Comorbid Insomnia Disorder Research Articles

The Association between Suicidal Ideation and Subtypes of Comorbid Insomnia Disorder in Apneic Individuals.

Background/Objectives: Given the existence of higher suicidality in apneic individuals, this study aimed to determine the potential role played by subtypes of the comorbid insomnia disorder (CID) in the occurrence of suicidal ideation for this specific subpopulation. Methods: To perform our analyses, 1488 apneic individuals were retrospectively extracted from the Sleep Laboratory hospitalization register. Only apneic individuals with suicidal ideation highlighted during the psychiatric interview and/or with a score ≥1 on item G of the Beck Depression Inventory confirmed during the clinical interview were included in the group with suicidal ideation. The likelihood of suicidal ideation associated with CID subtypes was investigated using logistic regression analyses. Results: The prevalence of suicidal ideation was 9.3% in our sample of apneic individuals. After hierarchically introducing the significant confounders for adjustment, multivariate logistic regression analyses demonstrated that unlike short sleep duration alone and CID without short sleep duration, the likelihood of suicidal ideation was only higher for CID with short sleep duration in apneic individuals. Conclusions: Thus, we highlighted in this study that CID with short sleep duration could play a major role in higher suicidality for apneic individuals, which seems to require systematic screening and appropriate treatment of this comorbid sleep disorder to enable better management of suicidal risk in this specific subpopulation.

Risk of Comorbid Insomnia Disorder Associated with Major Depression in Apneic Patients: A Cross-Sectional Study.

Given the limitations of available studies, the objective of this study was to explore the role played by current and remitted major depression in the occurrence of comorbid insomnia disorder for apneic patients. Data from 1488 apneic patients were extracted from the medical reports of polysomnographic recordings available in the database of the Sleep Laboratory. The presence of comorbid insomnia disorder in these apneic patients was defined based on the diagnostic criteria of the American Academy of Sleep Medicine Work Group. The risk of comorbid insomnia disorder associated with current or remitted major depression in apneic patients was investigated using multivariate logistic regression models. After adjustment for the main confounding factors, multivariate logistic regression analyses revealed that remitted and current major depression were significantly associated with the occurrence of comorbid insomnia disorder in apneic patients. The findings of this study seem to indicate that comorbid insomnia disorder could be a residual symptom and a marker of major depression in apneic patients, which justifies the establishment of an adequate treatment for major depressive episodes and their potential residual symptoms to allow the better management of comorbid insomnia disorder and the better prevention of its potential negative consequences in this particular subpopulation.

Lemborexant does not impact waketime cognition in subjects with comorbid insomnia disorder and mild obstructive sleep apnea

Lemborexant does not impact waketime cognition in subjects with comorbid insomnia disorder and mild obstructive sleep apnea

The effects of Daridorexant 50 mg on Patients with Comorbid Insomnia Disorder and Untreated Mild Obstructive Sleep Apnea: A Subgroup Post-hoc Analysis of a Phase 3 Clinical Trial

The effects of Daridorexant 50 mg on Patients with Comorbid Insomnia Disorder and Untreated Mild Obstructive Sleep Apnea: A Subgroup Post-hoc Analysis of a Phase 3 Clinical Trial

Effect of lemborexant on cognition in patients with comorbid insomnia disorder and mild obstructive sleep apnea

Effect of lemborexant on cognition in patients with comorbid insomnia disorder and mild obstructive sleep apnea

Associations between sleep difficulties and health outcomes in treatment-seeking veterans.

Sleep disturbance in UK Armed Forces personnel appears to be frequent due to factors such as hostile sleeping environments and can persist even once they have transitioned into civilian life. Despite this, there is currently very limited literature surrounding the prevalence and associated factors of insomnia disorder among UK veterans. This study aimed to expand knowledge of the prevalence and associated demographic, military, health and functional outcomes with probable insomnia disorder within a clinical sample of veterans. Treatment-seeking veterans from a national UK mental health charity were invited to complete a questionnaire including socio-demographic, military, health and well-being questions. Of the sample, 489 (43%) completed the questionnaire. Seventy per cent of the sample reported having probable insomnia disorder. Having probable insomnia disorder was significantly associated with being younger and having physical health problems. Moreover, unadjusted models found associations between probable insomnia disorder and common mental health difficulties, obsessive-compulsive disorder and complex post-traumatic stress disorder. The results suggest that many UK veterans with physical and mental health difficulties experience co-morbid insomnia disorder. Therefore, it is important that clinical services are aware of this prevalence and use targeted interventions to reduce the frequency of insomnia disorder in this population.

