Wendy M. Troxel

Chronic Stress Burden, Discrimination, and Subclinical Carotid Artery Disease in African American and Caucasian Women

This study examined the association between a composite index of stress that included measures of life events, ongoing stress, discrimination, and economic hardship and subclinical carotid disease among 109 African America and 225 Caucasian premenopausal women. African Americans reported more chronic stress and had higher carotid intima-media thickness (IMT) as compared with Caucasians. Among African Americans only, the composite stress index and unfair treatment were associated with higher IMT. These effects were partially mediated by biological risk factors. African American who reported experiencing racial discrimination had marginally more carotid plaque than did those who did not report experiencing racial discrimination. The results suggest that African Americans may be particularly vulnerable to the burden of chronic stress.

Marital Status and Quality in Middle-Aged Women: Associations With Levels and Trajectories of Cardiovascular Risk Factors

The current study compared cardiovascular risk profiles and trajectories (i.e., within-person changes) of women who were married or cohabitating and who had high relationship satisfaction with those of women with moderate or low satisfaction and with those of women who were single, divorced, and widowed. Participants were 493 women from the Healthy Women Study, a prospective investigation of health during and after the menopausal transition. Risk factors were measured across more than 5 occasions and 13 years, on average. Data were analyzed using a multilevel modeling technique. Overall, women in relationships with high satisfaction had lower levels of biological, lifestyle, and psychosocial risk factors when compared with the other groups. In some cases, women in satisfying marriages also showed a lower risk trajectory on risk factors relative to other women. Hence, marriage appears to confer health benefits for women, but only when marital satisfaction is high.

Marital happiness and sleep disturbances in a multi-ethnic sample of middle-aged women.

Previous research suggests that divorced individuals, particularly women, have higher rates of sleep disturbances as compared to married individuals. Among the married, however, little is known about the association between relationship quality and sleep. The present study examined the association between marital happiness and self-reported sleep disturbances in a sample of midlife women drawn from the Study of Womens Health Across the Nation (SWAN), a multi-site, multi-ethnic, community-based study (N = 2,148). Marital happiness was measured using a single item from the Dyadic Adjustment Scale, and sleep disturbance was assessed using 4 items from the Womens Health Initiative Insomnia Rating Scale (WHIIRS). After controlling for relevant covariates, maritally happy women reported fewer sleep disturbances, with the association evident among Caucasian women and to a lesser extent among African American women.

It's more than sex: exploring the dyadic nature of sleep and implications for health.

Sleep is a critical health behavior and one that is typically shared between husbands and wives or romantic partners. However, the science of sleep has traditionally conceptualized and evaluated sleep at the level of the individual. Considering the social context of sleep represents a significant shift in sleep research and also offers a critical opportunity for investigating sleep as a novel pathway linking close relationships with health. The purpose of this review is to integrate research that focuses on how sleep affects or is affected by close relationship functioning and to provide a heuristic framework for understanding the interface between close relationships, sleep, and health. Exploring the links between close relationships and sleep may contribute to our understanding of why some relationships confer health benefits, whereas others confer health risks.

Insomnia and Objectively Measured Sleep Disturbances Predict Treatment Outcome in Depressed Patients Treated with Psychotherapy or Psychotherapy-Pharmacotherapy Combinations

