Thomas A. Willis

Parent-reported sleep problems during development and self-reported anxiety/depression, attention problems, and aggressive behavior later in life

OBJECTIVE To examine associations between sleep problems during development and subsequent emotional and behavioral difficulties. DESIGN Prospective longitudinal study. SETTING The Dutch province of Zuid-Holland. PARTICIPANTS At time 1 of data collection, a representative sample of 2076 children aged 4 to 16 years participated in the study. OUTCOME MEASURES Parents rated their childrens (4-19 years old) sleep at 5 assessments by completing the Child Behavior Checklist. Participants reported on their own emotional and behavioral symptoms at a later assessment (when aged 18-32 years) by completing the Young Adult Self-Report. RESULTS After adjusting for sex, age, socioeconomic status, and parent-rated scores through development for the difficulty being predicted, having any parental reports of sleeping less than others was a risk indicator of high scores on the Anxious/Depressed scale (odds ratio, 1.43; 95% confidence interval, 1.07-1.90; P = .01) and the Aggressive Behavior scale (odds ratio, 1.51; 95% confidence interval, 1.13-2.02; P = .005). There was some (albeit less robust) support for links between other reported sleep difficulties and later problems. Parental reports of sleeping more than others and nightmares were not associated with later difficulties. CONCLUSIONS Physicians should inquire about sleep problems during child development and should be aware that some, but perhaps not others, may constitute risk indicators of later difficulties.

Cortisol awakening rise in middle-aged women in relation to psychological stress

OBJECTIVES The cortisol awakening rise (CAR) is defined as cortisol secretory activity in the first 45-60 min immediately post-awakening. It has been suggested that psychological factors may disrupt the normal awakening rise. Recent research has shown that psychological stress may influence the magnitude of the CAR, however the findings have been mixed. This study examined the impact of stress on the CAR and the diurnal mean in a sample of middle-aged women. METHOD One hundred and eighteen healthy female participants who reported experiencing high or low stress were recruited. Salivary cortisol levels were measured immediately upon awakening (at 0, 15, 30, and 45 min) and at 3, 6, 9 and 12 h on two consecutive days. A number of metabolic and inflammatory biomarkers were also assessed together with measures of mood disturbance and health behaviour. RESULTS The magnitude of the CAR, assessed by the area under the response curve (AURC) estimate, was significantly lower in the high stress group compared to the low stress group indicating that participants who experienced high stress secreted lower levels of cortisol. The effect was largely accounted for by differences 30 min after waking. The diurnal mean was also lower for the high stress group. Although participants in the high stress group had a slightly worse inflammatory profile, only low-density lipoprotein levels were found to be significantly higher, compared to the low stress group. Lifestyle indicators and mood were also found to be significantly poorer in the high stress group. CONCLUSIONS The results suggest that psychological stress may be associated with a smaller cortisol awakening rise, a lower diurnal mean, poor lifestyle choices and high levels of psychological distress. These findings may have broader implications for future health risk and for an individuals ability to cope with imminent daily stressors and demands.

Associations between sleep quality and anxiety and depression symptoms in a sample of young adult twins and siblings.

OBJECTIVES Little is known about the aetiology of the links between sleep disturbance and anxiety and depression symptoms. The aim of this study was to estimate genetic and environmental influences on these associations. METHODS Questionnaires were completed by 1556 young adults from twin and sibling pairs (61.5% female). RESULTS Sleep disturbance was moderately correlated with symptoms of anxiety (r=.39) and depression (r=.50). There was substantial overlap between genes influencing sleep disturbance and those influencing symptoms of anxiety (rA=.58) and depression (rA=.68). Overall, the associations between sleep and symptoms of both anxiety and depression were mainly due to genes (explaining 74% and 58% of the covariances respectively), with the remainder due to nonshared environmental factors. CONCLUSIONS Moderate phenotypic and genetic correlations between the phenotypes support the view that sleep disturbance is related to the presence of various psychiatric difficulties, but also warrants independent consideration and treatment.

