Cognitive Behavioral Treatment as a Digital Therapeutic for Insomnia

Insomnia is a sleep disorder characterized by clinically significant distress caused by difficulty in initiating or maintaining sleep, or early-morning awakening. By definition, insomnia must affect important areas of functioning and occur more than three nights per week for at least 3 months. Insomnia is highly prevalent, with a high relapse rate and a tendency to become chronic. Therefore, the demand for insomnia treatment is high. The current first-line treatment recommended for insomnia is cognitive behavioral therapy for insomnia (CBTi). Conventional CBTi is a multicomponent intervention program that includes: 1) a behavioral component made up of stimulus control therapy, sleep restriction therapy, and muscle relaxation; 2) a cognitive component; and 3) an educational component focused on sleep hygiene. Despite considerable evidence of CBTi efficacy, accessibility and cost remain major barriers. Recently, internet-delivered digital CBTi (dCBTi) has emerged as a potential answer for the growing demand and poor treatment accessibility. This review will discuss the history of CBTi as a first-line treatment for insomnia, the current status and limitations of CBTi, the efficacy of dCBTi as an alternative, and the future of dCBTi in pioneering digital therapeutics.ope

Recent Advances in Alcohol Use Disorders : Characteristics and Treatment of Alcohol Use Disorder in Woman

The paper reviews recent advances regarding characteristics and treatment issues of alcohol use disorders in women. Women’s greater sensitivity to alcohol might explain why alcohol dependence and the physical damage caused by alcohol progress more rapidly in women. There was a significantly higher lifetime prevalence of psychiatric comorbidity in women than in men with alcohol use disorders. Furthermore, comorbid diagnoses are more often primary in women. All of these differences have important treatment implications.ope

Korean Medication Algorithm for Bipolar Disorder 2010: Comparisons with Other Treatment Guidelines

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) was developed in 2002 and thereafter revised in 2006. It was secondly revised in 2010 (KMAP-BP 2010). The aim of this study was to compare KMAP-BP 2010 with other recently published treatment algorithm and guidelines for bipolar disorder. The authors reviewed the 4 recently published guidelines and treatment algorithms for bipolar disorder [The British Association for Psychopharmacology Guideline for Treatment of Bipolar Disorder, Canadian Network for Mood and Anxiety Treatments Guidelines for the Management of Patients with Bipolar Disorder, The World Federation Society of Biological Psychiatry Guideline for Biological Treatment of Bipolar Disorder and National Institute for Health and Clinical Experience (NICE) Clinical Guideline] to compare the similarities and discrepancies between KMAP-BP 2010 and the others. In aspects of treatment options, most treatment guidelines had some similarities. But there were notable discrepancies between the recommendations of other guidelines and those of KMAP-BP in which combination or adjunctive treatments were favored. Most guidelines advocated new atypical antipsychotics as first-line treatment option in nearly all phases of bipolar disorder and lamotrigine in depressive phase and maintenance phase. Lithium and valproic acid were still commonly used as mood stabilizers in manic phase and strongly recommended valproic acid in mixed or psychotic mania. Mood stabilizers or atypical antipsychotics were selected as first-line treatment option in maintenance treatment. As the more evidences were accumulated, more use of atypical antipsychotics such as quetiapine, aripiprazole and ziprasidone were prominent. This review suggests that the medication strategies of bipolar disorder have been reflected the recent studies and clinical experiences, and the consultation of treatment guidelines may provide clinicians with useful information and a rationale for making sequential treatment decisions. It also has been consistently stressed that treatment algorithm or guidelines are not a substitute for clinical judgment; they may serve as a critical reference to complement of individual clinical judgment.ope

