Digital cognitive behaviour therapy for insomnia in individuals with self-reported insomnia and chronic fatigue: A secondary analysis of a large scale randomized controlled trial

Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co-occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self-reported insomnia in a community-based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self-reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form-12 mental health, Short Form-12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9-week follow-up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form-12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community-based sample of adults with insomnia, co-occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders.publishedVersio

Dysfunctional beliefs and attitudes about sleep (DBAS) mediate outcomes in dCBT-I on psychological distress, fatigue, and insomnia severity

Objective/background Digital cognitive behavioral therapy for insomnia (dCBT-I) improves several sleep and health outcomes in individuals with insomnia. This study investigates whether changes in Dysfunctional Beliefs and Attitudes about Sleep (DBAS) during dCBT-I mediate changes in psychological distress, fatigue, and insomnia severity. Patients/methods The study presents a secondary planned analysis of data from 1073 participants in a randomized control trial (Total sample = 1721) of dCBT-I compared with patient education (PE). Self-ratings with the Dysfunctional Beliefs and Attitudes about Sleep (DBAS), the Hospital Anxiety Depression Scale (HADS), the Chalder Fatigue Scale (CFQ), and the Insomnia Severity Index (ISI) were obtained at baseline and 9-week follow-up. Hayes PROCESS mediation analyses were conducted to test for mediation. Results and conclusion sDBAS scores were significantly reduced at 9-week follow-up for those randomized to dCBT-I (n = 566) compared with PE (n = 507). The estimated mean difference was −1.49 (95% CI -1.66 to −1.31, p < .001, Cohen's d. = 0.93). DBAS mediated all the effect of dCBT-I on the HADS and the CFQ, and 64% of the change on the ISI (Estimated indirect effect −3.14, 95% CI -3.60 to −2.68) at 9-week follow-up compared with PE. Changes in the DBAS fully mediated the effects of dCBT-I on psychological distress and fatigue, and the DBAS partially mediated the effects on insomnia severity. These findings may have implications for understanding how dCBT-I works and highlights the role of changing cognitions in dCBT-I.publishedVersio

Attention outcome in the acute stage following uncomplicated and complicated mild traumatic brain injury

This thesis examined the consequences mild Traumatic Brain Injury (TBI) has on neuropsychological measures of attention two weeks after injury, using the Cambridge Neuropsychological Test Automated Battery (CANTAB). Most studies report attention to be impaired after mild TBI. Moreover, attention might be more impaired in patients with findings on neuroimaging, characterized as having a complicated mild TBI, because networks controlling attention are widespread in the brain and axonal injuries like traumatic axonal injury are suggested pathophysiology after mild TBI. Mild TBI patients do also often report psychological complaints. Psychological and other mild TBI comorbid factors make it difficult to determine the effect neuropathology has on neuropsychological performance. The CANTAB is potentially better suited to assess neuropsychological functioning after mild TBI, since traditional neuropsychological measures have been criticized. It was hypothesized that I) Mild TBI patients would perform worse on neuropsychological measures of attention and report more distress on selected self-reported measures than healthy matched controls 2 weeks after injury. II) That complicated mild TBI patients would perform worse on neuropsychological measures of attention than uncomplicated mild TBI patients and healthy matched controls 2 weeks after injury. A final sample of 62 patients with mild TBI and 49 healthy matched controls were compared on performance in the CANTAB analyzed with multivariate and univariate analysis. The participants answered questionnaires assessing self-reported symptoms, these were analyzed with univariate measures. All patients were examined with MRI at 3 Tesla within 72 hours after injury. There was no statistical significant difference between patients with mild TBI and matched healthy controls on measures of attention. CT and MRI results identified 7 patients with complicated mild TBI, a group too small to analyze statistically. The patients reported significantly more complaints on concentration, memory and pain compared to controls. It was concluded that the sample in this thesis was representative for the mild TBI population and that although some patients reported complaints on some self-reported measures, most patients with mild TBI show good neuropsychological outcome of attention two weeks after injury

Sleep and mild traumatic brain injury

Sleep and mild traumatic brain injury Many of the individuals who present to emergency departments or hospitals with a mild traumatic brain injury (mild TBI), often called a concussion, experience problems for a long time after their injury. Sleep-wake disturbances are among the most reported problems. We lack, however, critical knowledge regarding how long these problems lasts, if individuals with mild TBI are more vulnerable to develop such problems and what short-term and long-term consequences sleep-wake disturbances have. The main aim of the present thesis was to investigate the clinical course of sleep-wake disturbances after mild TBI and the consequences of sleep-wake disturbances after mild TBI as compared to patients with other types of injuries and individuals without any injury. We found that increased sleep need, poor sleep quality, excessive daytime sleepiness and fatigue was more common after mild TBI than after other types of injuries. In another study we found that sleeping two hours less than normal (partial sleep deprivation) led to more impulsive responses and lower levels of positive emotions (affect) for healthy young adults. Finally, we found that individuals with mild TBI was particularly vulnerable to the negative consequences poor sleep quality have on the ability to concentrate over time and for mental health, compared to patients with other types of injuries. Taken together, these findings confirm that sleep-wake disturbances are common and persistent problems after a mild TBI and that such problems may have short-term and long-term consequences for cognitive and mental health. These findings are an important step towards developing more person-adapted and targeted treatment for patients with mild TBI and other patient groups

Trajectories of Persistent Postconcussion Symptoms and Factors Associated With Symptom Reporting After Mild Traumatic Brain Injury

