Cognitive behavioral therapy for insomnia (CBT-I) is the most prominent nonpharmacologic treatment for insomnia disorders. Although meta-analyses have examined primary insomnia, less is known about ...the comparative efficacy of CBT-I on comorbid insomnia.
To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions for (1) remission from insomnia; (2) self-reported sleep efficiency, sleep onset latency, wake after sleep onset, total sleep time, and subjective sleep quality; and (3) comorbid symptoms.
A systematic search was conducted on June 2, 2014, through PubMed, PsycINFO, the Cochrane Library, and manual searches. Search terms included (1) CBT-I or CBT or cognitive behavioral and its variations or behavioral therapy and its variations or behavioral sleep medicine or stimulus control or sleep restriction or relaxation therapy or relaxation training or progressive muscle relaxation or paradoxical intention; and (2) insomnia or sleep disturbance.
Studies were included if they were randomized clinical trials with at least one CBT-I arm and had an adult population meeting diagnostic criteria for insomnia as well as a concomitant condition. Inclusion in final analyses (37 studies) was based on consensus between 3 authors' independent screenings.
Data were independently extracted by 2 authors and pooled using a random-effects model. Study quality was independently evaluated by 2 authors using the Cochrane risk of bias assessment tool.
A priori main outcomes (ie, clinical sleep and comorbid outcomes) were derived from sleep diary and other self-report measures.
At posttreatment evaluation, 36.0% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio, 3.28; 95% CI, 2.30-4.68; P < .001). Pretreatment and posttreatment controlled effect sizes were medium to large for most sleep parameters (sleep efficiency: Hedges g = 0.91 95% CI, 0.74 to 1.08; sleep onset latency: Hedges g = 0.80 95% CI, 0.60 to 1.00; wake after sleep onset: Hedges g = 0.68; sleep quality: Hedges g = 0.84; all P < .001), except total sleep time. Comorbid outcomes yielded a small effect size (Hedges g = 0.39 95% CI, 0.60-0.98; P < .001); improvements were greater in psychiatric than in medical populations (Hedges g = 0.20 95% CI, 0.09-0.30; χ2 test for interaction = 12.30; P < .001).
Cognitive behavioral therapy for insomnia is efficacious for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia. A small to medium positive effect was found across comorbid outcomes, with larger effects on psychiatric conditions compared with medical conditions. Large-scale studies with more rigorous designs to reduce detection and performance bias are needed to improve the quality of the evidence.
Objective: Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety ...disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches. Method: The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life. Results: The pre-post within-group and controlled effect sizes were moderately strong (Hedges's g = 0.54 and Hedges's g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments. Conclusion: CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life.
Disruptions to mood, cognition, and other daytime functioning are common and debilitating symptoms of Parkinson's disease (PD), and there is evidence that sleep problems contribute to these symptoms. ...However, previous studies are limited by reliance on self-reported sleep and cross-sectional designs. With the aim of assessing sleep as a possible treatment target for improving daytime functioning in PD, we used smartphone-based ecological momentary assessment (EMA) and actigraphy to investigate temporal associations between sleep (objective and subjective) and daytime functioning.
Twenty participants with mild-moderate PD wore actigraphs and completed sleep diaries for 14-15 days. They reported daytime functioning (anxiety, positive affect, cognitive function, fatigue, and social function) twice daily via smartphone-administered questionnaires. Multilevel modeling examined whether sleep quantity/quality predicted next-day functioning, and whether current mood (anxiety, positive affect) predicted later sleep.
Average completion rates for sleep diaries and daytime questionnaires were 94% and 91%, respectively. Subjective sleep quality predicted next-day anxiety (B = −.75, SE = .25, p= .003), but objective sleep did not predict any daytime functioning variables (p's>.112). Positive affect predicted later subjective sleep quality (B = 0.03, SE = .01, p = .003) but not objective sleep quantity/quality (p's>.107).
We demonstrated the feasibility of using EMA in PD. On a daily timescale, subjective sleep quality was bidirectionally associated with mood, whereas objective sleep was not associated with any daytime functioning. This discrepancy suggests that perception of sleep is important for mood in PD, which could provide targets for non-pharmacological interventions.
Abstract
BACKGROUND
Poor sleep quality is increasingly recognized as an important and potentially modifiable risk factor for cardiovascular disease (CVD). Impaired endothelial function may be 1 ...mechanism underlying the association between poor sleep and CVD risk. The present study examined the relationship between objective measures of sleep quality and endothelial function in a sample of untreated hypertensive adults.
METHODS
Participants were 127 men (N = 74) and women (N = 53), including 55 African Americans and 72 White Americans, aged 40–60 years (mean age, 45.3 ± 8.5 years), with untreated hypertension (systolic blood pressure 130–159 mm Hg and/or diastolic blood pressure 85–99 mm Hg). Noninvasive brachial artery flow-mediated dilation (FMD) was assessed by ultrasound. Sleep parameters, including sleep efficiency (SE), total sleep time (TST), and subjective sleep quality, were assessed over 7 consecutive days by wrist actigraphy.
RESULTS
Participants averaged 7.76 ± 1 hours in bed, with an average SE of 78 ± 9%, and TST of 6 ± 1 hours. Brachial FMD averaged 3.5 ± 3.1%. In multivariate analyses controlling for sex, race, body mass index, clinic blood pressure, income, smoking, alcohol use, and baseline arterial diameter, SE was positively associated with FMD (β = 0.28, P = 0.012). Subjective sleep quality (β = −0.04, P = 0.63) and TST (β = −0.11, P = 0.25) were unrelated to FMD.
CONCLUSIONS
Poor sleep as indicated by low SE was associated with impaired FMD. These findings for SE are consistent with previous observations of other measures implicating poor sleep as a CVD risk factor. Interventions that improve sleep may also help lower CVD risk.