Obstructive Sleep Apnea Is a Distinct Physiological Endotype in Individuals with Comorbid Insomnia and Sleep Apnea (COMISA).

With up to 40% of individuals with either insomnia or obstructive sleep apnea (OSA) demonstrating clinically significant symptoms of the other disorder, the high degree of comorbidity amongst the two most common sleep disorders suggests a bi-directional relationship and/or shared underpinnings. Whilst the presence of insomnia disorder is believed to influence the underlying pathophysiology of OSA, this influence is yet to be examined directly. To investigate whether the four OSA endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) are different in OSA patients with and without comorbid insomnia disorder. Using the ventilatory flow pattern captured from routine polysomnography, the four OSA endotypes were measured in 34 OSA patients who met diagnostic criteria for insomnia disorder (COMISA) and 34 OSA patients without insomnia (OSA-only). Patients demonstrated mild-to-severe OSA (AHI: 25.8±2.0 events/h) and were individually matched according to age (50.2±1.5 years) sex (42M:26F), and body mass index (29.3±0.6 kg/m2). Compared to OSA patients without comorbid insomnia, COMISA patients demonstrated significantly lower respiratory arousal thresholds (128.9 [118.1-137.1] vs. 147.7 [132.3-165.0] %Veupnea, U=261, 95%CI[-38.3, -13.9], d=1.1, p<.001), less collapsible upper airways (i.e., higher Vpassive: 88.2 [85.5-94.6] vs. 72.9 [64.7-79.2] %Veupnea, U=1081, 95%CI[14.0, 26.7], d=2.3, p<.001) and more stable ventilatory control (i.e., lower loop gain: 0.51 [0.44-0.56] vs. 0.58 [0.49-0.70], U=402, 95%CI[-0.2, -0.01], d=.05, p=.03). Muscle compensation was similar between groups. Moderated linear regression revealed the arousal threshold moderated the relationship between collapsibility and OSA severity in COMISA, but not OSA-only patients. A low arousal threshold is an overrepresented endotypic trait in individuals with COMISA and may exhibit a greater relative contribution to OSA pathogenesis in these patients. Contrastingly, the prevalence of a highly collapsible upper airway in COMISA was low, suggesting that anatomical predisposition may contribute less to OSA development in COMISA. Based on our findings we theorise that conditioned hyperarousal perpetuating insomnia may translate to a reduced arousal threshold to respiratory events, thereby increasing the risk or severity of OSA. Therapies which target increased nocturnal hyperarousal (e.g., through CBT-I) may be effective in individuals with COMISA.

P.051 Effect of lemborexant on cognition in patients with comorbid insomnia disorder and mild obstructive sleep apnea