Korean Medication Algorithm for Bipolar Disorder 2010: Introduction

OBJECTIVE: Psychopharmacological treatment of bipolar disorder is quite complex because of its clinical features of different episodes and various course. We published Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) in 2002, that appeared to be helpful in clinical situation by feasibility study in 2005, and revised KMAP-BP in 2006. New papers in which some drugs are effective in treating bipolar disorder have been published, and the demand for revision of KMAP-BP are increased. METHODS: The questionnaire was sent to 94 experts, 65 of whom replied. It was composed of 40 questions about clinical situations, and each question includes various sub-items. Based on KMAP-BP 2006 and new data, some questions sub-items are amended. Safety issues and consideration on special populations were added in this revision. Each option was categorized on three parts (the first-line, the second-line, or the third-line) by its 95% confidence interval. RESULTS: In acute manic episode, even though it is euphoric, mixed, or psychotic, combination of a mood stabilizer (MS) with an atypical antipsychotic (AAP) is recommended as first-line strategy. Mood stabilizer monotherapy is first-line in hypomanic episode. Among the mood stabilizers, valproic acid and lithium are selected as first-line. Monotherapy with mood stabilizer is recommended in mild to moderate bipolar depression. However, triple combination of a mood stabilizer, an atypical antipsychotic and an antidepressant (AD), is the first-line strategy in non-psychotic severe depression. Also combination of MS and AAP (MS+AAP) and combination of MS and AD (MS+AD) are recommended as first-line. In psychotic bipolar depression, combination of MS, AAP, and AD (MS+AAP+AD), combination of MS and AAP (MS+AAP), and combination of AAP and AD (AAP+AD) are first-line strategies. In bipolar depression, lithium, lamotrigine, and valproic acid are selected as first-line mood stabilizer, and quetiapine, olanzapine and aripiprazole are preferred antipsychotics. Bupropion and (es)citalopram are first-line antidepressant in moderated depression, and (es)citalopram, bupropion, and paroxetine are recommended as firstline in severe depression. Preferred strategy for rapid cycling patients is combination of MS with AAP. In maintenance treatment, combination of MS with AAP and monotherapy of MS are recommended as first-line. CONCLUSION: In treating bipolar disorder, even the first step of treatment, consensus of experts are changed from our studies in 2002 and 2006. This medication algorithm, with some limitations, may reflect the clinical practice and recent researches.ope

Empathic Tendency and Theory of Mind Skills in Young Individuals with Schizophrenia: Its’ Associations with Self-Reported Schizotypy and Executive Function

Objectives Social function deficit is known as a core feature of schizophrenia. This study aimed to investigate differences in empathic tendencies and theory of mind (ToM) skills between healthy controls and young individuals with schizophrenia, and to examine the associations between empathic tendencies, ToM skills and schizotypy, and executive function in schizophrenia. Methods Thirty patients with schizophrenia and 30 healthy controls were enrolled and assessed using the interpersonal relationship index (IRI; perspective taking, fantasy, empathic concern, and personal distress subscales), ToM-Picture Story Task (ToM-PST; sequence and cognitive questionnaire), Wisconsin schizotypy scale (revised physical anhedonia and perceptual aberration), and Stroop tests for empathic tendencies, ToM skills, schizotypy, and executive function. Results In individuals with schizophrenia, the IRI for perspective taking and ToM-PST score for cognitive function were lower, and the IRI for personal distress was higher than those in healthy controls. The IRIs for perspective taking and fantasy were related to revised physical anhedonia, and that for empathic concern was associated with revised physical anhedonia and perceptual aberration. The ToM-PST score for sequence was associated with the Stroop test score for schizophrenia. Conclusion These findings indicate deficits in empathic tendencies and ToM skills, which may be independently and primarily associated with schizotypy and executive function in young individuals with schizophrenia.ope

Factors Associated with Cognitive Function in Breast Cancer Patients Complaining Cognitive Decline

Objectives : Cognitive complaints are reported frequently after breast cancer treatments. The causes of cognitive decline are multifactorial, a result of the effect of cancer itself, chemotherapy, and psychological factors such as depression and anxiety. However, cognitive decline does not always correlate with neuropsychological test performance. The purpose of this study was to examine the relationship of subjective cognitive decline with objective measurement and to explore associated factors of cognitive function in breast cancer survivors. Methods : We included 29 breast cancer survivors who complain cognitive decline at least 6 months after treatment and 20 age-matched healthy controls. Neuropsychological tests were performed in all participants. Multivariable regression analysis evaluated associations between neuropsychological test scores and psychological distress including depression and anxiety, also considering age, education, and comorbidity. Results : There were no statistically significant differences in neuropsychological test performances. However, the breast cancer survivors showed a significantly higher depression(p=0.002) and anxiety(p<0.001) than the healthy controls did. Among the cancer survivors, poorer executive function was strongly associated with higher depression(${\beta}=-0.336$ 수식 이미지, p=0.001) and anxiety(${\beta}=-0.273$ 수식 이미지, p=0.009), after controlling for age, education, and comorbidity. In addition, poorer attention was also significantly related with depression(${\beta}=-0.375$ 수식 이미지, p=0.023) and anxiety (${\beta}=-0.404$ 수식 이미지, p=0.013). Conclusions : The results of this study showed the discrepancies between subjective complaints and objective measures of cognitive function in breast cancer survivors. It suggests that subjective cognitive decline could be indicators of psychological distress such as depression and anxiety.ope

