Social support, negative social exchange, and response to case formulation-based cognitive behavior therapy.

We investigated associations between pretreatment social support, negative social exchange, and slope of weekly symptom change for depression, anxiety, and stress over the course of ideographic, case formulation-based, cognitive behavior therapy. Participants were 74 adults treated in a private practice setting. We used self-report measures to assess social support and negative social exchange at intake and to assess symptoms on a weekly basis. At pretreatment, a higher level of social support was associated with lower levels of depression, and a higher level of negative social exchanges was associated with higher levels of depression and stress. Pretreatment social support was not significantly associated with slope of symptom change. However, a higher level of pretreatment negative social exchanges was associated with steeper slope of change in symptoms of depression and stress during treatment. These findings suggest that the association between pretreatment negative social exchanges and subsequent symptoms may be stronger than that of social support and subsequent symptoms. Additionally, we discuss the possibility that having data on negative social exchanges at the start of treatment may benefit the outcome of ideographic, case formulation-based, cognitive behavior therapy.

Impact of comorbid anxiety and depressive disorders on treatment response to cognitive behavior therapy for insomnia.

OBJECTIVE: To evaluate the impact of comorbid anxiety or depressive disorders on treatment response to cognitive-behavior therapy (CBT) for insomnia, behavior therapy (BT), or cognitive therapy (CT). METHOD: Participants were 188 adults (117 women; Mage = 47.4 years) with chronic insomnia, including 45 also presenting a comorbid anxiety or mild to moderate depressive disorder. They were randomized to BT (n = 63), CT (n = 65), or CBT (n = 60). Outcome measures were the proportion of treatment responders (decrease of ≥8 points on the Insomnia Severity Index; ISI) and remissions (ISI score < 8) and depression and anxiety symptoms. RESULTS: Proportion of treatment responders and remitters in the CBT condition was not significantly different between the subgroups with and without comorbidity. However, the proportion of responders was lower in the comorbidity subgroup compared to those without comorbidity in both the BT (34.4% vs. 81.6%; p = .007) and CT (23.6% vs. 57.6%; p = .02) alone conditions, although remission rates and prepost ISI change scores were not. Pre to post change scores on the depression (-10.6 vs. -3.9; p < .001) and anxiety measures (-9.2 vs. -2.5; p = .01) were significantly greater in the comorbidity subgroup relative to the subgroup without comorbidity but only for those treated with the full CBT; no difference was found for those treated with either BT or CT alone. CONCLUSIONS: The presence of a comorbid anxiety or mild to moderate depressive disorder did not reduce the efficacy of CBT for insomnia, but it did for its single BT and CT components when used alone. (PsycINFO Database Record

Change in Dysfunctional Beliefs About Sleep in Behavior Therapy, Cognitive Therapy, and Cognitive-Behavioral Therapy for Insomnia.

As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.

Increasing psychotherapists' adoption and implementation of the evidence-based practice of progress monitoring.

Evidence-based practices (EBPs) reach consumers slowly because practitioners are slow to adopt and implement them. We hypothesized that giving psychotherapists a tool + training intervention that was designed to help the therapist integrate the EBP of progress monitoring into his or her usual way of working would be associated with adoption and sustained implementation of the particular progress monitoring tool we trained them to use (the Depression Anxiety Stress Scales on our Online Progress Tracking tool) and would generalize to all types of progress monitoring measures. To test these hypotheses, we developed an online progress monitoring tool and a course that trained psychotherapists to use it, and we assessed progress monitoring behavior in 26 psychotherapists before, during, immediately after, and 12 months after they received the tool and training. Immediately after receiving the tool + training intervention, participants showed statistically significant increases in use of the online tool and of all types of progress monitoring measures. Twelve months later, participants showed sustained use of any type of progress monitoring measure but not the online tool.

Inter-episode affective intensity and instability: predictors of depression and functional impairment in bipolar disorder.