Background: Some sleep-promoting medications are associated with cognitive impairment, making treatment of comorbid obstructive-sleep-apnea (OSA) and insomnia (COMISA) challenging. Lemborexant is a dual-orexin-receptor-antagonist approved for insomnia treatment. This post-hoc analysis evaluated cognition in the subgroup of subjects with mild-OSA (apnea-hypopnea-index ≥5–&lt;15 events/h-of-sleep). Methods: Study E2006-G000-304 was a 1-month, randomized, double-blind, placebo (PBO)- and active-comparator (zolpidem-ER 6.25mg [ZOL])-controlled study of lemborexant 5/10mg (LEM5/LEM10). Subjects ≥55y with insomnia disorder/sleep maintenance problems were enrolled (N=1006). A cognitive-performance assessment battery (CPAB) was performed at morning waketime of Days(D)2/3 and D30/31. Change-from-baseline (CFB) for mean power-of-attention (PoA), continuity-of-attention (CoA), quality-of-memory (QoM), and speed-of-memory-retrieval (SoMR) for CPAB tasks was analyzed. Results: The mild-OSA subgroup comprised 410 (40.8%) subjects. On D2/3 and D30/31, CFB for PoA, CoA, QoM, and SoMR for LEM5/LEM10 were not significantly different than PBO. On D2/3, PoA and QoM were significantly worse with ZOL vs PBO; QoM was significantly better with LEM5/LEM10 vs ZOL. On D30/31, SoMR was significantly worse with ZOL vs PBO and significantly better with LEM5/LEM10 vs ZOL. LEM safety in the subgroup was consistent with the overall study population. Conclusions: Memory and attention domains in subjects with COMISA characterized by mild-OSA were not impacted by LEM, unlike ZOL.Support: Eisai Inc.

0331 Effects of Cognitive Behavioral Therapy for Insomnia (CBTI) on Daytime Cognitive Functioning: A Report from the AIR Trial

Abstract Introduction Prior studies have shown that CBTI improves patient reported outcomes including daytime fatigue, mood status and quality of life, yet there are limited data concerning the effects of therapy on objective measures of daytime function. The current study tested the effects of CBTI on measures derived from the psychomotor vigilance test (PVT) in a sample of patients with comorbid insomnia disorder and sleep apnea. Methods Patients with insomnia and comorbid OSA, who were prescribed PAP therapy (N =155; Mage= 56.8±12.5 yrs.; 58.1% women) were randomized to digital CBTI (dCBTI) or Sleep Hygiene (CTRL). They completed PVT at baseline and after 8 weeks of treatment. Patients in the dCBTI arm who reached remission were offered no additional insomnia treatment, whereas those who did not were randomly assigned to 8 weeks of continued access to dCBTI or to a therapist delivered CBTI. Patients again completed the PVT after this second 8-week treatment phase. PVT outcome measures included mean reaction time, attentional lapses and efficiency scores. Linear mixed models were used to compare the PVT measures of patients receiving either of the CBTI treatment sequences with those assigned to the CTRL. Results Analyses showed significant group x time interactions for PVT attentional lapses (F = 3.04; p &amp;lt; .05) and for efficiency scores (F= 4.06; p&amp;lt; .025). Those who received either of the CBTI treatment sequences showed a greater reduction in attentional lapses and greater improvement in their efficiency scores from baseline to the post-treatment assessments than did those assigned the CTRL. Conclusion Findings indicate that CBTI improves objective indices of daytime cognitive functioning among those with comorbid apnea and insomnia disorder. Further tests of CBTI’s effects on these and other measures of cognitive functioning are warranted in other samples of insomnia patients who do and do not have medical, psychiatric and sleep disorder comorbidities. Support (if any) Funding support from the National Heart, Lung and Blood Institute, Grant # 1R01HL130559-01A1.

Internet-delivered cognitive behavioural therapy for insomnia disorder in depressed patients treated at an outpatient clinic for mood disorders: protocol of a randomised controlled trial

