Improvement of Insomnia Symptoms following a Single 4-Hour CBT-I Workshop.

STUDY OBJECTIVES: : Cognitive behavioral treatment for insomnia (CBT-I) is the first line of treatment for insomnia. However, the expanded use of CBT-I is limited by the number of specialty-trained clinicians in addition to the duration and cost of individual treatment sessions. One viable option is a single-session educational group format delivered by a trained health educator. METHODS: : In a preliminary, single group pretest-posttest design, the effectiveness of group CBT-I delivered to community dwelling individuals with self-reported insomnia symptoms was evaluated. Participants completed the Insomnia Severity Index (ISI) and provided information on sleep aid use, prior to and 1-month post attendance of a single 4-hour CBT-I workshop. RESULTS: : Participants (N = 45) were 54 ± 16 years and 71% female. ISI scores significantly improved from baseline (20.09 ± 4.1) to 1-month follow-up (11.89 ±5.7; t = 10.1, p < .001) with an average change of 8.2 ± 5.4 points. Frequency of sleep aid use significantly dropped (χ2 = 105.7, p = .017). Eighty percent of participants reported sleeping better or much better at follow-up. Twenty percent of participants met criteria for remission of insomnia and 35.6% of participants had ISI change scores meeting criteria for a Minimally Important Difference associated with improvements in fatigue, work productivity, and health related quality of life. CONCLUSIONS: : These preliminary data suggest that a single 4-hour CBT-I workshop delivered by a health educator can significantly improve insomnia symptoms, improve subjective sleep quality, and reduce sleep aid use among community dwelling adults with and without co-morbidities within 1-month.

Current knowledge/study rationale: In order to disseminate CBT-I to a broader section of the population with insomnia complaints, novel approaches need to be incorporated and assessed. The utilization of a single 4-hour group CBT-I session may be a suitable choice for many people experiencing insomnia.Study Impact: In comparison to the 4-8 individual sessions commonly available, this format shows promise as another option for treatment of insomnia, and preliminarily shows comparable effectiveness for various sleep outcomes. Moreover, by utilizing a non-clinician health educator to provide these workshops, the number of people that may be helped with CBT-I is increased.Abbreviations: CBT-I: Cognitive Behavioral Treatment for InsomniaCGI: clinical global improvementISI: Insomnia Severity IndexISR: Intensive sleep retrainingMID: Minimally important differenceOTC: Over the counterROC: Receiver operator curveSCID-DSM-V: Structured Clinical Interview for the Diagnostic Statistical Manual-V.

Insomnia and Anxiety: Diagnostic and Management Implications of Complex Interactions.

Concurrent clinical presentation of insomnia and anxiety is frequent in clinical practice. The onset and course of anxiety and insomnia are intimately related; traditional conceptualizations of insomnia as secondary to anxiety are no longer clinically viable. Evolving evidence suggests a relationship between these 2 conditions that is complex and reciprocal and that evolves over time. In terms of diagnosis and management, unless initial assessment and intervention are initiated in the earliest stages of illness, emerging opinion supports recognition of cooccurring anxiety and insomnia as independent comorbid conditions with each condition likely requiring targeted therapeutic attention to achieve optimal therapeutic outcomes.

Predictors and patterns of insomnia symptoms in OSA before and after PAP therapy.

OBJECTIVE: Identify factors that predict improvement versus persistence of insomnia symptoms following treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy. METHODS: Archival data from 68 PAP-treated sleep apnea patients aged 25-83 were analyzed using nonparametric tests and stepwise regression to assess the relationships between insomnia symptoms, multiple OSA variables, and PAP use over time. RESULTS: Pretreatment insomnia symptom severity (ISS; b = -0.72, p < 0.001), PAP average use (b = -0.01, p = 0.01) and respiratory disturbance index (RDI; b = -0.02, p = 0.03) predict change in insomnia following PAP therapy. Forty-five percent (24/53) of the subjects with moderate to severe insomnia at pretreatment reported no/mild symptoms after PAP therapy and were considered improved. Improved subjects had lower pretreatment ISS (p < 0.001), higher RDI (p = 0.01), and higher average PAP use (p < 0.035) than subjects with persistent insomnia. Number of medications and comorbidities were similar between improved and persistent groups. New onset of insomnia symptoms occurred in 13% (2/15) of the patients with no/mild pretreatment insomnia. CONCLUSIONS: Although ISS declines following PAP treatment, 55% of OSA patients have persistent moderate to severe symptoms despite treatment. More severe OSA is linked to higher likelihood of insomnia improvement and the effect of PAP therapy on insomnia may be mediated by OSA severity. Persistent insomnia is unrelated to medication use or comorbidities and may represent an independent, self-sustaining disorder requiring targeted intervention.