Investigating effort–reward imbalance and work–family conflict in relation to morningness–eveningness and shift work

Abstract The effort–reward imbalance model (ERI; Siegrist, 1996) has been found to be a strong predictor of both psychological and physiological outcomes. Morningness–eveningness (M-E) is believed to relate to shift workers’ ease of adjustment to irregular working patterns. However, it has not been investigated in conjunction with the ERI model. The present study (1) explored whether M-E acts as a predictor of psychological adjustment to shift work, above and beyond the contribution of the ERI model and (2) examined whether the formulation of the ERI model may be overly complex. A sample of police employees (N=112) completed a baseline questionnaire that contained the ERI model and a measure of M-E. Two months later, participants completed measures of work–family conflict and burnout. Regression analyses demonstrated that ERI was a significant predictor of psychological adjustment to shift work. Moreover, and for the first time, M-E was found to make a unique contribution to the prediction of work–family conflict, such that evening types reported greater levels of maladjustment. However, it did not make a unique contribution to the prediction of burnout. The possibility that the ERI model is unnecessarily complex received partial support, with the ratio score only contributing additional variance in one of four regressions. The results indicate that adjustment to shift work and attendant effects on work–family conflict can be affected by an individuals morning-evening typology.

The influence of morningness–eveningness on anxiety and cardiovascular responses to stress

The relationship between cardiovascular responses to stress and health outcomes is inconsistent. In this study, the effects of morningness-eveningness and time of day upon cardiovascular activity at rest and in response to stress were examined. Sixty morning-types and evening-types completed two testing sessions (one morning, one afternoon) that comprised a battery of three stress tasks and a measure of anxiety. The results failed to support a time of day effect upon cardiovascular activity, but there was evidence of an interaction between time of day and morningness-eveningness upon heart rate (HR) and rate pressure product (RPP; HRxSBP). Evening-types exhibited higher HR and RPP in the afternoon, both at rest and during stress. A time of day effect was shown for mood, with anxiety levels higher in the morning than the afternoon. These results are discussed in terms of their health and methodological implications.

Anxiety Disorders and Sleep in Children and Adolescents

Sleep problems are common in children and adolescents. A growing body of research has explored the relationship between sleep problems and anxiety in youth. When reviewing the literature, methodologic inconsistencies need to be considered, such as variation in conceptualization of sleep problems, measurement of sleep, and the classification of anxiety. Despite this, there seems to be good evidence of concurrent and longitudinal associations between sleep difficulties and anxiety in community and clinical samples of young people. Potential mechanisms are proposed. There is a need for further exploration of these relationships, with the hope of aiding preventive capability and developing useful treatments.

Combating child obesity: impact of HENRY on parenting and family lifestyle

The rise in child obesity poses a serious public health challenge. It has been argued that efforts may be best targeted towards prevention, but there is a relative dearth of initiatives targeting infants. Earlier evaluation of the impact of HENRY (Health Exercise Nutrition for the Really Young) has shown an improvement in the way practitioners work with families and a positive impact upon their work setting and personal life.

Trial Protocol: Using genotype to tailor prescribing of nicotine replacement therapy: a randomised controlled trial assessing impact of communication upon adherence.

BackgroundThe behavioural impact of pharmacogenomics is untested; informing smokers of genetic test results for responsiveness to smoking cessation medication may increase adherence to this medication. The objective of this trial is to estimate the impact upon adherence to nicotine replacement therapy (NRT) of informing smokers that their oral dose of NRT has been tailored to a DNA analysis. Hypotheses to be tested are as follows:IAdherence to NRT is greater among smokers informed that their oral dose of NRT is tailored to an analysis of DNA (genotype), compared to one tailored to nicotine dependence questionnaire score (phenotype).II Amongst smokers who fail to quit at six months, motivation to make another quit attempt is lower when informed that their oral dose of NRT was tailored to genotype rather than phenotype.Methods/DesignAn open label, parallel groups randomised trial in which 630 adult smokers (smoking 10 or more cigarettes daily) using National Health Service (NHS) stop smoking services in primary care are randomly allocated to one of two groups:i. NRT oral dose tailored by DNA analysis (OPRM1 gene) (genotype), orii. NRT oral dose tailored by nicotine dependence questionnaire score (phenotype)The primary outcome is proportion of prescribed NRT consumed in the first 28 days following an initial quit attempt, with the secondary outcome being motivation to make another quit attempt, amongst smokers not abstinent at six months. Other outcomes include adherence to NRT in the first seven days and biochemically validated smoking abstinence at six months. The primary outcome will be collected on 630 smokers allowing sufficient power to detect a 7.5% difference in mean proportion of NRT consumed using a two-tailed test at the 5% level of significance between groups. The proportion of all NRT consumed in the first four weeks of quitting will be compared between arms using an independent samples t-test and by estimating the 95% confidence interval for observed between-arm difference in mean NRT consumption (Hypothesis I). Motivation to make another quit attempt will be compared between arms in those failing to quit by six months (Hypothesis II).DiscussionThis is the first clinical trial evaluating the behavioural impact on adherence of prescribing medication using genetic rather than phenotypic information. Specific issues regarding the choice of design for trials of interventions of this kind are discussed.Trial detailsFunder: Medical Research Council (MRC)Grant number: G0500274ISRCTN: 14352545Date trial stated: June 2007Expected end date: December 2009Expected reporting date: December 2010