BackgroundMajor depression is a highly prevalent disorder causing severe personal distress, and high societal costs. Patients with depression often have comorbid insomnia disorder (ID) leading to even worse personal distress and worse treatment outcomes. Recent results from a non-randomised pilot study with internet-delivered Cognitive Behavioural Therapy (CBTi) for Insomnia (I-Sleep) added to regular depression care were promising regarding feasibility and initial effects on insomnia complaints and depression. However, no randomised controlled trial (RCT) has been performed yet to access the (cost-) effectiveness of I-Sleep for depression. Therefore, this protocol article presents the design of an RCT aimed to assess the (cost-) effectiveness of I-Sleep in addition to usual care for depression compared to usual care alone in depressed patients with a comorbid Insomnia Disorder (ID) treated at outpatient clinics for mood disorders. Methods /designThis is a multi-centre RCT with measurements at baseline and at 3, 6, 9, and 12 months of follow-up. Patients with depression and an ID are randomised to either I-Sleep treatment followed by regular depression care or to regular depression care alone. Our aim is to recruit one hundred and seventy-five patients from multiple outpatient clinics for mood disorders. The primary outcome is the change in depressive symptoms over 12 months of follow-up measured with the Patient Health Questionnaire (PHQ-9). Secondary outcomes are recovery from depression (PHQ-9), insomnia severity (Insomnia Severity Index, ISI), daily functioning (Work and Social Adjustment Scale, WSAS), general quality of life (EuroQol 5-level version, EQ-5D-5L), and societal costs (Adapted versions of the iMTA Productivity Cost Questionnaire, iPCQ and iMTA Medical Cost Questionnaire, iMCQ).DiscussionWe hypothesize that the addition of I-Sleep to usual care will result in a significant improvement in depression treatment outcomes and quality of life as well as a decrease in healthcare and societal costs compared to usual care alone. This study is the first pragmatic RCT evaluating the effectiveness and cost-effectiveness of adding CBTi to usual care for depression.Trial registrationNetherlands Trial Register (NL8955). Registered on October 6th2020. https://trialsearch.who.int/Trial2.aspx?TrialID=NL8955

O053 Obstructive sleep apnea is a distinct physiological phenotype in individuals with comorbid insomnia and sleep apnea (COMISA)

Abstract Introduction Obstructive sleep apnea (OSA) pathophysiology varies among individuals, though the influence of comorbid insomnia on this pathophysiology is unknown. We examined whether upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold differ between OSA patients with and without comorbid insomnia disorder. Methods We noninvasively determined the four traits using the ventilatory flow pattern captured from standard polysomnography in 34 comorbid insomnia and obstructive sleep apnea (COMISA) and 34 OSA patients without insomnia (OSA-only). Participants had mild-to-severe OSA ( AHI 25.8±2.0 events/h) and were matched according to age (50.2±1.5 years) sex (42M:26F), and body mass index (29.3±0.6 kg/m²). Results COMISA patients had significantly lower respiratory arousal thresholds (128.9 [118.1–137.1] vs. 147.7 [132.3–165.0] %Veupnea, U=261, p&amp;lt;.001), less collapsible upper airways (i.e., higher Vpassive 88.2 [85.5–94.6] vs. 72.9 [64.7–79.2] %Veupnea, U=1081, p&amp;lt;.001) and more stable ventilatory control (i.e., lower loop gain: 0.51 [0.44–0.56] vs. 0.58 [0.49–0.70], U=402, p=.03) relative to OSA-only controls. Muscle compensation did not significantly differ between groups. Discussion OSA patients with comorbid insomnia appear to have OSA driven more by heightened nocturnal arousability than by the contribution of anatomical factors, compared to OSA patients without insomnia. Heightened nocturnal arousability as the driver of apneic events in COMISA suggests the conditioned arousal perpetuating insomnia may also increase risk or severity of OSA. Further research should investigate whether targeting increased arousal propensity (e.g., through CBT-I) provides therapeutic benefit to individuals with COMISA.

Risk of Cardiovascular Disease in Apnoeic Individuals: Role of Comorbid Insomnia Disorder.

Given the limited data available, the aim of this study was to examine the 10-year cardiovascular disease (CVD) risk associated with comorbid insomnia disorder and its specific subtypes in apnoeic individuals. Data from 1104 apnoeic individuals recruited from the database of the Erasme Hospital Sleep Laboratory were analysed. Only apnoeic individuals with a Framingham Risk Score ≥10% were included in the group at moderate-to-high 10-year CVD risk. Logistic regression analyses were conducted to examine the risk of 10-year CVD risk associated with comorbid insomnia disorder and its specific subtypes in apnoeic individuals. Moderate-to-high 10-year CVD risk was present in 59.6% of the apnoeic individuals in our sample. After adjustment for the main confounding factors, multivariate logistic regression analyses revealed that comorbid insomnia disorder and, more particularly, its subtype with short sleep duration were significantly associated with moderate-to-high 10-year CVD risk in apnoeic individuals. In this study, we demonstrate that comorbid insomnia disorder and, more specifically, its subtype with short sleep duration appear to have a negative cumulative effect on 10-year CVD risk in apnoeic individuals, which justifies more systematic research and adequate therapeutic management of this disorder to allow for better cardiovascular disease prevention in this particular subpopulation.

