Actigraphy in the assessment of insomnia

Objective: The present study explores the clinical utility and sensitivity of actigraphy as an outcome measure in the treatment of chronic insomnia. Design: Following a screening-adaptation night, polysomnography, actigraphy, and sleep-diary data were collected in the sleep laboratory for 2 baseline nights and 2 posttreatment nights. Setting: A university-affiliated sleep disorders center. Participants: Seventeen participants with chronic primary insomnia. Mean age was 41.6 years. Interventions: Participants took part in a treatment protocol investigating different sequential treatments for insomnia (these results are reported elsewhere). Measurements and Results: Compared to polysomnography, both actigraphy and sleep-diary instruments underestimated total sleep time and sleep efficiency and overestimated total wake time. Also, actigraphy underestimated sleep-onset latency while the sleep diary overestimated it as compared to polysomnography. Actigraphy data were more accurate than sleep-diary data when compared to polysomnography. Finally, actigraphy was sensitive in detecting the effects of treatment on several sleep parameters. Conclusions: These results suggest that actigraphy is a useful device for measuring treatment response and that it should be used as a complement to sleep-diary evaluation

Au-delà de l’ABC du traitement cognitivocomportemental de l’insomnie

L’insomnie est un trouble dont la prévalence dans la population québécoise est d’environ 30% de façon occasionnelle et 10% de façon chronique. Le médecin, qui voit souvent des patients qui en sont atteints, est en mesure de diagnostiquer un trouble de sommeil, car il connaît les difficultés qui l’accompagnent et les conséquences qui en découlent. Toutefois, dans le contexte d’une consultation en cabinet, offrir un traitement efficace et de surcroît non pharmacologique est très difficile

Exploring a behavioural therapy for insomnia in shift workers

About 30% of Canadian workers are on shift work schedules, and 8% to 32% of them suffer from Shift Work Disorder (SWD). Only a few behavioural treatments exist to treat this population. This study explores the efficacy and feasibility of sleep restriction therapy for insomnia in a group of night shift workers. Six participants (3 women) meeting SWD criteria were recruited. Mean age was 45.7 years old (SD=8.2). A multiple baseline design was used. After baseline, each participant received six to eight weekly treatment sessions. They completed several self reported questionnaires and a daily sleep diary throughout the study. For each sleep period, sleep variables were calculated from the sleep diary. Two participants had a high treatment response and all others participants had a moderate response. Moreover, all participants presented at least two significant clinical improvements. Five participants presented a decreased in both sleepiness scores. The study suggests that sleep restriction therapy is effective, feasible, and reliable. Sleep restriction therapy for insomnia could improve sleep and diminish sleepiness in shift workers suffering from SWD. The present study opens new possibilities of treatment for shift workers that deserve greater attention in the future

Insomnia in shift work

Background: Shift work disorder involves insomnia and/or excessive sleepiness associated with the work schedule. The present study examined the impact of insomnia on the perceived physical and psychological health of adults working on night and rotating shift schedules compared to day workers. Methods: A total of 418 adults (51% women, mean age 41.4 years), including 51 night workers, 158 rotating shift workers, and 209 day workers were selected from an epidemiological study. An algorithm was used to classify each participant of the two groups (working night or rotating shifts) according to the presence or absence of insomnia symptoms. Each of these individuals was paired with a day worker according to gender, age, and income. Participants completed several questionnaires measuring sleep, health, and psychological variables. Results: Night and rotating shift workers with insomnia presented a sleep profile similar to that of day workers with insomnia. Sleep time was more strongly related to insomnia than to shift work per se. Participants with insomnia in the three groups complained of anxiety, depression, and fatigue, and reported consuming equal amounts of sleep-aid medication. Insomnia also contributed to chronic pain and otorhinolaryngology problems, especially among rotating shift workers.Work productivity and absenteeism were more strongly related to insomnia. Conclusion: The present study highlights insomnia as an important component of the sleep difficulties experienced by shift workers. Insomnia may exacerbate certain physical and mental health problems of shift workers, and impair their quality of life