BACKGROUND AND OBJECTIVES: Dysregulated affect is a hallmark feature of acute episodes of bipolar disorder (BD) and persists during inter-episode periods. Its contribution to course of illness is not yet known. The present report examines the prospective influence of inter-episode affect dysregulation on symptoms and functional impairment in BD. METHODS: Twenty-seven participants diagnosed with inter-episode bipolar I disorder completed daily measures of negative and positive affect for 49 days (±8 days) while they remained inter-episode. One month following this daily assessment period, symptom severity interviews and a measure of functional impairment were administered by telephone. RESULTS: More intense negative affect and positive affect during the inter-episode period were associated with higher depressive, but not manic, symptoms at the one-month follow-up assessment. More intense and unstable negative affect, and more unstable positive affect, during the inter-episode period were associated with greater impairment in home and work functioning at the follow-up assessment. All associations remained significant after controlling for concurrent symptom levels. LIMITATIONS: The findings need to be confirmed in larger samples with longer follow-up periods. A more comprehensive assessment of functional impairment is also warranted. CONCLUSIONS: The findings suggest that a persistent affective dysregulation between episodes of BD may be an important predictor of depression and functional impairment. Monitoring daily affect during inter-episode periods could allow for a more timely application of interventions that aim to prevent or reduce depressive symptoms and improve functioning for individuals with BD.

Physical activity and sleep: Day-to-day associations among individuals with and without Bipolar Disorder.

OBJECTIVE: To evaluate the relative role of psychopathology in the relationship between physical activity and sleep, the present study investigated the day-to-day relationship between physical activity and sleep in individuals without a psychiatric disorder and individuals with bipolar disorder using a longitudinal, naturalistic design. METHOD: Participants in two groups-a healthy group with no psychiatric illness (N=36) and an inter-episode bipolar disorder group (N=32)- were studied over a two-month period. Physical health was assessed by the SF-36. Daily subjective and objective measures of physical activity and sleep were collected. A total of 6,670 physical activity measurements and 6,548 sleep measurements were logged. RESULTS: The bipolar disorder group exhibited poorer physical health on the SF-36 and more sleep disturbance relative to the healthy group. No group differences were found in physical activity, nor in models examining the relationship between physical activity and sleep. Hierarchical linear models indicated that for every standard deviation increase in sleep disturbance (i.e., increased total wake time), there was a three percent decrease in subsequent day physical activity, in both the healthy and bipolar groups. Increased physical activity was associated with improved sleep for participants who reported greater average sleep disturbance. CONCLUSIONS: The results for all participants in the study suggest that reduced physical activity and sleep difficulties may be mutually maintaining processes, particularly for individuals who suffer from poor sleep. Findings also raise the potential importance of targeting physical activity and sleep concurrently in interventions aimed at improving physical and mental health.

Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: a randomized controlled trial.

OBJECTIVE: To examine the unique contribution of behavior therapy (BT) and cognitive therapy (CT) relative to the full cognitive behavior therapy (CBT) for persistent insomnia. METHOD: Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60). RESULTS: Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups. CONCLUSIONS: Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.

Social support and social strain in inter-episode bipolar disorder.

OBJECTIVES: This study focused on social support and social strain and their cross-sectional associations with instabilities in sleep and social rhythms in inter-episode bipolar disorder (BD). METHODS: Thirty-five adults diagnosed with inter-episode BD type I and 38 healthy controls completed measures of perceived social support and social strain. Group differences in support and strain were examined. Within the BD group, instabilities in sleep and social rhythms were assessed with 28 days of daily diary and actigraphy. Correlation and regression analyses were used to examine cross-sectional and prospective associations between social support, social strain, instabilities in sleep and social rhythms, and mood symptoms. RESULTS: The BD group reported lower social support and higher social strain than the control group. Additionally, social strain was positively correlated with manic and depressive symptoms in the BD group. Furthermore, there was a cross-sectional association between social support and more stable sleep on actigraphy in the BD group, although social support did not predict future sleep instability. CONCLUSIONS: These results indicate that inter-episode BD is associated with deficient social support and elevated social strain compared to controls, and that this may be due to persistent inter-episode mood symptoms. Social strain may be particularly important given its association with manic and depressive symptoms. The results also raise the possibility that sleep instability is related to poor social support in BD.

Restless pillow, ruffled mind: sleep and affect coupling in interepisode bipolar disorder.

