasizes self-reported snoring and other breathing symptoms. Nocturia, a symptom with a precise pathophysiological link to sleep apnea, has not been assessed as a screening tool for this common disorder of sleep respiration. In a large sample of adults presenting to area sleep centers, we aimed to determine the predictive power of nocturia for OSA and compare findings with other markers of OSA commonly used to screen for this disease.MethodsThis was a retrospective chart review. A consecutive sample of 1,007 adult patients seeking treatment at two sleep centers in New Mexico completed detailed medical and sleep history questionnaires and completed diagnostic polysomnography testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of nocturia, snoring, high body mass index, sex, and age for OSA were determined. Hierarchical linear regression determined unique variance contribution to the apnea–hypopnea index, the objective measure of sleep apnea severity.ResultsThe results are as follows: sensitivities—snoring, 82.6% and nocturia, 84.8%; specificities—snoring, 43.0% and nocturia, 22.4%; PPVs—snoring, 84.7% and nocturia, 80.6%; and NPVs—snoring, 39.6% and nocturia, 27.9%. With hierarchical linear regression, patient-reported nocturia frequency predicted apnea–hypopnea index (OSA severity) above and beyond body mass index, sex, age, and self-reported snoring (P < 0.0001).ConclusionsNocturia appears comparable to snoring as a screening tool for OSA in patients presenting to a sleep medical center. Research in urology and primary care clinics is needed to definitively clarify the use of nocturia as a screening instrument for obstructive sleep apnea.

Mindfulness-Based Cognitive Therapy Improves Polysomnographic and Subjective Sleep Profiles in Antidepressant Users with Sleep Complaints

Background: Many antidepressant medications (ADM) are associated with disruptions in sleep continuity that can compromise medication adherence and impede successful treatment. The present study investigated whether mindfulness meditation (MM) training could improve self-reported and objectively measured polysomnographic (PSG) sleep profiles in depressed individuals who had achieved at least partial remission with ADM, but still had residual sleep complaints. Methods: Twenty-three ADM users with sleep complaints were randomized into an 8-week Mindfulness-Based Cognitive Therapy (MBCT) course or a waitlist control condition. Pre-post measurements included PSG sleep studies and subjectively reported sleep, residual depression symptoms. Results: Compared to controls, the MBCT participants improved on both PSG and subjective measures of sleep. They showed a pattern of decreased wake time and increased sleep efficiency. Sleep depth, as measured by stage 1 and slow-wave sleep, did not change as a result of mindfulness training. Conclusions: MM is associated with increases in both objectively and subjectively measured sleep continuity in ADM users. MM training may serve as more desirable and cost-effective alternative to discontinuation or supplementation with hypnotics, and may contribute to a more sustainable recovery from depression.

Disrupting life events and the sleep-wake cycle in depression

BACKGROUND Social rhythm disruption life events are significant predictors of mood relapse in bipolar patients. However, no research has examined the relationship between these events and their hypothesized mechanism of action: disrupted sleep-wake patterns. The goal of this study was to test whether participants with major depressive disorder have a greater disruption of daily sleep and motor activity following disrupting life events when compared to normal controls. METHOD Over the course of 2 weeks, 39 normal controls and 39 individuals with major depressive disorder completed life events interviews and wore actigraphs to obtain estimates of sleep/wake activity. RESULTS Statistically significant interactions indicated that the presence of at least one disrupting life event in the previous 4 months correlated with elevations in the amount of time spent awake after sleep onset [beta=0.45, deltaF(1,73)=4.80, p<0.05], and decreases in the percentage of time spent asleep [beta=-0.53, deltaF(1,73)=6.57, p<0.05], in depressed individuals but not in normal controls. CONCLUSIONS The results indicated that depressed individuals may be more susceptible to the effects of life events on sleep than normal controls. This is the first study to date to correlate life events with objective measures of sleep. However, prospective longitudinal research is necessary to clarify the temporal relationship among these variables.

Illuminating the Impact of Habitual Behaviors in Depression

Researchers have hypothesized that habitual behaviors are zeitgebers for the circadian clock. However, few studies have examined the relationship between habitual behaviors and light, the strongest zeitgeber. Depression is an ideal model in which to explore this relationship because depression is a disorder associated with disruptions in circadian biological activity, sleep, and social rhythms (or patterns of habitual behaviors). We hypothesized that individuals with fewer habitual behaviors have less average exposure to light from morning rise time to evening bedtime and that a reduction in light exposure increases the likelihood of depression. Thirty‐nine depressed and 39 never‐depressed participants wore an ambulatory light monitor and completed the Social Rhythm Metric over the course of 2 weeks. Linear and logistic regression techniques were used to calculate regression coefficients, and confidence limits based on the distribution of the product of two normal random variables were computed to test the significance of the mediation effect. Infrequent habitual behaviors were associated with a decrease in average levels of light exposure, and low levels of light increased the likelihood of depression. This mediation effect was partial; the overall number of habitual behaviors had a direct relationship with depression above and beyond the association with light exposure. Longitudinal studies are needed to empirically demonstrate the direction of relationships between each of the variables tested.

