Comorbid Insomnia Research Articles

Psychological treatment of depression with other comorbid mental disorders: systematic review and meta-analysis

ABSTRACT Most people with a mental disorder meet criteria for multiple disorders. We conducted a systematic review and meta-analysis of randomized trials comparing psychotherapies for people with depression and comorbid other mental disorders with non-active control conditions. We identified studies through an existing database of randomized trials on psychotherapies for depression. Thirty-five trials (3,157 patients) met inclusion criteria. Twenty-seven of the 41 interventions in the 35 trials (66%) were based on CBT. The overall effect on depression was large (g = 0.65; 95% CI: 0.40 ~ 0.90), with high heterogeneity (I2 = 78%; 95% CI: 70 ~ 83). The ten studies in comorbid anxiety showed large effects on depression (g = 0.90; 95% CI: 0.30 ~ 1.51) and anxiety (g = 1.01; 95% CI: 0.28 ~ 1.74). For comorbid insomnia (11 comparisons) a large and significant effect on depression (g = 0.99; 95% CI: 0.16 ~ 1.82) and insomnia (g = 1.38; 95% CI: 0.38 ~ 2.38) were found. For comorbid substance use problems (12 comparisons) effects on depression (g = 0.25; 95% CI: 0.06 ~ 0.43) and on substance use problems (g = 0.25; 95% CI: 0.01 ~ 0.50) were significant. Most effects were no longer significant after adjustment for publication bias and when limited to studies with low risk of bias. Therapies are probably effective in the treatment of depression with comorbid anxiety, insomnia, and substance use problems.

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

Physical activity levels associated with insomnia and depressive symptoms in middle-aged and elderly patients with chronic schizophrenia.

Previous evidence suggested that physical activity had beneficial effects on psychopathological symptoms, insomnia, or depressive symptoms in people with schizophrenia. This study investigated the association between physical activity levels and insomnia and depressive symptoms in middle-aged and elderly hospitalized patients with chronic schizophrenia (CS). 179 participants were enrolled. We used the 30-item Positive and Negative Syndrome Scale (PANSS-30) to assess the psychopathological symptoms. We used the Insomnia Severity Index scale (ISI) and 17-item Hamilton Depression Scale (HAMD-17) to evaluate insomnia and depressive symptoms. Daily physical activity time less than 30 min, within 30-60 min, and more than 60 min were defined as physical inactivity, moderate physical activity, and vigorous physical activity, respectively. The Chi-square test, analysis of variance (ANOVA), and Mann-Whitney U-test were applied for categorical, continuous, and non-normal distribution variables, respectively. The Pearson or Spearman's correlation analyses were utilized to examine the association between physical activity levels, ISI total scores, HAMD total scores, and socio-demographic and clinical variables. Finally, socio-demographic variables with a P-value < 0.05 in the comparison between insomnia/depressive group and non-insomnia/depressive group were considered for inclusion in binary logistic regression analysis to determine the relationship between physical activity levels and insomnia or depressive symptoms. The ISI total scores (r = -0.247, P = 0.001) and HAMD total scores (r = -0.312, P < 0.001) were negatively correlated with physical activity levels. Logistic regression analysis revealed that older age, higher depressive factor scores, and lower physical activity level were influential factors of insomnia symptoms in CS patients (P < 0.05). In addition, vigorous physical activity (compared with physical inactivity) and higher negative and depressive factor scores were independently associated with depressive symptoms in CS patients (P < 0.05). Physical activity levels were influential factors in comorbid insomnia and depressive symptoms in CS patients. Given the benefits of physical activity, it should be strengthened as a routine adjunct to clinical treatment or psychiatric care so as to improve the physical and mental health of patients with psychiatric symptoms.

The prevalence and clinical features of fibromyalgia in Chinese hospitalpatients with primary headache: The survey of fibromyalgia comorbid with headache.

