Todd M. Bishop

Insomnia as a Precipitating Factor in New Onset Mental Illness: a Systematic Review of Recent Findings

PurposeWe aimed to systematically review recent publications (01/2014–03/2017) with longitudinal designs allowing for the assessment of the prospective risk of insomnia on new onset mental illness in key conditions: anxiety, depression, bipolar disorder, posttraumatic stress disorder, substance use disorders, and suicide.Recent FindingsA literature yielded 1859 unique articles meeting search criteria were identified; 16 articles met all selection criteria and reviewed with some studies reporting on more than one mental health outcome. Overall, the review supports the hypothesis that insomnia is a predictor of subsequent mental illness.SummaryThe evidence is strongest for an insomnia-depression relationship. The new studies identified and reviewed add to a modest number of publications supporting a prospective role of insomnia in new onset mental illness in three areas: anxiety disorders, bipolar disorder, and suicide. The few selected new studies focused on SUD were mixed, and no studies focused on PTSD were identified that met the selection criteria. Treatment of insomnia may also be a preventive mental health strategy.

Moral injury: A new challenge for complementary and alternative medicine

Moral injury represents an emerging clinical construct recognized as a source of morbidity in current and former military personnel. Finding effective ways to support those affected by moral injury remains a challenge for both biomedical and complementary and alternative medicine. This paper introduces the concept of moral injury and suggests two complementary and alternative medicine, pastoral care and mindfulness, which may prove useful in supporting military personnel thought to be dealing with moral injury. Research strategies for developing an evidence-base for applying these, and other, complementary and alternative medicine modalities to moral injury are discussed.

Advances in the management of insomnia

Insomnia is highly prevalent and associated with considerable morbidity. Several very efficacious treatments, both pharmacologic and non-pharmacologic, exist for the management of insomnia. New modes of delivery and new formulations of existing sedative-hypnotic medications have been introduced. Novel agents are still being developed and tested to arrive at a hypnotic that has limited side effects while still being efficacious. Innovations with respect to behavioral interventions, which are drastically under-utilized, have focused mainly on making these interventions more widely available through dissemination efforts, briefer formats and more accessible platforms.

Sleep Disturbance and its Association with Suicidal Ideation in Veterans

Suicide is a major public health focus with increasing importance among veterans. Post-traumatic stress disorder (PTSD), depression, and alcohol use are associated with increased rates of suicidal thoughts, with some indications that suicide is also linked to sleep disturbance. The current study examined the association of sleep disturbance with suicidal ideation (SI) among 654 veterans. Logistic regression revealed that after controlling for age, alcohol dependence, depression, and PTSD, sleep disturbance remained associated with SI. In this sample of veterans, the relationship of sleep disturbance to SI does not appear to be solely attributable to comorbid factors. Identification of sleep difficulties may aid in the early detection of SI, allowing for intervention prior to symptom escalation.

Sleep and Suicide in Older Adults: An Opportunity for Intervention.

Whether as a standalone disorder or as a symptom associated with existing pathology, the prevalence of sleep disturbance increases with age. Older adults also experience a myriad of risk factors for suicide, including depression, and have elevated rates of suicide. There is now significant evidence linking sleep disturbances to suicidal thoughts and behaviors. The use of pharmacologic means to treat insomnia (e.g., sedative hypnotics) is also commonplace among older cohorts and has been associated with suicide. Behavioral treatment of insomnia represents an efficacious alternative to pharmacotherapy among older adults, which while improving sleep, may concurrently reduce depressive symptomatology. Implications and clinical recommendations of the sleep-suicide relationship are discussed.

The Relationship Between Sleep Disturbance, Suicidal Ideation, Suicide Attempts, and Suicide Among Adults: A Systematic Review

Suicide is a significant global health concern; identification of modifiable risk factors can guide future research and prevention efforts. A systematic literature review was undertaken to summarize whether disrupted sleep, which has garnered increased attention as a risk factor for suicidal thoughts and behaviors, has continued to be associated with suicide in recent years. The search resulted in 1,806 abstracts with 188 identified for full text review. Limiting studies to 2012-2015 publications with adult participants and an interpretable relationship between sleep and suicide outcomes left 36 articles for the review. Five new articles focused on suicide decedents, eight on veteran/military populations, but relatively few were longitudinal studies (n = 4) and none assessed sleep apnea. A majority of studies used statistical methods to control for psychopathology, strengthening the overall finding that recent work lends further support for disrupted sleep as an important risk factor, and potential warning sign, for suicide. [Psychiatr Ann. 2016;46(3):177186.] Globally, nearly 1 million deaths per year are attributable to suicide.1 In the United States, suicide now represents the 10th leading cause of death and the leading cause Wilfred R. Pigeon, PhD, is a Research Director, VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center; and an Associate Professor, Department of Psychiatry, University of Rochester Medical Center. Todd M. Bishop, PhD, is an Advanced Post-Doctoral Fellow, VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center; and a Research Fellow, Department of Psychiatry, University of Rochester Medical Center. Caitlin E. Titus, MS, is a Research Coordinator, VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center. Address correspondence to Wilfred R. Pigeon, PhD, VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, 400 Fort Hill Avenue, Canandaigua, NY 14424; email: Wilfred.pigeon2@va.gov. T. M. B. is supported, in part, by the United States Department of Veterans Affairs Advanced Fellowship Program in Mental Health Illness Research & Treatment, VISN 2 Center of Excellence for Suicide Prevention at the Canandaigua VA Medical Center, which supported this work. Disclaimer: The authors’ views or opinions do not necessarily represent those of the Department of Veterans Affairs, the National Institutes of Health, or the United States Government. Disclosure: Wilfred R. Pigeon discloses fees received for non-CME services from Merck & Co. and the Sharpe Dohme Company (a pharmaceutical manufacturer). The remaining authors have no relevant financial relationships to disclose. doi: 10.3928/00485713-20160128-01 Wilfred R. Pigeon, PhD; Todd M. Bishop, PhD; and Caitlin E. Titus, MS