Comorbid insomnia and sleep disordered breathing.

OPINION STATEMENT: Sufficient evidence has accumulated to warrant conceptualization of comorbid insomnia and sleep disordered breathing (SDB) as a distinct clinical syndrome. As such, diagnostic and treatment approaches should be founded on an integrated and multidisciplinary approach with equivalent clinical attention and priority given to both insomnia and respiratory aspects of patients' presenting complaints. Several well established and effective treatments exist for both insomnia and SDB. Although questions of optimal treatment combination and sequence remain to be examined, current evidence provides preliminary guidance regarding the sequential or concurrent management of insomnia and sleep disordered breathing when comorbid. Unsatisfactory response to pharmacotherapy or cognitive-behavioral therapy for chronic insomnia should trigger evaluation for comorbid sleep-related breathing disturbance prior to more aggressive or off label pharmacotherapy. Presence and course of insomnia symptoms should be monitored closely in SDB patients with persistence of insomnia symptoms following SDB treatment prompting targeted treatment of insomnia. Aggressive treatment of insomnia prior to or in combination with SDB treatment may be particularly indicated in situations where insomnia is suspected to interfere with diagnosis or treatment of SDB. Insomnia and sleep disordered breathing appear to uniquely contribute to the morbidity of patients with this comorbidity. With this in mind, active engagement and monitoring of SDB and insomnia will often be necessary to achieve optimal outcomes.

Is insomnia an independent predictor of obstructive sleep apnea?

INTRODUCTION: Obstructive sleep apnea (OSA) is a disorder with high prevalence in primary care. However, little research exists on screening for OSA in primary care samples. METHODS: One hundred family medicine patients completed standardized symptom and demographic questionnaires and a structured clinical interview for sleep disorders. Two-step logistic regression was performed to determine the independent predictive value of insomnia for clinical identification of OSA. Additional t tests were computed to examine age and sex patterns of insomnia. RESULTS: A model including body mass index and daytime sleepiness predicted OSA status (χ(2) = 18.63; P < .001) and explained 27% of the variance in OSA clinical diagnosis. Addition of insomnia scores to the model significantly improved predictive utility (χ(2) = 25.79; P < .001) and explained 36% of the variance in OSA. Insomnia scores were higher for women compared with men (P = .033) and women with OSA compared with women without OSA (P = .007). CONCLUSIONS: Inquiry regarding insomnia may improve clinical identification of OSA when screening for OSA in primary care. This finding possibly is unique to the evaluation of OSA in a primary care versus sleep laboratory sample. The predictive utility of insomnia may be specific to women.

Acetazolamide as an adjunct to CPAP treatment: a case of complex sleep apnea in a patient on long-acting opioid therapy.

A 41-year-old white woman on long-acting opioid therapy was diagnosed with moderate obstructive sleep apnea. On initiation of continuous positive airway pressure (CPAP), she manifested severe central apnea that was unresponsive to supplemental oxygen and interfered with CPAP titration. Acetazolamide, 250 mg, nightly at bedtime was initiated, and CPAP titration was repeated. On acetazolamide, optimal CPAP pressure was obtained with no manifestation of clinically significant central respiratory disturbance. This case suggests that acetazolamide may be an effective adjunct to positive airway pressure therapy in patients on long-acting opioids. A need exists for examination of acetazolamide in this capacity.