The aims were to explore the prevalence and clinical features of fibromyalgia in Chinese hospital patients with primary headache. Studies done in non-Chinese populations suggest that around one-third of patients with primary headache have fibromyalgia, but data from mainland China are limited. Investigations into the prevalence and clinical features of fibromyalgia in Chinese patients with primary headache would improve our understanding of these two complex disease areas and help guide future clinical practice. This cross-sectional study included adults with primary headache treated at 23 Chinese hospitals from September 2020 to May 2021. Fibromyalgia was diagnosed using the modified 2010 American College of Rheumatology criteria. Mood and insomnia were evaluated employing the Hospital Anxiety and Depression Scale and the Insomnia Severity Index. A total of 2782 participants were analyzed. The fibromyalgia prevalence was 6.0% (166/2782; 95% confidence interval: 5.1%, 6.8%). Compared to primary headache patients without combined fibromyalgia, patients with primary headache combined with fibromyalgia were more likely to be older (47.8 vs. 41.7 years), women (83.7% [139/166] vs. 72.8% [1904/2616]), less educated (65.1% [108/166] vs. 45.2% [1183/2616]), and with longer-duration headache (10.0 vs. 8.0 years). Such patients were more likely to exhibit comorbid depression (34.3% [57/166] vs. 9.9% [260/2616]), anxiety (16.3% [27/166] vs. 2.7% [70/2612]), and insomnia (58.4% [97/166] vs. 17.1% [447/2616]). Fibromyalgia was more prevalent in those with chronic (rather than episodic) migraine (11.1% [46/414] vs. 4.4% [72/1653], p < 0.001) and chronic (rather than episodic) tension-type headache (11.5% [27/235] vs. 4.6% [19/409], p=0.001). Most fibromyalgia pain was in the shoulders, neck, and upper back. The prevalence of fibromyalgia in mainland Chinese patients with primary headache was 6.0%. Fibromyalgia was more common in those with chronic rather than episodic headache. The most common sites of fibromyalgia pain were the neck, shoulders, and back.

Concurrent and longitudinal associations among insomnia symptoms, internalizing problems, and chronic pain in youth.

Although insomnia symptoms and chronic pain are associated, less is known about the temporal nature of the associations between these variables or the impact of internalizing symptoms on the associations. Concurrent and longitudinal associations were examined among insomnia symptoms, internalizing symptoms, and pain in youth with chronic pain in this retrospective analysis of clinical records. We hypothesized the following: (a) pain, insomnia symptoms, and internalizing symptoms would be significantly interrelated at all waves, (b) insomnia symptoms would more strongly predict future pain than the reverse, and (c) internalizing symptoms would mediate the longitudinal association between insomnia symptoms and pain. Youth (N = 132; age M = 15.34 years, SD = 1.86 years) were assessed at their initial and two subsequent appointments (time between appointments M = 6.48 months, SD = 4.43 months). At each appointment, youth reported their pain severity, insomnia symptoms, and internalizing symptoms. Confirmatory factor analyses (CFAs) and cross-lagged panel models using structural equation modeling were conducted. CFAs and the cross-lagged panel model with pain and insomnia symptoms as latent constructs converged. Pain and insomnia symptoms were positively correlated within each wave. We found bidirectional longitudinal associations between insomnia symptoms and pain. Overall, these data demonstrate a bidirectional relationship between insomnia symptoms and pain, as well as weak support for internalizing symptoms mediating the association between pain and insomnia symptoms. Treatment of youth with chronic pain should prioritize concurrent or early treatment of comorbid insomnia symptoms to maximize response to pain treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association between insomnia phenotypes and subclinical myocardial injury: the Multi-Ethnic Study of Atherosclerosis.

To assess whether the association between insomnia and subclinical myocardial injury, as measured by cardiac troponin T (cTnT), differs across insomnia phenotypes. We measured cTnT in 2188 participants in the Multi-Ethnic Study of Atherosclerosis study who had completed sleep questionnaires and undergone unattended polysomnography (PSG) and 7-day actigraphy. Insomnia symptoms were defined as reporting at least one of the following ≥5 nights/week over the past 4 weeks: trouble falling asleep, waking up several times a night, having trouble getting back to sleep after waking up too early, or taking sleeping pills to help falling asleep. Obstructive sleep apnea (OSA) was defined as an apnea-hypopnea index (AHI >15 events/h). Participants were classified into insomnia phenotypes, including comorbid insomnia and OSA (COMISA) and insomnia associated with actigraphy-estimated short sleep (<6 h) or sleep fragmentation. The mean age was 68.8 (SD 9.2) years, 53.6% were male. In total, 47.8% met threshold levels for insomnia symptoms, and 43.1% had an AHI >15. In adjusted linear regression models COMISA (β 0.08 [standard error (SE) 0.03], p < .01) and insomnia with short sleep duration (β 0.07 [SE 0.03], p < .05) were each associated with higher cTnT compared to a reference group with no insomnia. Insomnia with fragmented sleep (β 0.03 [SE 0.02]) was not associated with higher cTnT (p > .05) in adjusted analyses. OSA was associated with higher cTnT (β 0.09 [SE 0.03], p < .01) in adjusted models. COMISA and insomnia with short sleep duration, but not insomnia symptoms alone or fragmented sleep, were associated with increased circulating cTnT in older adults.