Disturbances in sleep and affect are prominent features of bipolar disorder, even during interepisode periods. Few longitudinal studies have prospectively examined the relationship between naturally occurring sleep and affect, and no studies to date have done so during interepisode periods of bipolar disorder and using the entire set of "gold standard" sleep parameters. Participants diagnosed with bipolar I disorder who were interepisode (n = 32) and healthy controls (n = 36) completed diagnostic and symptom severity interviews, and a daily sleep and affect diary, as well as an actigraphy sleep assessment, for eight weeks (M = 54 days, ± 8 days). Mutual information analysis was used to assess the degree of statistical dependence, or coupling, between time series data of sleep and affect. As measured by actigraphy, longer sleep onset latency was coupled with higher negative affect more strongly in the bipolar group than in the control group. As measured by sleep diary, longer wakefulness after sleep onset and lower sleep efficiency were coupled with higher negative affect significantly more strongly in the bipolar group than in the control group. By contrast, there were no significant differences between groups in the degree of coupling between any measures of sleep and positive affect. Findings support the coupling of sleep disturbance and negative affect during interepisode bipolar disorder. Ongoing monitoring of sleep-affect coupling may provide an important target for intervention in bipolar disorder.

A test of the bidirectional association between sleep and mood in bipolar disorder and insomnia.

The present study investigates sleep, mood, and the proposed bidirectional relationship between the two in psychiatric disorders. Participants with interepisode bipolar disorder (n = 49), insomnia (n = 34), and no psychiatric history (n = 52) completed seven consecutive days of sleep diaries and mood measures. The interepisode bipolar and insomnia participants exhibited greater sleep disturbance than the healthy control individuals. Negative mood was equally heightened in both interepisode bipolar disorder and insomnia, and there were no differences between the three groups in positive mood. Total wake time was associated with next morning negative mood in bipolar disorder, whereas evening negative mood was associated with subsequent total wake time in both bipolar disorder and insomnia. Additionally, positive mood was associated with subsequent total wake time for the insomnia group. Results support the theory that disruptions in nighttime sleep and daytime mood may be mutually maintaining and suggest the potential importance of transdiagnostic or universal processes.

Emotional and physiological responses to normative and idiographic positive stimuli in bipolar disorder.

BACKGROUND: Few studies have examined differences in emotional responding among distinct types of positive stimuli. This is important to understand both for individuals characterized by extreme positive mood (i.e., bipolar disorder) and healthy adults. METHODS: Using a multi-method within-subjects design, the current study examined physiological, behavioral, and self-reported responses to normative (film) and idiographic (memory) happy stimuli in bipolar (BD; n=25) and healthy control groups (CTL; n=23). RESULTS: For both groups, the happy films were associated with greater self-reported and behavioral displays of positive emotion compared to the happy memory. Furthermore, the BD group displayed greater cardiac vagal tone - a putative marker of positive emotion - across both the film and memory. CONCLUSION: Normative stimuli were more potent elicitors of positive emotion compared to idiographic stimuli. The study provided further evidence for cardiac vagal tone as a potential biomarker of extreme positive emotion in BD.

Hooked on a feeling: rumination about positive and negative emotion in inter-episode bipolar disorder.

Rumination has been consistently implicated in the onset and maintenance of depression. Less work has examined rumination in the context of bipolar disorder, especially rumination about positive emotion. The present study examined rumination about negative and positive emotion in interepisode bipolar disorder (BD; n = 39) and healthy controls (CTL; n = 34). Trait rumination about positive and negative emotion, as well as experiential and physiological responses to a rumination induction, was measured. Illness course was also assessed for the BD group. Results indicated that the BD group reported greater trait rumination about positive and negative emotion compared with the CTL group, though no group differences emerged during the rumination induction. For the BD group, trait rumination about positive and negative emotion, as well as increased cardiovascular arousal (i.e., heart rate), was associated with greater lifetime depression frequency; trait rumination about positive emotion was associated with greater lifetime mania frequency. These findings suggest that interepisode BD is associated with greater rumination about positive and negative emotion, which in turn is associated with illness course.

Hypersomnia in inter-episode bipolar disorder: does it have prognostic significance?