Healthcare utilization and symptom variation among veterans using Behavioral Telehealth Center services.

Substance use and mental health problems are often underdiagnosed and undertreated in primary care. Veterans affairs facilities are using the Behavioral Telehealth Center (BTC) to provide evidence-based assessments for primary care patients via telephone. Whether participation in BTC services is associated with (1) increases in healthcare utilization and (2) decreases in symptoms based on behavioral health screening instruments, post-BTC services compared with pre-BTC services were investigated. Retrospective data were extracted for 1,820 patients who were referred to the BTC. Differences in utilization rates and symptom scores pre- and post-BTC services were tested using repeated measures analysis of covariance while controlling for relevant sociodemographic variables. Participants (1) utilized significantly more substance use and mental health treatment services and (2) had significantly lower alcohol and depression screening scores post-BTC services compared with pre-BTC services. This initial evaluation provides support that BTC services are associated with increased healthcare utilization and decreased alcohol and depressive symptoms.

Current Pharmacological and Nonpharmacological Options for the Management of Insomnia

Insomnia continues to be a major public health concern and to have a pronounced and detrimental effect on health care costs, productivity, and quality of life. Efficacious pharmacological and nonpharmacological interventions have emerged over the past few decades, giving providers several options for addressing this disruptive condition; these are herein reviewed. Benzodiazepines have long been the pharmacological treatment of choice for insomnia; however, novel hypnotics being developed by the pharmaceutical industry show promise in addressing insomnia with fewer side effects. From the nonpharmacological perspective, several different single-component interventions such as stimulus control have been shown to be effective, although a combination of these approaches (eg, cognitive-behavioral therapy for insomnia) also enjoy strong empirical support. Future research should continue to examine how sequencing of treatment components, treating different patient cohorts, and combinations of pharmacological and nonpharmacological treatments influence patient outcome.

Brief cognitive behavioral therapy for insomnia delivered to depressed veterans receiving primary care services: A pilot study

BACKGROUND Depression and insomnia are treatable, often co-occur and are common among primary care patients. Treatments designed for primary care must be brief, effective and ideally have the potential to address multiple symptoms. A brief form of cognitive behavioral therapy for insomnia (CBT-I) was piloted among depressed primary care patients with insomnia some of whom endorsed suicidal ideation. METHODS Veterans Affairs primary care patients were randomized to either CBT-I or sleep hygiene. CBT-I consisted of two, 20-40min in-person sessions and two 15-20min telephone sessions; SH consisted of one in-person and one telephone session. Participants were assessed at baseline, post-treatment, and a 3 month follow-up. RESULTS Compared to SH (n=14), brief CBT-I (n=13) had large effects on insomnia severity, sleep efficiency, number of awakenings, and time awake after sleep onset with between group effect sizes ranging from .75 to 1.09 at post-treatment and .66-.89 at follow-up, though significance was not maintained at follow-up. Although both groups experienced significant reductions in depression severity, statistically significant group by time interactions were not observed for depression. LIMITATIONS Notable limitations include the small sample size, having excluded patients with the most severe suicide risk, and the absence of objective testing to detect presence of sleep disorders other than insomnia. CONCLUSIONS The effects observed for insomnia outcomes, corroborate support for using CBT-I in depressed patients and extend this support to a brief from of CBT-I structured for delivery in primary care. Whether a brief form of CBT-I delivered to patients in primary care who endorse suicidal ideation would have a significant effect on depressive symptoms and/or suicidal ideation remains to be tested in a fully powered trial.

Imaging diagnosis-intracranial cryptococcal mass in a cat.

A 4-year-old neutered female domestic shorthair was evaluated for mentation changes and left prosencephalic signs. This imaging report describes the imaging findings for this patient. A diagnosis of a cryptococcal mass was made based on imaging and additional diagnostics. Complete resolution of the mass was demonstrated by follow-up imaging. This report serves as a reminder that masses associated with cryptococcal infection should be included on the differential list for cats with intracranial masses. In addition, this report provides evidence that large intracranial cryptococcal masses may resolve with long-term medical therapy.