Risk of resistant hypertension associated with insomnia in patients with obstructive sleep apnea

ObjectivesPatients with obstructive sleep apnea (OSA) have a high prevalence of hypertension but vary in blood pressure (BP) control, which may be partially explained by comorbid insomnia. We investigated the association of insomnia symptoms with uncontrolled BP and resistant hypertension (RH) in OSA patients. MethodsBetween 2018 and 2021, hypertensive patients with OSA were enrolled. Information on demographic characteristics, insomnia symptoms, class of antihypertensive medications, BP control and sleep study data were collected. Controlled BP was defined as systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg (BP standard); uncontrolled BP as above BP standard with use of 1–2 classes of antihypertensive medication; and RH as above BP standard with the use of ≥3 classes of antihypertensive medication (including a diuretic). Multinomial logistic regression models were fit to determine the association between insomnia symptoms and uncontrolled BP or RH (versus controlled BP) after multivariable adjustment. ResultsAmong the analytic sample (n = 326), 64.1% of participants had uncontrolled BP and 15.6% had RH. OSA severity was associated with a higher odds of RH (OR, 2.92; 95% CI, 1.71–4.99). After adjustment for confounders including demographic characteristics, sedative hypnotics usage, sleepiness, OSA severity and quality of life, participants experiencing insomnia symptoms had a 3.0 times higher odds of RH. Insomnia was not associated with uncontrolled BP. ConclusionsExperiencing insomnia was associated with increased odds of RH in OSA patients. These results suggest that comorbid insomnia may contribute to inadequate BP control in OSA patients.

Comorbid Insomnia and Sleep Apnea: Assessment and Management Approaches.

Comorbid insomnia and sleep apnea (COMISA) is a highly prevalent and debilitating condition that is more difficult to treat compared with insomnia alone or sleep apnea alone. Approximately 30% to 50% of sleep clinic patients with sleep apnea report comorbid insomnia symptoms. Comorbid insomnia is associated with lower adherence to positive airway pressure therapy for obstructive sleep apnea. Management approaches that include targeted treatments for both insomnia and sleep apnea lead to the best treatment outcomes for patients with COMISA. Therefore, sleep clinics should incorporate insomnia and COMISA management pathways including access to cognitive behavioral therapy for insomnia.

Sertraline as an adjunctive treatment for insomnia comorbid with other mental health disorders

• Antidepressant agents have heterogeneous sleep-related effects; some disrupt sleep due to their activating properties, while others improve sleep secondary to their sedative actions. Understanding and exploiting such effects can inform the selection of a psychotropic medication when insomnia is comorbid with a psychiatric disorder for which an antidepressant is indicated. • Familiarity with sertraline-induced sedation, an uncommon side effect, should enable prescribers to change the dose schedule of the drug rather than discontinuing it. This would preserve any therapeutic gains for the primary target symptoms, and potentially attenuate comorbid insomnia. • Some clinicians may not be aware of the possible sedating effects of sertraline and usually dismiss the concern of sedation to a symptom of depression such as fatigue or lack of energy, untreated sleep apnea, or an adverse effect from another medication. The selective serotonin reuptake inhibitor (SSRI), sertraline, enhances serotonergic transmission and is used in the treatment of major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder and premenstrual dysphoric disorder. Sertraline use is associated with a higher prevalence of anxiety, agitation, insomnia , and restlessness than other selective SSRIs, with the exception of fluoxetine. Given these activating properties, it is usually administered in the morning to prevent insomnia. However, a small number of individuals experience sedation during SSRI treatment. While the underlying mechanism remains poorly characterized, we present a series of cases in which the sedating effect of sertraline were effectively exploited to treat insomnia in patients with comorbid psychiatric conditions such as posttraumatic stress disorder (PTSD) and depression.

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.