Developing ‘high impact’ guideline-based quality indicators for UK primary care: a multi-stage consensus process

BackgroundQuality indicators (QIs) are an important tool for improving clinical practice and are increasingly being developed from evidence-based guideline recommendations. We aimed to identify, select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence-based practice using routinely recorded clinical data in United Kingdom (UK) primary care.MethodsWe reviewed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘high impact’ QIs relevant to primary care based upon explicit prioritisation criteria. We then field tested the QIs using remotely extracted, anonymised patient records from 89 randomly sampled primary care practices in the Yorkshire region of England.ResultsOut of 2365 recommendations and QIs originally reviewed, we derived a set of 18 QIs (5 single, 13 composites – comprising 2–9 individual recommendations) for field testing. QIs predominantly addressed chronic disease management, in particular diabetes, cardiovascular and renal disease, and included both processes and outcomes of care. Field testing proved to be critical for further refinement and final selection.ConclusionsWe have demonstrated a rigorous and transparent methodology to develop a set of high impact, evidence-based QIs for primary care from clinical guideline recommendations. While the development process was successful in developing a limited set of QIs, it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine, structured recording of clinical care.

Monozygotic Twin Differences in Non-shared Environmental Factors Associated with Chronotype

Twin studies have highlighted that a large proportion of variability in chronotype is accounted for by individual-specific environmental factors (non-shared environmental influences). However, little research has aimed to identify specific non-shared environmental influences on chronotype. Although epidemiological studies have shed light on possible environmental influences on chronotype, a substantial amount of research has highlighted the importance of genetic influences on exposure toward specific environments, a process termed gene-environment correlation. It is possible that associations between the environment and chronotype are in part determined by genetics, rather than being purely environmental in origin. One way of exploring the contribution of purely non-shared environmental components on associations between chronotype and the environment is to use the monozygotic twin differences design. This design allows us to tease apart the influences of genetics and the environment to identify purely environmental components. One hundred eighty-nine monozygotic twin pairs (mean age 19.81 years, SD = 1.26, range = 18-22 years, 66.1% female) completed the Horne and Östberg Morningness-Eveningness Questionnaire as a measure of chronotype and questionnaires assessing the following candidate non-shared environmental influences: dependent and independent negative life events, educational attainment, employment status, relationship status, deviant peers, affiliation with deviant peers, general health, smoking, drug use, and alcohol use. Linear regression analyses indicated the presence of gene-environment correlation for the majority of associations between chronotype and candidate environmental influences. When controlling for genetic and shared environmental effects, within monozygotic twin-pair differences in chronotype were associated with within monozygotic twin-pair differences in dependent negative life events (β = −0.27, p < 0.001), educational attainment (β = −0.14, p < 0.05), smoking status (β = 0.22, p < 0.01), and drug use (β = −0.16, p < 0.01). These results suggest that some of the association between these variables is purely environmental in nature. The associations between the remaining environmental variables and chronotype, however, may be intertwined with underlying genetic factors. These findings add to our understanding of genetic and environmental mechanisms underlying the biological clock.