Insomnia treatment acceptability and preferences of male Iraq and Afghanistan combat Veterans and their healthcare providers

Sleep difficulty is a prevalent problem among returning Veterans. Although there is strong evidence for the efficacy and durability of cognitive-behavioral treatment for insomnia (CBT-I) in the general population, the interventions require motivation, attention, and adherence from patients to achieve successful outcomes. Given the unique characteristics of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who have experienced blast-related injuries and other trauma, CBT-I for these patients may require modification, including alternative delivery methods, to ensure effective implementation and positive outcomes. We interviewed 18 OIF/OEF Veterans who screened positive for mild traumatic brain injury and 19 healthcare providers to determine the acceptability of insomnia treatments and preferences for the interventions and treatment delivery. Veterans and providers had distinct preferences for insomnia treatment and its delivery. The treatments the Veterans found most acceptable were also the ones they preferred: relaxation treatment and pharmacotherapy. The providers identified relaxation therapy as the most acceptable treatment. Veterans preferred the individual treatment format as well as electronic methods of treatment delivery. Despite some differences between patients and providers, a compromise through modification of empirically supported behavioral treatments is feasible, and implications for preference-based insomnia intervention development and testing are discussed.

A pilot study of CPAP adherence promotion by peer buddies with sleep apnea.

STUDY OBJECTIVES To evaluate patient ratings of the acceptability of a peer buddy system (PBS). To promote continuous positive airway pressure (CPAP) therapy adherence in patients with obstructive sleep apnea (OSA). To obtain preliminary data on the effectiveness of PBS on sleep-specific health-related quality of life and CPAP adherence. DESIGN Prospective, randomized, and controlled study. SETTING Academic Center. PARTICIPANTS Thirty-nine patients with OSA and 13 patients with OSA who were experienced CPAP users. INTERVENTIONS Recently diagnosed patients with OSA were randomly assigned to either the PBS to promote CPAP adherence (intervention group) or usual care (control group). MEASUREMENTS Patient satisfaction, Functional Outcomes of Sleep Questionnaire (FOSQ), CPAP adherence, vigilance, self-efficacy, and patient activation were measured. RESULTS Ninety-one percent of the subjects rated the PBS as very satisfactory (68%) or satisfactory (23%). During the 90 days of therapy, weekly CPAP adherence was greater in the intervention than the usual care group (MANOVA; F = 2.29; p = 0.04). Patient satisfaction was positively correlated with CPAP adherence (R(2) = 0.14; p = 0.02). We did not find any group differences for FOSQ, vigilance, self-efficacy, or patient activation in this pilot study. CONCLUSION Our pilot study suggests that the PBS intervention is feasible and received high patient satisfaction ratings. CPAP adherence may be improved by peer-driven intervention, but a larger, adequately powered study is needed. CLINICAL TRIAL INFORMATION ClinicalTrials.gov identifier: NCT01164683. COMMENTARY A commentary on this article appears in this issue on page 551. CITATION Parthasarathy S; Wendel C; Haynes PL; Atwood C; Kuna S. A pilot study of CPAP adherence promotion by peer buddies with sleep apnea. J Clin Sleep Med 2013;9(6):543-550.

Examination of insomnia and insomnia treatment in psychiatric inpatients

Despite the high comorbidity of insomnia with psychiatric illness, few studies have examined insomnia or insomnia treatments in psychiatric inpatients. The present study had two overall goals. First, we sought to describe insomnia symptoms in 76 US veterans hospitalized for a wide-range of psychiatric illnesses. Next, we sought to examine whether participation in one session of group therapy for insomnia was associated with improvement in Insomnia Severity Index (ISI) scores for a subset of these inpatients (n = 19). Data were extracted from the clinical charts of 140 inpatients admitted into the 26-bed psychiatric ward at the New Mexico VA Healthcare System. The majority of the veterans had clinical insomnia in the moderate-to-severe range, and only 18% of the sample reported no clinically-significant insomnia. There was a significant reduction in ISI scores approximately 1 week after attendance at the group therapy session, which appears to be unrelated to the length of hospitalization, but might be related to psychiatric stabilization. This is the first study to examine insomnia symptoms in a mixed, psychiatric inpatient population. Group therapy for insomnia might be a particularly useful treatment option given polypharmacy and substance dependency issues often arising in this population.

Effects of a behavioral sleep medicine intervention on trauma symptoms in adolescents recently treated for substance abuse

Abstract This study tested whether improvement in sleep by an integrative, behavioral sleep intervention was associated with improvement in traumatic stress (TS) symptoms in a sample of 20 adolescents who were recently treated for substance abuse. Sleep was measured throughout the intervention via daily sleep diaries, and traumatic stress symptoms were assessed by the Global Appraisal of Individual Needs (GAIN) at baseline, post-intervention, 3-months post-intervention, and 12-months post-intervention. Individuals with more time in bed and more total sleep time at the beginning of the intervention had more improvement in TS symptom trajectories across the intervention and at the 12-month follow-up assessment. Interaction trends also emerged indicating that adolescents who, throughout the sleep intervention, went to bed later and fell asleep faster had greater improvements in TS symptoms over time. Overall, these results indicate that stimulus control, a therapy that encourages patients to attempt sleep only when they are sleepy, may be particularly helpful for adolescents with TS symptoms, sleep disturbances, and substance abuse histories.