P086 The insomnia severity index is related to the respiratory arousal threshold in people with Co-Morbid Insomnia and Sleep Apnoea (COMISA)

Abstract Introduction People with co-morbid insomnia and sleep apnoea (COMISA) have worse symptoms and require a tailored therapy approach for their sleep disorders. The relationship between the respiratory arousal threshold, a key OSA non-anatomical contributor and insomnia symptoms is unclear. This study investigated the relationship between insomnia symptoms using the insomnia severity index (ISI) and the respiratory arousal threshold in people with OSA. Methods 46 people with OSA (11 female, age=50±15years, BMI=29±6kgm-2, AHI=33±20events/h) participated in a physiology sleep study to predict response to oral appliance therapy and completed the ISI. Standard polysomnography, an epiglottic airway pressure sensor, bipolar intramuscular electrodes inserted into the genioglossus and a nasal mask with a pneumotachograph to quantify airflow were used. The respiratory arousal threshold was measured as the nadir epiglottic pressure during a respiratory event prior to a cortical arousal. Following this, participants trialled mandibular advancement therapy. Results There was no relationship between ISI (average=12±6) and the arousal threshold (-24±10cmH₂O) in participants with OSA (r=0.1, p=0.42, n=46). However, in the 59% of people with COMISA (ISI ≥11), there was a positive relationship between ISI and arousal threshold, with increasing insomnia severity associated with lower arousal threshold (r=0.5, p=0.017, n=27). People with a BMI&amp;lt;30kgm-2 (n=27), also had a positive linear relationship between ISI and improvement in oral appliance therapy (r=0.49, p&amp;lt;0.01, n=27). Conclusion Greater insomnia symptoms in people with COMISA is associated with a lower respiratory arousal threshold. In non-obese people with OSA, higher ISI values are related to poor response to oral appliance therapy.

P018 Effect of CBT-I on sleep-wake state discrepancy in individuals with co-morbid insomnia and sleep apnoea: A randomised controlled trial

Abstract Introduction Cognitive behavioural therapy for insomnia (CBT-I) is the recommended treatment for insomnia and improves insomnia symptoms. However, CBT-I effects on sleep-wake state discrepancy have not previously been examined in a sample of individuals with co-morbid insomnia and sleep apnoea (COMISA). This randomised controlled trial investigated the effect of CBT-I, versus no-treatment control, on sleep-wake state discrepancy in people with COMISA. Methods 145 participants had their subjective and objective sleep parameters recorded at pre- and post-treatment via overnight sleep diaries and polysomnography. Results Pre-treatment, individuals with COMISA significantly (p &amp;lt; 0.05) underestimated their sleep duration (M min = −51.9, SD = 94.1) and sleep efficiency (M % = −9.6, SD = 18.3) and significantly (p &amp;lt; 0.05) overestimated sleep onset latency (M min = 34.5, SD = 86.1). Post-treatment, there were significant reductions in sleep-wake state discrepancy parameters in both groups, but no significant interaction effects to support any differences between CBT-I versus waitlist control groups (all interactions, p &amp;gt; 0.367). Discussion These findings suggest that treating the insomnia aspect of COMISA through CBT-I first may not be an effective method of reducing sleep-wake state discrepancy. This is possibly due to sleep apnoea being untreated, contributing to frequent awakenings and the discrepancy between perceived and polysomnography derived sleep parameters. Future studies could involve a COMISA group that receives treatment for their sleep apnoea symptoms before CBT-I.

P119 Co-morbid insomnia is associated with worse health, and lower CPAP recommendation rates and nightly use in people with sleep apnoea