OBJECTIVE Insomnia and objectively measured sleep disturbances predict poor treatment outcomes in patients with major depressive disorder (MDD). However, prior research has utilized individual clinical trials with relatively small sample sizes and has focused on insomnia symptoms or objective measures, but not both. The present study is a secondary analysis that examines the degree to which insomnia, objective sleep disturbances, or their combination predicts depression remission following pharmacotherapy and/or psychotherapy treatment. METHOD Participants were 711 depressed (DSM criteria) patients drawn from 6 clinical trials. Remission status, defined as a score of ≤ 7 on the Hamilton Depression Rating Scale (HDRS) over 2 consecutive months, served as the primary outcome. Insomnia was assessed via the 3 sleep items on the HDRS. Objectively measured short sleep duration (total sleep time ≤ 6 hours) and prolonged sleep latency (> 30 minutes) or wakefulness after sleep onset (> 30 minutes) were derived from in-laboratory polysomnographic sleep studies. Logistic regression predicted the odds of nonremission according to insomnia, each of the objective sleep disturbances, or their combination, after adjusting for age, sex, treatment modality, and baseline depressive symptoms. RESULTS Prolonged sleep latency alone (OR = 3.53; 95% CI, 1.28-9.73) or in combination with insomnia (OR = 2.11; 95% CI, 1.13-3.95) predicted increased risk of nonremission. In addition, insomnia and sleep duration individually and in combination were each associated with a significantly increased risk of nonremission (P values < .05). CONCLUSIONS Findings suggest that objectively measured prolonged sleep latency and short sleep duration independently or in conjunction with insomnia are risk factors for poor depression treatment outcome.

Perceived Racial Discrimination as an Independent Predictor of Sleep Disturbance and Daytime Fatigue

Perceived discrimination is a potential cause of racial and ethnic disparities in health. Disturbed sleep may serve as a mechanism linking perceived racism with health consequences. This study investigates data from 7,148 adults from Michigan and Wisconsin who participated in the 2006 Behavioral Risk Factor Surveillance System. Hierarchical logistic regression analyses explored associations between perceived racial discrimination and self-reported sleep disturbance and daytime fatigue. Sleep disturbance and daytime fatigue were reported in 19% and 21% of the sample, respectively. Black/African American respondents (21%) report perceiving worse experiences, compared to people of other races, when seeking health care at higher rates than non-Hispanic White respondents (3%). Results from logistic regression models show that perceived racial discrimination is associated with increased risks of sleep disturbance (odds ratio [OR] = 2.62, p < .0001) and daytime fatigue (OR = 2.07, p < .0001). After adjustment for all covariates, perceived discrimination remains a significant predictor of sleep disturbance (OR = 1.60, p = .04). The interaction between perceived racism and race (Black/African American vs. non-Hispanic White) was nonsignificant. This population-based research adds to the growing body of data, suggesting that perceived racism may impact health via its influence on sleep-wake behaviors.

Chronic exposure to everyday discrimination and sleep in a multiethnic sample of middle-aged women

OBJECTIVE Researchers have suggested that poor sleep may play a role in the association between discrimination and health, but studies linking experiences of discrimination to sleep are limited. The authors examined associations between reports of everyday discrimination over 4 years (chronic everyday discrimination) and subjective and objective indicators of poor sleep. METHOD Participants were 368 African American, Caucasian, and Chinese women from the Study of Womens Health Across the Nation Sleep Study. Everyday discrimination was assessed each year from baseline through the third follow-up exam via questionnaire with the Everyday Discrimination Scale (intraclass correlation coefficient over 4 years = .90). Subjective sleep complaints were measured beginning in Year 5 with the Pittsburgh Sleep Quality Index. Objective indices of sleep continuity, duration, and architecture were assessed via in-home polysomnography, beginning in Year 5. RESULTS In linear regression analyses adjusted for age, race/ethnicity, and financial strain, chronic everyday discrimination was associated with more subjective sleep complaints (Estimate = 1.52, p < .001) and polysomnography-assessed wakefulness after sleep onset (Estimate = .19, p < .02), a marker of sleep continuity. Findings did not differ by race/ethnicity and remained significant after adjusting for menopausal status, body mass index, medication use, and depressive symptoms. CONCLUSION Experiences of chronic everyday discrimination are independently associated with both subjective and objective indices of poor sleep. Findings add to the growing literature linking discrimination to key markers of biobehavioral health.

