Cognitive behavioural therapy for insomnia in inpatient psychiatric care: a systematic review.

Insomnia is highly prevalent among patients with psychiatric disorders. According to current guidelines, cognitive behavioural therapy for insomnia (CBT-I) represents the first-line treatment for chronic insomnia, also for patients with psychiatric comorbidity. While recent studies have demonstrated that CBT-I not only improves insomnia but also other health outcomes in patients with psychiatric disorders and comorbid insomnia in outpatient settings, the level of implementation and treatment potential of CBT-I in inpatient psychiatry is less clear. The objective of this systematic review is to present and discuss studies that have adapted CBT-I for inpatient psychiatric care. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO, were searched until June 2023. A total of 10 studies were identified, with the majority being non-randomised trials without comparison groups and small sample sizes. With preliminary character, studies report feasibility and potential efficacy in inpatient settings. Together, this review identifies a paucity of studies on CBT-I or derivates in inpatient psychiatry. Despite challenging in this setting, studies adapting CBT-I to the needs of severely ill patients and hospital settings might have the potential to improve mental health care

SLEEPexpert App – A Mobile Application to Support Insomnia Treatment for Patients with Severe Psychiatric Disorders

Cognitive behavior therapy for insomnia (CBT-I) is the first-line treatment for patients with insomnia disorder, including patients with severe mental disorders and comorbid insomnia. However, CBT-I is not sufficiently implemented in acute psychiatry settings. To make this treatment more accessible, we are currently adapting CBT-I to the needs of patients with severe psychiatric disorders in the form of a treatment program entitled SLEEPexpert. A core element of SLEEPexpert is keeping a sleep diary and restricting time in bed to increase sleep pressure. Here, we present a mobile application which supports the implementation of SLEEPexpert. The app is kept very simple, specifically designed for the target user group, and offers four main functionalities: entering information into the sleep diary, calculating the sleep efficiency and adapting the sleep window, delivering information on sleep and sleep disorders and accessing the recorded data in the sleep diary. Currently, we are preparing a usability test for the app aiming at fixing usability issues before running a clinical trial to assess the efficacy of this mHealth intervention

Co-ordination of brain and heart oscillations during non-rapid eye movement sleep

Oscillatory activities of the brain and heart show a strong variation across wakefulness and sleep. Separate lines of research indicate that non‐rapid eye movement (NREM) sleep is characterised by electroencephalographic slow oscillations (SO), sleep spindles, and phase–amplitude coupling of these oscillations (SO–spindle coupling), as well as an increase in high‐frequency heart rate variability (HF‐HRV), reflecting enhanced parasympathetic activity. The present study aimed to investigate further the potential coordination between brain and heart oscillations during NREM sleep. Data were derived from one sleep laboratory night with polysomnographic monitoring in 45 healthy participants (22 male, 23 female; mean age 37 years). The associations between the strength (modulation index [MI]) and phase direction of SO–spindle coupling (circular measure) and HF‐HRV during NREM sleep were investigated using linear modelling. First, a significant SO–spindle coupling (MI) was observed for all participants during NREM sleep, with spindle peaks preferentially occurring during the SO upstate (phase direction). Second, linear model analyses of NREM sleep showed a significant relationship between the MI and HF‐HRV (F = 20.1, r (2) = 0.30, p < 0.001) and a tentative circular‐linear correlation between phase direction and HF‐HRV (F = 3.07, r (2) = 0.12, p = 0.056). We demonstrated a co‐ordination between SO–spindle phase–amplitude coupling and HF‐HRV during NREM sleep, presumably related to parallel central nervous and peripheral vegetative arousal systems regulation. Further investigating the fine‐graded co‐ordination of brain and heart oscillations might improve our understanding of the links between sleep and cardiovascular health

Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis.