Abstract Introduction Co-morbid insomnia and sleep apnoea (COMISA) is associated with poor health and reduced adherence to continuous positive airway pressure (CPAP) therapy in sleep clinic samples. However, health and treatment correlates of COMISA in community-based samples of obstructive sleep apnoea (OSA) are poorly described. Methods Australian adults previously diagnosed with OSA were surveyed online. COMISA was defined as co-morbid OSA and nocturnal insomnia symptoms (difficulties falling asleep, maintaining sleep, and/or early morning awakenings at least a few nights a week over the past month). Logistic regression and ANCOVAs determined associations of COMISA with medical conditions and general health, controlling for age, gender, and body mass index. Treatment recommendation rates and average nightly use were compared between those with COMISA versus OSA-alone. Results Among 412 participants (54.6% male, mean age 58.5 [SD=13.9] years), 74.8% had COMISA. Compared to OSA-alone, COMISA was associated with higher rates of fair/poor general health (60.4% versus 46.6%, p=0.010), lower EQ-5D overall health (mean difference 7.55 [SD=2.73], p=0.010), and greater rates of depression diagnoses (56.3% versus 28.0%, p&amp;lt;0.001), which persisted after adjustment for covariates. People with COMISA reported lower rates of CPAP therapy recommendation (82.8%, versus 95.2%, p=0.002), and nightly use (mean difference 0.54 [SD=0.13] hours/night, p&amp;lt;0.001), and greater rates of upper-airway surgery recommendations (14%, versus 2.9%, p=0.002) and completion (13%, versus 1.9%, p=0.001). Conclusions COMISA was associated with worse health, depression, lower CPAP recommendations and use, and greater upper-airway surgery compared to those with OSA-alone.

O052 Association of co-morbid insomnia and sleep apnoea (COMISA) symptoms with all-cause mortality: Analysis of the NHANES 2005-2008 data

Abstract Introduction Co-morbid insomnia and sleep apnoea (COMISA) is a highly prevalent condition associated with negative health outcomes. This population-based study aimed to investigate the association between COMISA and all-cause mortality. Methods Sleep data in 6,877 participants (Age median [IQR]=45 [33,57], 50.1% male) were drawn from the National Health and Nutrition Examination Survey (2005-2008). Insomnia was defined as difficulties initiating sleep, long awakenings, and/or early morning awakenings on ≥16 nights/month, with daytime impairment. The STOP-Bang questionnaire was used to identify participants at high risk of obstructive sleep apnoea (OSA). COMISA was defined if participants met criteria for insomnia and high risk of OSA. The median (IQR) follow-up for mortality was 8.6 (7.8, 9.8) years. Cox regression models were used to determine the association between COMISA and all-cause mortality, controlling for socio-demographic characteristics, behavioural factors and chronic conditions. Results The prevalence of no insomnia/OSA, insomnia-alone, OSA-alone, and COMISA were 73.5, 3.0, 20.1, and 3.3%, respectively, and 6.7% of participants died by 11-year follow-up. Compared to participants with no insomnia/OSA, higher mortality risk was observed in participants with COMISA (HR=1.9; 95%CI=1.3-2.8) and insomnia alone (HR=1.5; 95%CI=1.0-2.3) after adjusting for socio-demographic characteristics, and behavioural factors. The relationship between COMISA and mortality persisted after additionally controlling for chronic conditions, sleep duration and sleeping pill use (HR=1.6; 95%CI=1.1-2.3), but the relationship between insomnia-alone and mortality did not (HR=1.4; 95%CI=0.9-2.3). Discussion Co-morbid insomnia and high-risk OSA is associated with increased risk of all-cause mortality. More research is needed to identify effective treatments for COMISA.

P120 Incidence, persistence and remission of co-morbid insomnia and sleep apnea (COMISA) over time in the Wisconsin Sleep Cohort data

Abstract Introduction Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent and debilitating condition that is more difficult to treat compared to either disorder alone. Previous studies have investigated the cross-sectional prevalence of COMISA, however no study has investigated rates of natural incidence, persistence, or remission of COMISA over time. Methods We used data from 566 people in the Wisconsin Sleep Cohort (Age M = 55.6 [sd = 7.5], 46.3% female). Symptoms of insomnia (difficulties initiating, maintaining sleep and/or early morning awakenings at least 5 times/month), and sleep apnea (AHI ≥ 5) were investigated at baseline, 4-years, and 8-years. COMISA was defined if both conditions were present. Results The prevalence of COMISA at baseline, year-4, and year-8 was 25.1%, 29.9%, and 25.8%, respectively. Among those with COMISA at baseline, 60.6% had persistent COMISA at year-4, and among people with COMISA at year-4, 46.8% had persistent COMISA at year-8. Very few people with COMISA experienced remission of both insomnia and sleep apnea at year-4 (5.6%) or year-8 (7.7%). There were 83 cases of incident COMISA at year-4 (19.6% of people without COMISA at baseline), and 67 cases of incident COMISA at year-8 (16.9% of people without COMISA at year-4). Discussion COMISA symptom prevalence was ≥25% at any given follow-up in this population-based sample. Approximately half of those with COMISA experienced persistent COMISA across any two follow-up occasions. Very few people with COMISA experience complete remission of both conditions. It is important to develop targeted treatments for this prevalent and persistent condition.