Qualitative studies of insomnia : current state of knowledge in the field

Despite its high prevalence and burden, insomnia is often trivialized, under-diagnosed, and under-treated in practice. Little information is available on the subjective experience and perceived consequences of insomnia, help-seeking behaviors, and treatment preferences. The use of qualitative approaches (e.g., ethnography, phenomenology, grounded theory) may help gain a better understanding of this sleep disorder. The present paper summarizes the evidence derived from insomnia studies using a qualitative research methodology (e.g., focus group, semi-structured interviews). A systematic review of the literature was conducted using PsycINFO and Medline databases. The review yielded 22 studies and the quality of the methodology of each of them was evaluated systematically using the critical appraisal skills programme (CASP) appraisal tool. Selected articles possess at least a very good methodological rigor and they were categorized according to their main focus: “Experience of insomnia”, “Management of insomnia” and “Medicalization of insomnia”. The main findings indicate that: 1) insomnia is often experienced as a 24-h problem and is perceived to affect several domains of life, 2) a sense of frustration and misunderstanding is very common among insomnia patients, which is possibly due to a mismatch between patients' and health care professionals' perspectives on insomnia and its treatment, 3) health care professionals pay more attention to sleep hygiene education and medication therapies and less to the patient's subjective experience of insomnia, and 4) health care professionals are often unaware of non-pharmacological interventions other than sleep hygiene education. An important implication of these findings is the need to develop new clinical measures with a broader scope on insomnia and more targeted treatments that take into account the patient's experience of insomnia. Greater use of qualitative approaches in future research may produce novel and more contextualized information leading to a more comprehensive understanding of insomnia

Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia : a randomized controlled trial

Context: Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome. Objectives: To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome. Design, Setting, and Patients: Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005. Interventions: Participants received CBT alone or CBT plus 10 mg/d (taken at bedtime) ofzolpidemforaninitial6-weektherapy,followedbyextended6-monththerapy.Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only. Main Outcome Measures: Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes). Results: Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P .001); a larger increase of sleep time was obtained with the combined approach (P=.04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P=.84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P=.52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P=.05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P=.04). Conclusion: In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT

Sleep and quality of life in urban poverty : the effect of a slum housing upgrading program

Study Objectives : To evaluate the effect of a housing transition on sleep quality and quality of life in slum dwellers, participating in a slum housing upgrading program. Design : Observational before-and-after study with a convergent-parallel mixed method design. Setting : Five slums located in the metropolitan area of Buenos Aires, Argentina. Participants : A total of 150 slum dwellers benefited by a housing program of the nonprofit organization TECHO (spanish word for “roof”). Interventions : Participants moved from their very low-quality house to a basic prefabricated 18 m2 modular house provided by TECHO. Measurements and Results : The Pittsburgh Sleep Quality Index (PSQI) and World Health Organization Quality of Life brief scale (WHOQOL-BREF) were administered before and after housing upgrading. Data about housing conditions, income, education, sleeping conditions, and cardiovascular risk were also collected. Semistructured interviews were used to expand and nuance quantitative data obtained from a poorly educated sample. Results showed that sleep quality significantly increased after the housing program (z = -6.57, P < 0.001). Overall quality of life (z = -6.85, P < 0.001), physical health domain (z = -4.35, P < 0.001), psychological well-being domain (z = -3.72, P < 0.001) and environmental domain (z = -7.10, P < 0.001) of WHOQOL-BREF were also improved. Interviews demonstrated the importance of serenity for improving quality of life. Conclusions : A minimal improvement in the quality of basic housing can significantly increase sleep quality and quality of life among slum dwellers. Understanding sleep and daily life conditions in informal urban settlements could help to define what kind of low-cost intervention may improve sleep quality, quality of life, and reduce existent sleep disparity

Adherence to cognitive behavior therapy for insomnia : an updated systematic review

This article discusses information extracted from 53 studies that have measured adherence to cognitive behavior therapy for insomnia. There has been an increase in more complex and less biased methods for assessing adherence that move beyond simply asking the patients whether they have adhered to the intervention or not. There is a need for a consensus around how to measure adherence, if clinicians want to arrive at an estimate of optimal adherence. Heterogeneity of studies, particularly in the way adherence is operationalized, prohibited conclusions about the relationship between adherence and outcome, as well as about predictors of adherence