BACKGROUND: Hypersomnia in inter-episode bipolar disorder has been minimally researched. The current study sought to document the prevalence of hypersomnia in a sample of inter-episode patients with bipolar disorder and to examine the relationship between hypersomnia and future bipolar depressive symptoms. METHODS: A total of 56 individuals with bipolar disorder (51 type I+5 type II) who were currently inter-episode, along with 55 non-psychiatric controls, completed a baseline assessment, including semi-structured interviews for psychiatric diagnoses, sleep disorders, and a battery of indices that included assessment of hypersomnia. Approximately 6 months later, participants were recontacted by telephone and mood was re-evaluated. RESULTS: Three of six indices suggested that approximately 25% of participants with bipolar disorder endorsed symptoms of hypersomnia in the inter-episode period. Within the bipolar group, hypersomnia in the inter-episode period was associated with future depressive symptoms. This finding was independent of baseline depressive symptoms and medication use. LIMITATIONS: Small sample size and concurrent psychopharmacology in the bipolar sample. DISCUSSION: Though no gold standard measure for hypersomnia currently exists, this research takes a step towards identifying a clinically and empirically useful hypersomnia assessment. This study demonstrates that hypersomnia in the inter-episode period of bipolar disorder relates to future depressive symptoms, and adds to the growing body of evidence on the importance of inter-episode symptoms predicting bipolar relapse.

Sensory gating in primary insomnia.

Although previous research indicates that sleep architecture is largely intact in primary insomnia (PI), the spectral content of the sleeping electroencephalographic trace and measures of brain metabolism suggest that individuals with PI are physiologically more aroused than good sleepers. Such observations imply that individuals with PI may not experience the full deactivation of sensory and cognitive processing, resulting in reduced filtering of external sensory information during sleep. To test this hypothesis, gating of sensory information during sleep was tested in participants with primary insomnia (n = 18) and good sleepers (n = 20). Sensory gating was operationally defined as (i) the difference in magnitude of evoked response potentials elicited by pairs of clicks presented during Wake and Stage II sleep, and (ii) the number of K complexes evoked by the same auditory stimulus. During wake the groups did not differ in magnitude of sensory gating. During sleep, sensory gating of the N350 component was attenuated and completely diminished in participants with insomnia. P450, which occurred only during sleep, was strongly gated in good sleepers, and less so in participants with insomnia. Additionally, participants with insomnia showed no stimulus-related increase in K complexes. Thus, PI is potentially associated with impaired capacity to filter out external sensory information, especially during sleep. The potential of using stimulus-evoked K complexes as a biomarker for primary insomnia is discussed.

Sleep architecture as correlate and predictor of symptoms and impairment in inter-episode bipolar disorder: taking on the challenge of medication effects.

This study was designed to clarify the association between inter-episode bipolar disorder (BD) and sleep architecture. Participants completed a baseline symptom and sleep assessment and, 3 months later, an assessment of symptoms and impairment. The effects of psychiatric medications on sleep architecture were also considered. Participants included 22 adults with BD I or II (inter-episode) and 22 non-psychiatric controls. The sleep assessment was conducted at the Sleep and Psychological Disorders Laboratory at the University of California, Berkeley. Follow-up assessments 3 months later were conducted over the phone. Results indicate that, at the sleep assessment, BD participants exhibited greater rapid eye movement sleep (REM) density than control participants with no other group differences in sleep architecture. Sleep architecture was not correlated with concurrent mood symptoms in either group. In the BD group, duration of the first REM period and slow-wave sleep (SWS) amount were positively correlated with manic symptoms and impairment at 3 months, while REM density was positively correlated with depressive symptoms and impairment at 3 months. The amount of Stage 2 sleep was negatively correlated with manic symptoms and impairment at 3 months. In contrast, for the control group, REM density was negatively correlated with impairment at 3 months. SWS and Stage 2 sleep were not correlated with symptoms or impairment. Study findings suggest that inter-episode REM sleep, SWS and Stage 2 sleep are correlated with future manic and depressive symptoms and impairment in BD. This is consistent with the proposition that sleep architecture may be a mechanism of illness maintenance in BD.

Sleep, illness course, and concurrent symptoms in inter-episode bipolar disorder.