Almost 70% of patients with mental disorders report sleep difficulties and 30% fulfill the criteria for insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia according to current treatment guidelines. Despite this circumstance, insomnia is frequently treated only pharmacologically especially in patients with mental disorders. The aim of the present meta-analysis was to quantify the effects of CBT-I in patients with mental disorders and comorbid insomnia on two outcome parameters: the severity of insomnia and mental health. The databases PubMed, CINHAL (Ebsco) und PsycINFO (Ovid) were searched for randomized controlled trials on adult patients with comorbid insomnia and any mental disorder comparing CBT-I to placebo, waitlist or treatment as usual using self-rating questionnaires as outcomes for either insomnia or mental health or both. The search resulted in 1994 records after duplicate removal of which 22 fulfilled the inclusion criteria and were included for the meta-analysis. The comorbidities were depression (eight studies, 491 patients), post-traumatic stress disorder (PTSD, four studies, 216 patients), alcohol dependency (three studies, 79 patients), bipolar disorder (one study, 58 patients), psychosis (one study, 50 patients) and mixed comorbidities within one study (five studies, 189 patients). The effect sizes for the reduction of insomnia severity post treatment were 0.5 (confidence interval, CI, 0.3-0.8) for patients with depression, 1.5 (CI 1.0-1.9) for patients with PTSD, 1.4 (CI 0.9-1.9) for patients with alcohol dependency, 1.2 (CI 0.8-1.7) for patients with psychosis/bipolar disorder, and 0.8 (CI 0.1-1.6) for patients with mixed comorbidities. Effect sizes for the reduction of insomnia severity were moderate to large at follow-up. Regarding the effects on comorbid symptom severity, effect sizes directly after treatment were 0.5 (CI 0.1-0.8) for depression, 1.3 (CI 0.6-1.9) for PTSD, 0.9 (CI 0.3-1.4) for alcohol dependency in only one study, 0.3 (CI -0.1 - 0.7, insignificant) for psychosis/bipolar, and 0.8 (CI 0.1-1.5) for mixed comorbidities. There were no significant effects on comorbid symptoms at follow-up. Together, these significant, stable medium to large effects indicate that CBT-I is an effective treatment for patients with insomnia and a comorbid mental disorder, especially depression, PTSD and alcohol dependency. CBT-I is also an effective add-on treatment with the aim of improving mental health in patients with depression, PTSD, and symptom severity in outpatients with mixed diagnoses. Thus, in patients with mental disorders and comorbid insomnia, given the many side effects of medication, CBT-I should be considered as a first-line treatment

The hierarchy of coupled sleep oscillations reverses with aging in humans.

A well-orchestrated coupling hierarchy of slow waves and spindles during slow wave sleep supports memory consolidation. In old age, duration of slow wave sleep and number of coupling events decreases. The coupling hierarchy deteriorates, predicting memory loss and brain atrophy. Here, we investigate the dynamics of this physiological change in slow wave-spindle coupling in a frontocentral electroencephalography position in a large sample (N=340, 237 female, 103 male) spanning most of the human lifespan (ages 15-83). We find that, instead of changing abruptly, spindles gradually shift from being driven by-, to driving slow waves with age, reversing the coupling hierarchy typically seen in younger brains. Reversal was stronger the lower the slow wave frequency, and starts around midlife (∼age 40-48), with an established reversed hierarchy at age 56-83. Notably, coupling strength remains unaffected by age. In older adults, deteriorating slow wave-spindle coupling, measured using phase slope index (PSI) and number of coupling events, is associated with blood plasma glial fibrillary acidic protein (GFAP) levels, a marker for astrocyte activation. Data-driven models suggest decreased sleep time and higher age lead to fewer coupling events, paralleled by increased astrocyte activation. Counterintuitively, astrocyte activation is associated with a back-shift of the coupling hierarchy (PSI) towards a "younger" status along with increased coupling occurrence and strength, potentially suggesting compensatory processes. As the changes in coupling hierarchy occur gradually starting at midlife, we suggest there exists a sizable window of opportunity for early interventions to counteract undesirable trajectories associated with neurodegeneration.Significance StatementEvidence accumulates that sleep disturbances and cognitive decline are bi-directionally and causally linked forming a vicious cycle. Improving sleep quality could break this cycle. One marker for sleep quality is a clear hierarchical structure of sleep oscillations. Previous studies showed that sleep oscillations decouple in old age. Here, we show that, rather, the hierarchical structure gradually shifts across the human lifespan and reverses in old age, while coupling strength remains unchanged. This shift is associated with markers for astrocyte activation in old age. The shifting hierarchy resembles brain maturation, plateau, and wear processes. This study furthers our comprehension of this important neurophysiological process and its dynamic evolution across the human lifespan

TRY plant trait database – enhanced coverage and open access

Plant traits - the morphological, anatomical, physiological, biochemical and phenological characteristics of plants - determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait‐based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits - almost complete coverage for ‘plant growth form’. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait–environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives

Augmentation of psychotherapy with neurobiological methods: current state and future directions