Clinical Management of Insomnia with Brief Behavioral Treatment (BBTI)

Insomnia is a highly prevalent and debilitating sleep disorder. It is well documented that psychological treatments, including cognitive-behavioral therapy for insomnia (CBTI), are efficacious treatments, with effect sizes of comparable magnitude to that of pharmacologic treatment. However, a critical shortage of specialty-trained clinicians with experience in sleep medicine and cognitive-behavioral therapy principles has limited the widespread dissemination of CBTI. A brief (four sessions; two of which may be phone sessions) treatment, titled “Brief Behavioral Treatment for Insomnia” (BBTI), was developed to address many of the barriers to widespread dissemination associated with standard CBTI. Specifically, BBTI has an explicit behavioral focus, is overtly linked to a physiological model of sleep regulation, and utilizes a hardcopy workbook that facilitates its concise delivery format and ease of training clinicians. BBTI has demonstrated efficacy in treating older adults with insomnia (Buysse et al., 2011). This article describes the rationale for the development of BBTI, provides a session-by-session guide to the delivery of the treatment, and concludes with a discussion of contraindications, combined pharmacotherapy treatment, and future directions for the use of BBTI in diverse populations and utilizing different modalities of delivery.

Does social support differentially affect sleep in older adults with versus without insomnia

OBJECTIVE Insomnia is a significant public health problem, particularly among older adults. We examined social support as a potential protective factor for sleep among older adults (60 years and older) with insomnia (n=79) and age- and sex-matched controls without insomnia (n=40). METHODS Perceived social support, sleep quality, daytime sleepiness, and napping behavior were assessed via questionnaires or daily diaries. In addition, wrist actigraphy provided a behavioral measure of sleep continuity parameters, including sleep latency (SL), wakefulness after sleep onset (WASO), and total sleep time (TST). Analysis of covariance for continuous outcomes or ordinal logistic regression for categorical outcomes were used to examine the relationship between social support and sleep-wake characteristics and the degree to which observed relationships differed among older adults with insomnia versus non-insomnia controls. Covariates included demographic characteristics, depressive symptoms, and the number of medical comorbidities. RESULTS The insomnia group had poorer subjective sleep quality, longer diary-assessed SL and shorter TST as compared to the control group. Higher social support was associated with lesser actigraphy-assessed WASO in both individuals with insomnia and controls. There was a significant patient group by social support interaction for diary-assessed SL, such that higher levels of social support were most associated with shorter sleep latencies in those with insomnia. There were no significant main effects of social support or social support by patient group interactions for subjective sleep quality, daytime sleepiness, napping behavior, or TST (diary or actigraphy assessed). CONCLUSION These findings extend the literature documenting the health benefits of social support, and suggest that social support may similarly influence sleep in individuals with insomnia as well as non-insomnia controls.

Attachment Anxiety, Relationship Context, and Sleep in Women With Recurrent Major Depression

Objective: To examine the relationship between attachment anxiety, marital status, bed-partner status, and sleep in recurrently depressed women. Methods: The current study measured polysomnography (PSG) and subjective sleep quality in 107 women with recurrent major depression. Women were categorized as high or low in attachment anxiety based on Bartholomew and Horowitz’s Relationship Questionnaire (1991). Results: There were no significant main or interaction effects of any of the relationship measures on subjective sleep quality. In contrast, PSG results indicated that women with bed partners displayed better sleep efficiency (p < .005). Marital status was also associated with sleep efficiency (p < .05), and married women displayed significantly shorter sleep latencies as compared with never married women (p < .05). Anxiously attached women displayed a reduced percentage of stage 3–4 sleep (p < .05). Moreover, a significant interaction between attachment anxiety and marital status (p < .05) suggested that anxiously attached women who were previously married (i.e., divorced, separated, or widowed) displayed a particularly low percentage of stage 3–4 sleep. Conclusions: Depressed women who exhibit an anxious attachment style and have experienced a marital rupture show reduced stage 3–4 sleep, which may signal a concomitant reduction in restorative cognitive and metabolic processes. Relationship context influences sleep continuity. These results provide a more nuanced approach to considering qualitative and structural aspects of relationships that may influence sleep. PSG = polysomnography; MDD = major depressive disorder; REM = rapid eye movement; PSQI = Pittsburgh Sleep Quality Index; HRSD = Hamilton Rating Scale for Depression; IPT-M = Interpersonal Psychotherapy Maintenance; RQ = Relationship Questionnaire; MS = marital status; A = attachment style; BP = bed-partner status.