We investigated associations between sleep, illness course, and concurrent symptoms in 21 participants with bipolar disorder who were inter-episode. Sleep was assessed using a week-long diary. Illness course and symptoms were assessed via validated semi-structured interviews. Lower and more variable sleep efficiency and more variable total wake time were associated with more lifetime depressive episodes. Variability in falling asleep time was positively correlated with concurrent depressive symptoms. Sleep efficiency was positively correlated with concurrent manic symptoms. These findings suggest that inter-episode sleep disturbance is associated with illness course and that sleep may be an important intervention target in bipolar disorder.

The effect of mood on sleep onset latency and REM sleep in interepisode bipolar disorder.

The present study investigates whether interepisode mood regulation impairment contributes to disturbances in sleep onset latency (SOL) and rapid eye movement (REM) sleep. Individuals with interepisode bipolar disorder (n = 28) and healthy controls (n = 28) slept in the laboratory for 2 baseline nights, a happy mood induction night, and a sad mood induction night. There was a significant interaction whereby on the happy mood induction night the bipolar group exhibited significantly longer SOL than did the control group, while there was no difference on the baseline nights. In addition, control participants exhibited shorter SOL on the happy mood induction night compared to the baseline nights, a finding that was not observed in the bipolar group. On the sad mood induction night, participants in both groups had shorter SOL and increased REM density when compared to the baseline nights. Bipolar participants exhibited heightened REM density compared to control participants on both nights. These results raise the possibility that regulation of positive stimuli may be a contributor to difficulties with SOL, while hyperactivity may be characteristic of REM sleep.

Transdiagnostic emotion regulation processes in bipolar disorder and insomnia.

Research and treatment have traditionally adopted a 'disorder-focused' approach by targeting one specific disorder, aiming to understanding its cause, maintenance and treatment. The aim of the present study was to contribute to the burgeoning interest in examining common, or 'transdiagnostic,' processes across disorders. Three candidate transdiagnostic processes involved in emotion regulation - rumination, worry, and automatic negative thoughts - were examined in euthymic bipolar I disorder (n=21) and insomnia (n=19), and a non-clinical control group (n=20). Rumination and worry were endorsed to a larger degree by the bipolar and insomnia groups compared to the control group. However, while the bipolar group had more negative automatic thoughts than the control group, there were no significant differences in negative automatic thoughts between the bipolar and insomnia groups or the insomnia and control groups. These results suggested that rumination and worry, but not negative automatic thoughts, might be common across bipolar disorder and insomnia. However, these findings no longer remained significant when current symptoms of anxiety and depression were controlled for. Prospective and experimental studies are needed to test the extent to which these processes contribute to the etiology or maintenance of insomnia and bipolar disorder.

Critical thinking about adverse drug effects: lessons from the psychology of risk and medical decision-making for clinical psychopharmacology.

Systematic biases in decision-making have been well characterized in medical and nonmedical fields but mostly ignored in clinical psychopharmacology. The purpose of this paper is to sensitize clinicians who prescribe psychiatric drugs to the issues of the psychology of risk, especially as they pertain to the risk of side effects. Specifically, the present analysis focuses on heuristic organization and framing effects that create cognitive biases in medical practice. Our purpose is to increase the awareness of how pharmaceutical companies may influence physicians by framing the risk of medication side effects to favor their products.

Cognitive behavioral therapy for rapid-cycling bipolar disorder: a pilot study.

Bipolar disorder is characterized by depressive and/or manic episodes that interfere with daily functioning. Between 10%-24% of bipolar patients experience a rapid-cycling course, with 4 or more mood episodes occurring per year. Characterized by nonresponse to standard mood stabilizing medications, patients with rapid-cycling bipolar disorder are particularly in need of effective, adjunctive treatments. Adjunctive cognitive-behavioral therapy (CBT) has been shown to improve adherence to medication and reduce relapse rates in patients with bipolar disorder. However, no published trials to date have examined the application of CBT to the treatment of patients with a rapid-cycling course of illness, with only a single case study published in the literature. We recently developed a CBT protocol that addresses the specific needs of bipolar patients with rapid cycling. The present study was designed to investigate outcomes with this CBT protocol. Study participants were 10 patients with rapid-cycling bipolar disorder, 6 of whom completed the study. Completers showed significant decreases in depressive mood, and improvements remained stable during the 2-month follow-up. This suggests that CBT for rapid cycling may have beneficial effects.