Background: Psychotherapy and pharmacotherapy are first-line treatments for mental disorders. Despite recent improvements, only approximately 50% of the patients reach sustained remission, indicating a need for novel developments. The main concept put forward in this systematic review and hypothesis article is the targeted co-administration of defined neurobiological interventions and specific psychotherapeutic techniques. Methods: We conducted a systematic literature search for randomized controlled trials comparing the efficacy of augmented psychotherapy to psychotherapy alone. Results: Thirty-five trials fulfilled the inclusion criteria. The majority (29 trials) used augmentation strategies such as D-cycloserine, yohimbine, or sleep to enhance the effects of exposure therapy for anxiety disorders. Fewer studies investigated noninvasive brain stimulation with the aim of improving cognitive control, psychedelic compounds with the aim of enhancing existentially oriented psychotherapy, and oxytocin to improve social communication during psychotherapy. Results demonstrate small augmentation effects for the enhancement of exposure therapy - however, some of the studies found negative results. Other methods are less thoroughly researched, and results are mixed. Conclusions: This approach provides an open matrix for further research and has the potential to systematically guide future studies

Modulating overnight memory consolidation by acoustic stimulation during slow wave sleep – a systematic review and meta-analysis

Study objectives: The low-frequency high-amplitude oscillations of slow wave sleep are considered to promote the consolidation of episodic memory. Previous research suggests that sleep slow waves can be entrained and enhanced by presenting short acoustic stimuli to the up-states of endogenous waves. Several studies have investigated the effects of these increases in slow wave activity on overnight memory consolidation, with inconsistent results. The aim of this meta-analysis was to evaluate the accumulated evidence connecting acoustic stimulation during sleep to episodic memory consolidation. Methods: A systematic literature search was conducted in October 2020 using Pubmed, Web of Science and PsycInfo. Main study inclusion criteria were the application of acoustic slow wave enhancement in healthy participants and an assessment of pre- and post-sleep episodic memory performance. Effect sizes were pooled using a random effects model. Results: Ten primary studies with 11 experiments and 177 participants were included. Results showed a combined effect size (Hedges' g) of 0.25 (p=0.07). Subgroup models based on young adults (n = 8), phase-locked stimulation approaches (n = 8) and their combination (n = 6) showed combined effect sizes of 0.31 (p=0.051), 0.36 (p=0.047) and 0.44 (p=0.01), respectively. There was no indication of publication bias or bias in individual studies. Conclusions: Acoustic enhancement of slow wave sleep tends to increase the overnight consolidation of episodic memory but effects remain small and - with the exception of subgroup models - at trend levels. Currently, the evidence is not sufficient to recommend the use of commercially available devices

SLEEPexpert+: Blending Internet-Based Cognitive Behavioral Therapy for Insomnia with In-Person Psychotherapy—A Feasibility Study in Routine Care

Insomnia is characterized by frequent and persistent difficulties initiating and maintaining sleep, along with impaired daytime functioning. Blended treatments are increasingly popular for treating psychological disorders such as depression. Blended treatments combine elements of face-to-face therapy and online interventions. A single-arm pre-post study investigated the feasibility of a blended treatment combining face-to-face cognitive behavioral therapy for insomnia and internet-based cognitive behavioral therapy for insomnia (SLEEPexpert+). The findings show that the therapists have a positive attitude toward blended CBT-I (b-CBT-I) and that they feel supported by the online components of the treatment. Possible barriers to implementing blended treatments are integrating the online materials into the face-to-face sessions and adapting one’s therapeutic style to the blended treatment approach. No definitive statements about the effectiveness of the b-CBT-I treatment can be made. However, of the six presented cases, five patients showed notably higher sleep efficiency and fewer insomnia symptoms at the end of the therapy. Program usage data indicate that participants mainly used the online components at the beginning of their treatment. Future studies should investigate the effectiveness of b-CBT-I with a sufficiently powered randomized controlled trial comparing b-CBT-I with an adequate control group in routine care

Shaping the slow waves of sleep: A systematic and integrative review of sleep slow wave modulation in humans using non-invasive brain stimulation

The experimental study of electroencephalographic slow wave sleep (SWS) stretches over more than half a century and has corroborated its importance for basic physiological processes, such as brain plasticity, metabolism and immune system functioning. Alterations of SWS in aging or pathological conditions suggest that modulating SWS might constitute a window for clinically relevant interventions. This work provides a systematic and integrative review of SWS modulation through non-invasive brain stimulation in humans. A literature search using PubMed, conducted in May 2020, identified 3220 studies, of which 82 fulfilled inclusion criteria. Three approaches have been adopted to modulate the macro- and microstructure of SWS, namely auditory, transcranial electrical and transcranial magnetic stimulation. Our current knowledge about the modulatory mechanisms, the space of stimulation parameters and the physiological and behavioral effects are reported and evaluated. The integration of findings suggests that sleep slow wave modulation bears the potential to promote our understanding of the functions of SWS and to develop new treatments for conditions of disrupted SWS