Associations between Insomnia Symptoms and Anxiety Symptoms in Adults in a Community Sample of Southeastern Pennsylvania, USA.

Although insomnia is reliably associated with anxiety symptoms, aspects of insomnia may differentially relate to one anxiety symptom versus another. Therefore, treatment for insomnia comorbidity with anxiety might be individually tailored to optimize treatment response. Working from this hypothesis, we analyzed data from a survey of 1007 community-dwelling adults. Insomnia was measured using the Insomnia Severity Index (ISI), categorizing items as nighttime disturbances, daytime dysfunction, or self-perceived dissatisfaction. Anxiety symptoms were measured with the Generalized Anxiety Disorder 7-item questionnaire (GAD-7). Linear and binomial logistic regression were used and adjusted for covariates. Post hoc forward stepwise analyses determined which components of the insomnia contributed to individual anxiety symptoms. Significant associations between nighttime disturbance (β = 0.88 [0.44, 1.3]), daytime dysfunction (β = 1.30 [0.81, 1.80]), dissatisfaction (β = 1.20 [0.60, 1.7]) and total GAD-7 score were maintained after adjusting for covariates. Nighttime disturbance was associated with excess worrying, restlessness, irritability, and fear of catastrophe. Daytime dysfunction was associated with all symptoms except for fear of catastrophe, and self-perceived dissatisfaction was associated with all symptoms except irritability. Stepwise analyses revealed that daytime dysfunction and dissatisfaction were most consistently related to anxiety symptoms.Greater attention should be paid to daytime dysfunction in patients with insomnia and anxiety, as improving daytime functioning may improve anxiety.

Cognitive Behavioral Therapy for Chronic Insomnia in Outpatients with Major Depression-A Randomised Controlled Trial.

The aim of this randomised controlled assessor-blinded trial was to examine the effect of cognitive behavioural therapy for insomnia on sleep variables and depressive symptomatology in outpatients with comorbid insomnia and moderate to severe depression. Forty-seven participants were randomized to receive one weekly session in 6 weeks of cognitive behavioural therapy for insomnia or treatment as usual. The intervention was a hybrid between individual and group treatment. Sleep scheduling could be especially challenging in a group format as patients with depression may need more support to adhere to the treatment recommendations. The primary outcome measure was the Insomnia Severity Index. Secondary measures were sleep diary data, the Dysfunctional Beliefs and Attitudes about Sleep Questionnaire, the Hamilton Depression Rating Scale, and the World Health Organization Questionnaire for Quality of Life and polysomnography. Compared to treatment as usual, cognitive behavioural therapy significantly reduced the insomnia severity index (mean ISI 20.6 to 12.1, p = 0.001) and wake after sleep onset (mean 54.7 min to 19.0 min, p = 0.003) and increased sleep efficiency (mean SE 71.6 to 83.4, p = 0.006). Total sleep time and sleep onset latency were not significantly changed. The results were supported by analyses of the other rating scales and symptom dimensions. In conclusion, cognitive behavioural therapy for insomnia as add-on to treatment as usual was effective for treating insomnia and depressive symptoms in a small sample of outpatients with insomnia and major depression. ClinicalTrials.gov Identifier: NCT02678702.

Variation in Gut Microbiota Composition is Associated with Sleep Quality and Cognitive Performance in Older Adults with Insomnia.