Insomnia and poor sleep are associated with an increased risk of developing cardiovascular disease (CVD) and its precursors, including hypertension. In 2022, the American Heart Association (AHA) ...added inadequate sleep to its list of health behaviors that increase the risk for CVD. It remains unknown, however, whether the successful treatment of insomnia and inadequate sleep can reduce heightened CVD risk. SLEEPRIGHT is a single-site, prospective clinical trial designed to evaluate whether the successful treatment of insomnia results in improved markers of CVD risk in patients with untreated hypertension and comorbid insomnia disorder. Participants (N = 150) will undergo baseline assessments, followed by a 6-week run-in period after which they will receive cognitive behavior therapy for insomnia (CBT-I), comprised of 6 hourly sessions with an experienced CBT-I therapist over a 6-week period. In addition to measures of insomnia severity, as well as both subjective and objective measures of sleep, the primary outcome measures are nighttime blood pressure (BP) and BP dipping assessed by 24-h ambulatory BP monitoring (ABPM). Secondary outcomes include several CVD risk biomarkers, including clinic BP, lipid profile, vascular endothelial function, arterial stiffness, and sympathetic nervous system (SNS) activity. Data analysis will evaluate the association between improvements in insomnia and sleep with primary and secondary CVD risk biomarker outcomes. The SLEEPRIGHT trial (ClinicalTrials.Gov NCT04009447) will utilize CBT-I, the current gold standard treatment for insomnia disorder, to evaluate whether reducing insomnia severity and improving sleep are accompanied by improved biomarkers of CVD risk in patients with untreated hypertension.
Honorable Mention, 2017 Foreword INDIES Book of the Year Awards in the Political Science Category From the hot savannah of Malawi to the cold, damp gray of Kosovo and into the volatile war zones of ...Iraq and Afghanistan, the United States and other donors have invested enormous financial and human resources in major peacekeeping and development efforts. Why then is the world no closer to being a "better and safer" place? Both a salient critique of US foreign assistance and a thought-provoking memoir, Flash Points describes the issues with personnel, language, and gender dynamics, as well as the cross- cultural challenges that often undermine and betray the best intentions of policy makers comfortably situated in Washington. Revealed in illuminating flashbacks, Jade Wu recalls her experiences in each of these four countries highlighting how, all too often, Americans in the field and the US government were unable to learn the lessons that ought to have been learned when dealing with host countries and their people. The final results were efforts poorly conceived and executed and, ultimately, detrimental to American national interests.
Abstract
Study Objectives
Prior work has established associations between post-traumatic stress disorder (PTSD), disrupted sleep, and cardiovascular disease (CVD), but few studies have examined ...health correlates of nightmares beyond risks conferred by PTSD. This study examined associations between nightmares and CVD in military veterans.
Methods
Participants were veterans (N = 3468; 77% male) serving since September 11, 2001, aged 38 years (SD = 10.4); approximately 30% were diagnosed with PTSD. Nightmare frequency and severity were assessed using the Davidson Trauma Scale (DTS). Self-reported medical issues were assessed using the National Vietnam Veterans Readjustment Study Self-report Medical Questionnaire. Mental health disorders were established using the Structured Clinical Interview for DSM-IV. The sample was stratified by the presence or absence of PTSD. Within-group associations between nightmare frequency and severity and self-reported CVD conditions, adjusting for age, sex, race, current smoking, depression, and sleep duration.
Results
Frequent and severe nightmares during the past week were endorsed by 32% and 35% of participants, respectively. Those endorsing nightmares that were frequent, severe, and the combination thereof were more likely to also evidence high blood pressure (ORs 1.42, OR 1.56, and OR 1.47, respectively) and heart problems (OR 1.43, OR 1.48, and OR 1.59, respectively) after adjusting for PTSD diagnosis and other covariates.
Conclusions
Nightmare frequency and severity among veterans are associated with cardiovascular conditions, even after controlling for PTSD diagnosis. Study findings suggest that nightmares may be an independent risk factor for CVD. Additional research is needed to validate these findings using confirmed diagnoses and explore potential mechanisms.
Graphical Abstract
Graphical Abstract
Highlights • There is little knowledge of episodic future thinking (EFT) in GAD. • Examined simulations of novel future events in GAD and control participants. • GAD participants spontaneously added ...less detail to EFT than did controls. • GAD group showed negative bias in ease of generating EFT, perception of plausibility.
Purpose Pharmacotherapy is an effective treatment for anxiety disorders, but its effects on quality of life (QOL) have not been examined systematically. Our objective was to conduct an effect size ...analysis of pharmacological interventions on QOL outcomes in patients with DSM-IV anxiety disorders. Methods Manual and electronic searches using PubMed, PsycINFO, and the Cochrane Library were conducted for records from the first available date through May 1, 2013 for trials of pharmacological interventions in patients with anxiety disorders, which had measures of QOL before and after treatment. Of 1,865 entries, 93 studies were identified as potentially relevant and 32 met inclusion criteria, of which results were examined from 22 studies reporting 27 distinct pharmacological trials, representing data from 4,344 anxiety disorder patients. Data were extracted independently by multiple observers to estimate within-group and placebo-controlled random effects of the treatment changes on QOL. We hypothesized that pharmacotherapy improves QOL, which is associated with improvement in anxiety symptoms. Results Pharmacological interventions effectively improved QOL from before to after treatment (Hedges' g = 0.59), although the controlled effect size is smaller among those trials with placebo interventions (Hedges' g = 0.32). These effect sizes were robust, increased with publication year, and increased with reductions in anxiety symptoms. Conclusions Pharmacological therapy is effective for improving QOL in anxiety disorders, and larger symptom reductions are associated with greater improvement in QOL.
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