0469 The Apnea and Insomnia Research (AIR) Trial: An Interim Report

Abstract Introduction Many sleep apnea patients suffer from comorbid insomnia disorder. Although cognitive behavioral insomnia therapy (CBTI) has proven effective for insomnia among such patients, access to trained CBTI providers remains limited. The current study is testing a digital CBTI (dCBTI) among PAP-prescribed sleep apnea patients with comorbid insomnia. Methods Patients enrolled in this trial complete baseline measures and are randomized to dCBTI or sleep hygiene (CTRL). After 8 weeks, all patients are reassessed. Patients in the dCBTI arm who reach remission by this time point are offered no additional insomnia treatment, whereas those who do not achieve insomnia remission are randomly assigned either another 8 weeks of dCBTI or a therapist delivered CBTI (TCBTI). All groups are reassessed at the end of this second 8-week treatment phase and then again at 3- and 6-month follow-ups. This report considers changes in scores on the Insomnia Severity Index (ISI) from baseline to the end of the second 8-week treatment, as well as insomnia remission (ISI &amp;lt; 8) and responder rates (&amp;gt; 8 point decline on the ISI) of dCBTI and TCBTI relative to the CTRL. The sample for this report included the first 305 participants (mean age = 56.5±12.5 yrs.; 57.1% females). Results Both dCBTI and TCBTI recipients showed greater (p = .0001) and comparable reductions in ISI scores from baseline to the end of the second 8-week treatment phase than did those in the CTRL group. Average ISI score improvements moved dCBTI and TCBTI recipients from moderately severe to mild insomnia symptoms. Significant group differences were noted for both the responder (X2 (2) =19.29, p &amp;lt; 0.0001) and remission rates (X2 (2) =13.89, p = 0.001). Responder rates for those participants switched to TCBTI (50%) were noteably higher than those continued with dCBTI (30.5%) and those in the CTRL group (19.2%); but remission rates were comparable (30.5% vs. 29.2%) and sigificantly higher than the rates shown by the CTRL group (19.2%). Conclusion The dCBTI tested compares well with TCBTI for reducing insomnia symptoms and achieving insomnia remission in those with insomnia and sleep apnea, but insomnia responder rates may be improved by switching patients to TCBTI. Support (If Any) Funding support from the National Heart, Lung and Blood Institute, Grant # 1R01HL130559-01A1.

Treating co-morbid insomnia and social anxiety disorder with sequential CBT protocols: a single-case experimental study.

Although insomnia disorder and social anxiety disorder are among the most prevalent psychiatric disorders, no studies have yet evaluated the use of sequential evidence-based treatment protocols in the population with co-morbid social anxiety disorder and insomnia disorder. This study aimed to investigate the effects of sequential treatments on co-morbid insomnia disorder and social anxiety disorder. As depression is a common co-morbid syndrome for both insomnia and social anxiety, a secondary aim was to examine depressive symptoms. A single-case repeated crossover AB design was used. Ten participants between 18 and 59 years of age with co-morbid DSM-5 diagnoses of insomnia disorder and social anxiety disorder received sequential treatments with cognitive behavioural therapy (CBT). Seven participants completed the treatment course. The primary outcomes were symptoms of insomnia and social anxiety, and the secondary outcome was symptoms of depression. The effects of CBT on people with co-morbid social anxiety disorder and insomnia disorder were mixed. The majority of participants improved their sleep quality and lessened symptoms of social anxiety and depression. However, participants differed in their degree of improvement concerning all three disorders. Sequential CBT treatments are potentially effective at decreasing symptoms of social anxiety and insomnia for people with co-morbid social anxiety disorder and insomnia disorder. The variation in outcome across participants makes firm conclusions about the treatment efficacy difficult to draw.