The importance of psychiatric disorders in end-stage kidney disease patients

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Pros and cons of pharmacotherapy in insomnia

The consultation of personnel in relation to sleep disorders in Korea increased by 1.6 times between 2008 and 2012, and the related days of clinical practice increased by nearly 12 times during the same period. Among the sleep disorders, the most common diagnosis is insomnia, which is most commonly treated with medication. Medication is not only easy to access, but also effective immediately. However, the beneficial effect of hypnotic medication on sleep disorder for an extended period of time may be trivial. Tolerance is another barrier to treating chronic insomnia. In addition, such adverse effects as psychomotor slowing, memory loss, forgetfulness, and decreased sense of balance can heighten the risk of motor vehicle accidents and falling-related injuries. Recently, there have been reports about the association between the chronic use of sleeping pills and cancer mortality and dementia incidence. However, there are still many limitations to understanding whether it is the chronic use of hypnotics, or coexisting mental and physical illness, which increases the risk. Nevertheless, it is worthwhile to pay special attention to the abovementioned risks when using hypnotics and to consider alternative treatment options like cognitive behavioral therapy for insomnia.ope

Persistent Sleep Disturbance: A Risk Factor for Recurrent Depression in Community-Dwelling Older Adults

STUDY OBJECTIVES: The objective of this study was to examine the associations between the temporal and severity characteristics of sleep disturbance and subsequent depression in community-dwelling older adults. DESIGN: A prospective cohort study with assessment of sleep disturbance and depression at baseline and across 2 years of follow-up. SETTING: Three urban communities in the United States. PARTICIPANTS: Community-dwelling older adults in whom prior depression (n = 145), current depression (n = 68), or never mentally ill (n = 206) were diagnosed at the baseline assessment. MEASUREMENTS AND RESULTS: Major depression at year 2, defined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Among patients with either a depression history or current depression at baseline, persistent sleep disturbance throughout year 1 was associated with persistent or recurrent depression at year 2, after adjustment for group status, antidepressant and hypnotic sedative use, severity of depressive symptoms, chronic medical burden, and sociodemographic variables (adjusted odds ratio = 5.20, 95% confidence interval [CI] = 1.16 to 23.29). Among those who were not depressed at year 1, persistent sleep disturbance throughout year 1 predicted depression recurrence during year 2 (adjusted hazards ratio = 16.05, CI = 1.21 to 213.06), independent of the severity of sleep disturbance. None of the older adults who were never mentally ill developed a depression. CONCLUSIONS: Persistent sleep disturbance during a year-long period is associated with depression the following year. Among older adults with prior depression, identification of those with persistent sleep disturbance may optimize the efficacy of sleep related interventions to improve depression remission and/or prevent late-life depression.ope

Can Digital Therapeutics Open a New Era of Sleep Medicine?

Digital therapeutics (DTx) are products that provide evidence-based interventions driven by high-quality software programs to prevent, manage, or treat a medical disease. DTx are receiving increasing attention as a new therapeutic approach. Several DTx for insomnia are on the market, some of which have received approval by national regulatory agencies. DTx for insomnia are usually based on cognitive behavioral therapy for insomnia. No DTx for other sleep disorders, such as narcolepsy or sleep-related breathing disorders, have received regulatory authority approval as a medical device. DTx have the substantial benefits of being accessible and relatively low-cost. However, several issues related to DTx have not yet been fully resolved, and discussions regarding DTx are still in the early stages. To use DTx for sleep disorders as an effective treatment option in the future, considering the current status of DTx is necessary. This review discusses definitions and background of DTx; specific DTx for insomnia that have been developed; use of DTx for sleep and related psychiatric comorbid symptoms; global regulatory processes for DTx, including prescribing and medical billing issues; and remaining challenges regarding the use of DTx.ope