Objective To examine the trajectories of persistent postconcussion symptoms (PPCS) after mild traumatic brain injury (MTBI) and to investigate which injury-related and personal factors are associated with symptom reporting. Design Prospective longitudinal cohort study. Follow-up at 3 and 12 months postinjury. Setting A level 1 trauma center and an emergency outpatient clinic. Participants Patients with MTBI (n=358), trauma controls (n=75), and community controls (n=78). Main outcome measures Symptoms were assessed with the British Columbia Postconcussion Symptom Inventory (BC-PSI). Participants were categorized as having moderate to severe PPCS (msPPCS) when reporting ≥3 moderate/severe symptoms or a BC-PSI total score of ≥13. BC-PSI total scores were compared between the groups and were further used to create cutoffs for reliable change by identifying uncommon and very uncommon change in symptoms in the community control group. Associations between symptom reporting and 25 injury-related and personal factors were examined. Results The MTBI group had a similar prevalence of msPPCS at 3 and 12 months (21%) and reported more symptoms than the control groups. Analyses of individual trajectories, however, revealed considerable change in both msPPCS and BC-PSI total scores in the MTBI group, where both worsening and improvement was common. Intracranial lesions on computed tomography were associated with a greater likelihood of improving from 3 to 12 months. Those with msPPCS at both assessments were more likely to be women and to have these personal preinjury factors: reduced employment, pain, poor sleep, low resilience, high neuroticism and pessimism, and a psychiatric history. Conclusions Group analyses suggest a stable prevalence of msPPCS the first year postinjury. However, there was considerable intraindividual change. Several personal factors were associated with maintaining symptoms throughout the first year

The prevalence and stability of sleep-wake disturbance and fatigue throughout the first year after mild traumatic brain injury

In this prospective, longitudinal study, we aimed to determine the prevalence and stability of sleep-wake disturbance (SWD) and fatigue in a large representative sample of patients (Trondheim mild traumatic brain injury [mTBI] follow-up study). We included 378 patients with mTBI (age 16–60), 82 matched trauma controls with orthopedic injuries, and 83 matched community controls. Increased sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue were assessed at 2 weeks, 3 months, and 12 months after injury. Mixed logistic regression models were used to evaluate clinically relevant group differences longitudinally. Prevalence of increased sleep need, poor sleep quality, and fatigue was significantly higher in patients with mTBI than in both trauma controls and community controls at all time points. More patients with mTBI reported problems with excessive daytime sleepiness compared to trauma controls, but not community controls, at all time points. Patients with complicated mTBI (intracranial findings on computed tomography or magnetic resonance imaging) had more fatigue problems compared to those with uncomplicated mTBI, at all three time points. In patients with mTBI who experienced SWDs and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third at 12 months. Interestingly, we observed limited overlap between the different symptom measures; a large number of patients reported one specific problem with SWD or fatigue rather than several problems. In conclusion, our results provide strong evidence that mTBI contributes significantly to the development and maintenance of SWDs and fatigue

Examining 3-month test-retest reliability and reliable change using the Cambridge Neuropsychological Test Automated Battery

The Cambridge Neuropsychological Test Automated Battery (CANTAB) is a battery of computerized neuropsychological tests commonly used in Europe in neurology and psychiatry studies, including clinical trials. The purpose of this study was to investigate test-retest reliability and to develop reliable change indices and regression-based change formulas for using the CANTAB in research and practice involving repeated measurement. A sample of 75 healthy adults completed nine CANTAB tests, assessing three domains (i.e., visual learning and memory, executive function, and visual attention) twice over a 3-month period. Wilcoxon signed-rank tests showed significant practice effects for 6 of 14 outcome measures with effect sizes ranging from negligible to medium (Hedge’s g: .15–.40; Cliff’s delta: .09–.39). The Spatial Working Memory test, Attention Switching Task, and Rapid Visual Processing test were the only tests with scores of adequate test-retest reliability. For all outcome measures, Pearson’s and Spearman’s correlation coefficients ranged from .39 to .79. The measurement error surrounding difference scores was large, thus requiring large changes in performance (i.e., 1–2 SDs) in order to interpret a change score as reliable. In the regression equations, test scores from initial testing significantly predicted retest scores for all outcome measures. Age was a significant predictor in several of the equations, while education was a significant predictor in only two of the equations. The adjusted R2 values ranged between .19 and .67. The present study provides results enabling clinicians to make probabilistic statements about change in cognitive functions based on CANTAB test performances

The Prevalence and Stability of Sleep-Wake Disturbance and Fatigue throughout the First Year after Mild Traumatic Brain Injury.

In this prospective, longitudinal study, we aimed to determine the prevalence and stability of sleep-wake disturbance (SWD) and fatigue in a large representative sample of patients (Trondheim mild traumatic brain injury [mTBI] follow-up study). We included 378 patients with mTBI (age 16-60), 82 matched trauma controls with orthopedic injuries, and 83 matched community controls. Increased sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue were assessed at 2 weeks, 3 months, and 12 months after injury. Mixed logistic regression models were used to evaluate clinically relevant group differences longitudinally. Prevalence of increased sleep need, poor sleep quality, and fatigue was significantly higher in patients with mTBI than in both trauma controls and community controls at all time points. More patients with mTBI reported problems with excessive daytime sleepiness compared to trauma controls, but not community controls, at all time points. Patients with complicated mTBI (intracranial findings on computed tomography or magnetic resonance imaging) had more fatigue problems compared to those with uncomplicated mTBI, at all three time points. In patients with mTBI who experienced SWDs and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third at 12 months. Interestingly, we observed limited overlap between the different symptom measures; a large number of patients reported one specific problem with SWD or fatigue rather than several problems. In conclusion, our results provide strong evidence that mTBI contributes significantly to the development and maintenance of SWDs and fatigue