363 The Apnea and Insomnia Research (AIR) Trial: An Interim Report

Abstract Introduction Many sleep apnea patients suffer from comorbid insomnia disorder. Although cognitive behavioral insomnia therapy (CBTI) is recommended as the first line insomnia treatment for such patients, access to trained providers of this treatment remains limited. The current study is testing he efficacy of an online CBTI among CPAP treated sleep apnea patient with comorbid insomnia. Methods Patients enrolled in this trial complete baseline measures and then are randomized to either an online version of Cognitive Behavioral Insomnia Therapy (CBTI) or no additional treatment beyond their CPAP therapy (CTRL). After 8 weeks of treatment all patients are reassessed. The current report considers changes in scores on the ISI and Epworth Sleepiness Scale (ESS) as well as average minutes of nightly CPAP use from pre-treatment to the end of the initial 8 weeks of online treatment relative to the no treatment CTRL. The sample for this report included the first 276 participants enrolled in this trial (mean age = 56.5±12.5 yrs; 58.7% females). Results Those receiving online CBTI showed greater reductions in their ISI scores from baseline to the end of the initial 8-week treatment phase than did those in the CTRL group (p = .0001). Average ISI score improvements among those receiving online CBTI moved patients from moderately severe insomnia to mild insomnia symptoms. In contrast, no differences were noted between the online CBTI and CTRL groups in regard to pre- to post-treatments changes on the ESS (p= .2541) scores or amount of CPAP use (p = .4383). Conclusion Whereas online CBTI does not seem to reduce daytime sleepiness or improve CPAP adherence among patients with comorbid sleep apnea and insomnia, it appears to be an effective intervention for reducing insomnia severity for this patient group. Support (if any) National Heart. Lung and Blood Institute Grant # 1R01HL130559-01A1

On the question of a primary and secondary origin of insomnia

Approximately 30% insomnia patients have associated somatic, neurological and psychiatric conditions. Clinician has to define causality of these conditions to determine a treatment plan. Secondary insomnia can result from the symptoms of a primary condition or form an impairment of central nervous system due to neurological disorder. Some associated conditions are characterized by high coincidence with insomnia, similar triggers and crossing genotype, neurophysiological and functional findings. This association with insomnia is observed in anxiety disorders, depression, chronic pain syndromes. The paper presents a concept of comorbid insomnia disorder which proposes the existence of a common neural structure which when affected causes the symptoms of both insomnia and comorbid disorder. Comorbid disorders can also be interconnected due to the overlap of the responsible nerve centers. Positive effect of specific pharmacological, psychotherapeutical and behavioral treatment on both conditions evidences this concept.

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea.

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

0510 The Apnea and Insomnia Research (AIR) Trial: A Preliminary Report

Abstract Introduction Many sleep apnea patients suffer from comorbid insomnia disorder. Although cognitive behavioral insomnia therapy (CBTI) is recommended as the first line insomnia treatment for such patients, access to trained providers of this treatment remains limited. The current study is testing he efficacy of an online CBTI among CPAP treated sleep apnea patient with comorbid insomnia. Methods Patients enrolled in this trial complete baseline measures and then are randomized to either an online version of Cognitive Behavioral Insomnia Therapy (CBTI) or no additional treatment beyond their CPAP therapy (CTRL). After 8 weeks of treatment all patients are reassessed. The current report considers changes in scores on the ISI and Epworth Sleepiness Scale (ESS) as well as average minutes of nightly CPAP use from pre-treatment to the end of the initial 8 weeks of online treatment relative to the no treatment CTRL. The sample for this report included the first 170 participants enrolled in this trial (mean age = 56.5±12.5 yrs; 60.1% females). Results Those receiving online CBTI showed greater reductions in their ISI scores from baseline to the end of the initial 8-week treatment phase than did those in the CTRL group (p = .0009). Average ISI score improvements among those receiving online CBTI moved patients from moderately severe insomnia to mild insomnia symptoms. In contrast, no differences were noted between the online CBTI and CTRL groups in regard to pre- to post-treatments changes on the ESS (p= .3771) scores or amount of CPAP use (p = .8053). Conclusion Whereas online CBTI does not seem to reduce daytime sleepiness or improve CPAP adherence among patients with comorbid sleep apnea and insomnia, it appears to be an effective intervention for reducing insomnia severity for this patient group. Support National Heart. Lung and Blood Institute Grant # 1R01HL130559-01A1