PurposeInsomnia, a chronic condition affecting 50% of older adults, is often accompanied by cognitive decline. The mechanism underlying this comorbidity is not fully understood. A growing literature suggests the importance of gut microbiota for brain function. We tested associations between sleep quality and cognitive performance with gut microbiota in older adults with insomnia.Patients and MethodsSeventy-two older adults with insomnia (age 73.2 ± 5.73 years, 56 females) provided stool samples for gut microbial sequencing. Microbiota profile was determined using the DADA2 bioinformatics pipeline. Cognition was assessed with the Cambridge Neuropsychological Test Automated Battery. Objective sleep quality was monitored by a two-week actigraphic recording, and participants completed the Insomnia Severity Index (ISI). We used partial canonical correspondence analysis (pCCA) to examine the relative contribution of insomnia, based on actigraphic sleep efficiency (SE) and ISI, and of cognitive status, based on the Multitasking test of Median Reaction Latency (MTTLMD) and the Spatial Working Memory Between Errors (SWMBE), to variance in microbiota composition. We used Pearson correlations to correlate insomnia and cognitive status parameters with microbiota amplicon sequence variants, genera, and families.ResultsThe pCCA revealed that sleep quality and cognitive performance explained a variation of 7.5–7.9% in gut microbiota composition in older adults with insomnia. Correlation analysis demonstrated that Lachnoclostridium (genus) correlates positively with SE (r=0.42; P=0.05) and negatively with MTTLMD (r=−0.29; P=0.03), whereas Blautia (genus) correlates negatively with MTTLMD (r=−0.31; P=0.01).ConclusionFindings demonstrate the associations of sleep quality and cognitive performance with variance in gut microbiota composition and with specific genus abundance in older adults with insomnia. Further studies should validate the findings, determine causal relationships, and evaluate potential interventions for the comorbidity of insomnia and cognitive impairment in older adults with insomnia.

All-Cause Mortality in People with Co-Occurring Insomnia Symptoms and Sleep Apnea: Analysis of the Wisconsin Sleep Cohort.

PurposeInsomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality.Patients and MethodsWisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings “often” or “almost always”, and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models.ResultsAmong 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00–2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk.ConclusionCo-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.

Stepped care management of insomnia co-occurring with sleep apnea: the AIR study protocol

BackgroundObstructive sleep apnea (OSA) and insomnia are commonly co-occurring conditions that amplify morbidity and complicates the management of affected patients. Unfortunately, previous research provides limited guidance as to what constitutes the best and most practical management approach for this comorbid patient group. Some preliminary studies show that when cognitive behavioral insomnia therapy (CBT-I) is combined with standard OSA therapies for these patients, outcomes are improved. However, the dearth of trained providers capable of delivering CBT-I has long served as a pragmatic barrier to the widespread use of this therapy in clinical practice. The emergence of sophisticated online CBT-I (OCBT-I) programs could improve access, showing promising reductions in insomnia severity. Given its putative scalability and apparent efficacy, some have argued OCBT-I should represent a 1st-stage intervention in a broader stepped care model that allocates more intensive and less assessable therapist-delivered CBT-I (TCBT-I) only to those who show an inadequate response to lower intensity OCBT-I. However, the efficacy of OCBT-I as a 1st-stage therapy within a broader stepped care management strategy for insomnia comorbid with OSA has yet to be tested with comorbid OSA/insomnia patients.Methods/designThis dual-site randomized clinical trial will use a Sequential Multiple Assignment Randomized Trial (SMART) design to test a stepped care model relative to standard positive airway pressure (PAP) therapy and determine if (1) augmentation of PAP therapy with OCBT-I improves short-term outcomes of comorbid OSA/insomnia and (2) providing a higher intensity 2nd-stage CBT-I to patients who show sub-optimal short-term outcomes with OCBT-I+PAP improves short and longer-term outcomes. After completing baseline assessment, the comorbid OSA/insomnia patients enrolled will be randomized to a 1st-stage therapy that includes usual care PAP + OCBT-I or UC (usual care PAP + sleep hygiene education). Insomnia will be reassessed after 8 weeks. OCBT-I recipients who meet “remission” criteria (defined as an Insomnia Severity Index score < 10) will continue PAP but will not be offered any additional insomnia intervention and will complete study outcome measures again after an additional 8 weeks and at 3 and 6 month follow-ups. OCBT-I recipients classified as “unremitted” after 8 weeks of treatment will be re-randomized to a 2nd-stage treatment consisting of continued, extended access to OCBT-I or a switch to TCBT-I. Those receiving the 2nd-stage intervention as well as the UC group will be reassessed after another 8 weeks and at 3- and 6-month follow-up time points. The primary outcome will be insomnia remission. Secondary outcomes will include subjective and objective sleep data, including sleep time, sleep efficiency, fatigue ratings, PAP adherence, sleepiness ratings, sleep/wake functioning ratings, and objective daytime alertness.DiscussionThis study will provide new information about optimal interventions for patients with comorbid OSA and insomnia to inform future clinical decision-making processes.Trial registrationClinicalTrials.gov, NCT03109210, registered on April 12, 2017, prospectively registered.