Sleep Disorders

Recent research has generated an enormous fund of knowledge about the neurobiology of sleep and wakefulness. Sleeping and waking brain circuits can now be studied by sophisticated neuroimaging techniques that map different areas of the brain during different sleep states and stages. Although the exact biologic functions of sleep are not known, sleep is essential, and sleep deprivation leads to impaired attention and decreased performance. Sleep is also believed to have restorative, conservative, adaptive, thermoregulatory, and consolidative functions. This review discusses the physiology of sleep, including its two independent states, rapid eye movement (REM) and non–rapid eye movement (NREM) sleep, as well as functional neuroanatomy, physiologic changes during sleep, and circadian rhythms. The classification and diagnosis of sleep disorders are discussed generally. The diagnosis and treatment of the following disorders are described: obstructive sleep apnea syndrome, narcolepsy-cataplexy sydrome, idiopathic hypersomnia, restless legs syndrome (RLS) and periodic limb movements in sleep, circadian rhythm sleep disorders, insomnias, nocturnal frontal lobe epilepsy, and parasomnias. Sleep-related movement disorders and the relationship between sleep and psychiatric disorders are also discussed. Tables describe behavioral and physiologic characteristics of states of awareness, the international classification of sleep disorders, common sleep complaints, comorbid insomnia disorders, causes of excessive daytime somnolence, laboratory tests to assess sleep disorders, essential diagnostic criteria for RLS and Willis-Ekbom disease, and drug therapy for insomnia. Figures include polysomnographic recording showing wakefulness in an adult; stage 1, 2, and 3 NREM sleep in an adult; REM sleep in an adult; a patient with sleep apnea syndrome; a patient with Cheyne-Stokes breathing; a patient with RLS; and a patient with dream-enacting behavior; schematic sagittal section of the brainstem of the cat; schematic diagram of the McCarley-Hobson model of REM sleep mechanism; the Lu-Saper “flip-flop” model; the Luppi model to explain REM sleep mechanism; and a wrist actigraph from a man with bipolar disorder. This review contains 14 highly rendered figures, 8 tables, 115 references, and 5 MCQs.

Identifying the best sleep measure to screen clinical insomnia in a psychiatric population

BackgroundInsomnia symptoms are highly prevalent among patients with psychiatric disorders, and this mandates the need to identify the best self-administered sleep measure to screen for clinical insomnia among them. MethodsA total of 400 psychiatric outpatients completed the Pittsburgh Sleep Quality Index, Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Flinders Fatigue Scale, Functional Outcomes of Sleep Questionnaire, and Dysfunctional Beliefs and Attitudes about Sleep Scale in a cross-sectional study. The sensitivity, specificity, positive, and negative predictive values of these six sleep scales were assessed and compared in relation to both ICD-10 and DSM-5 insomnia disorder status established using the interviewer-administered Brief Insomnia Questionnaire. ResultsReceiver operator characteristic curves with the area under the curve (AUC) revealed the ISI to be the most accurate measure to discriminate cases and non-cases on both ICD-10 (AUC = 0.88, 95% CI = 0.84–0.92) and DSM-5 (AUC = 0.82, 95% CI = 0.78–0.86) criteria with “good” accuracy. The cut-off scores of ≥14 and ≥ 11 for the ISI provided optimal sensitivity and specificity for the detection of ICD-10 and DSM-5 insomnia, respectively. DiscussionWith the new calling from DSM-5 to treat sleep symptoms in the presence of a co-existing mental condition, early detection of psychiatric patients with clinically significantly insomnia using a simple but accurate self-report sleep measure becomes important. Our study suggests that the ISI could be used as a potential screening tool for comorbid insomnia disorder in patients with mental disorders.