Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder.

STUDY OBJECTIVES: To examine beliefs about prescription sleep medications (hypnotics) among individuals with insomnia disorder seeking cognitive behavioral therapy for insomnia and predictors of wishing to reduce use. METHODS: Baseline data was collected from 245 adults 50 years and older enrolled in the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study. T-tests compared characteristics of prescription sleep medication users with those of nonusers. Linear regression assessed predictors of patients' beliefs about sleep medication necessity and hypnotic-related concerns. Among users, we examined predictors of wishing to reduce sleep medications, including perceived hypnotic dependence, beliefs about medications, and demographic characteristics. RESULTS: Users endorsed stronger beliefs about the necessity of sleep medications and less concern about potential harms than nonusers (P < .01). Stronger dysfunctional sleep-related cognitions predicted greater beliefs about necessity and concern about use (P < .01). Patients wishing to reduce sleep medications reported greater perceived hypnotic dependence than those disinterested in reduction (P < .001). Self-reported dependence severity was the strongest predictor of wishing to reduce use (P = .002). CONCLUSIONS: Despite expressing strong beliefs about necessity, and comparatively less concern about taking sleep medications, three-quarters of users wished to reduce prescription hypnotics. Results may not generalize to individuals with insomnia not seeking nonpharmacological treatments. Upon completion, the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study will provide information about the extent to which therapist-led and digital cognitive behavioral therapy for insomnia contribute to prescription hypnotic reduction. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING); URL: https://clinicaltrials.gov/ct2/show/NCT03532282; Identifier: NCT03532282. CITATION: Tully IA, Kim JP, Simpson N, et al. Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder. J Clin Sleep Med. 2023;19(7):1247-1257.

Sleep and affect: A conceptual review.

Everyday experience suggests that sleep and affect are closely linked, with daytime affect influencing how we sleep, and sleep influencing subsequent affect. Yet empirical evidence for this bidirectional relationship between sleep and affect in non-clinical adult samples remains mixed, which may be due to heterogeneity in both construct definitions and measurement. This conceptual review proposes a granular framework that deconstructs sleep and affect findings according to three subordinate dimensions, namely domains (which are distinct for sleep and affect), methods (i.e., self-report vs. behavioral/physiological measures), and timescale (i.e., shorter vs. longer). We illustrate the value of our granular framework through a systematic review of empirical studies published in PubMed (N = 80 articles). We found that in some cases, particularly for sleep disturbances and sleep duration, our framework identified robust evidence for associations with affect that are separable by domain, method, and timescale. However, in most other cases, evidence was either inconclusive or too sparse, resulting in no clear patterns. Our review did not find support for granular bidirectionality between sleep and affect. We suggest a roadmap for future studies based on gaps identified by our review and discuss advantages and disadvantages of our granular dimensional framework.

Worry and Rumination Have Distinct Associations with Nighttime versus Daytime Sleep Symptomology.

Objective: To assess whether worry and rumination differ in predicting nighttime sleep disturbance versus daytime sleep-related impairment, as assessed using short forms from the Patient Reported Outcomes Measurement Information System (PROMIS). Participants: Adults recruited from the United States population (N = 459) via an online crowdsourcing service. Methods: Factor analysis explored whether items comprising validated measures of worry and rumination loaded onto separate factors. Hierarchical multiple regression models entered worry and rumination in a stepwise fashion to assess their relative strength in predicting PROMIS sleep disturbance and sleep-related impairment, after controlling for 17 covariates. All analyses were run twice using sleep-specific and general measures of worry and rumination. Results: Worry and rumination items loaded onto separate factors. In the regression analysis of sleep-specific cognition, only worry entered the model predicting sleep disturbance, whereas rumination entered after worry in the model predicting sleep-related impairment. In the analysis of general cognition, both cognitive process variables significantly predicted the PROMIS outcomes. Worry was the stronger predictor of sleep disturbance, whereas rumination was the stronger predictor of sleep-related impairment. Conclusions: Worry and rumination were observed to be distinct constructs that separately contributed to predicting daytime sleep-related impairment. Future studies should more closely examine how cognitive processes relate to insomnia symptomology during the day.

Brief Behavioral Treatment of Insomnia.

Cognitive behavioral treatment for insomnia (CBTI) is an effective treatment of insomnia; however, there are insufficient CBTI providers for the 10% to 25% of the population who have insomnia. Brief behavioral treatment for insomnia (BBTI) is a 4-session manualized treatment paradigm administrable in medical settings by nonpsychologist health professionals. BBTI is effective in reducing symptoms of insomnia, such as sleep onset latency, wake after sleep onset, and sleep efficiency. In some cases, BBTI resulted in full remission from insomnia. Ongoing clinical trials are further testing the efficacy of BBTI using alternative treatment deliveries and in primary medical care settings.

Health and demographic discriminators of an insomnia identity and self-reported poor quantitative sleep.

OBJECTIVES: To identify factors that most saliently characterize the profile of individuals who complain of chronic insomnia, with or without quantitative sleep impairment. DESIGN: Community-dwelling adults reported on their demographics and functioning via questionnaires and completed 2 weeks of sleep diaries. SETTING: Shelby County in the Memphis, TN, area. PARTICIPANTS: Population-based sample, stratified by sex and age to maximally represent sleep and health across the life span. MEASUREMENTS: Participants were classified into 4 groups according to whether or not they endorsed a chronic insomnia complaint and whether they demonstrated good or poor quantitative sleep on diaries. Discriminant analysis determined which of the following variables significantly maximized spread among the sleep groups: age, sex, race, body mass index, household education, number of medications, frequency of substance use, number of medical conditions, depression, anxiety, fatigue, daytime sleepiness, and daytime insomnia impact. RESULTS: On the most powerful discriminant function, participants with more medical conditions, greater depression and anxiety, and older age were more likely to complain of chronic insomnia than to not complain and, within these levels, to have poor rather than good quantitative sleep. A second function found African Americans particularly likely to be noncomplaining poor sleepers compared to Whites. CONCLUSIONS: Findings make progress in clarifying the profile of individuals who self-identify as having chronically poor sleep. Notably, general depression and anxiety surpassed sleep-related daytime impairment measures in discriminating complaining sleepers. Negativistic self-appraisals driving diffuse psychological symptoms may thus be viable intervention targets for reducing persistent insomnia complaints independently of sleep-specific concerns.

Systematic Review of Community Paramedicine and EMS Mobile Integrated Health Care Interventions in the United States.

Emergency medical services (EMS) in the United States are frequently used for nonurgent medical needs. Use of 911 and the emergency department (ED) for primary care-treatable conditions is expensive, inefficient, and undesirable for patients and providers. The objective is to describe the outcomes from community paramedicine (CP) and mobile integrated health care (MIH) interventions related to the Quadruple Aim. Three electronic databases were searched for peer-review literature on CP-MIH interventions in the United States. Eight articles reporting data from 7 interventions were included. Four studies reported high levels of patient satisfaction, and only 3 measured health outcomes. No study reported provider satisfaction measures. Reducing ED and inpatient utilization were the most common study outcomes, and programs generally were successful at reducing utilization. With reduced utilization, costs should be reduced; however, most studies did not quantify savings. Future studies should conduct economic analyses that not only compare the intervention to traditional EMS services, but also measure potential cost savings to the EMS agencies running the intervention. Most cost savings from reduced utilization will be to insurance companies and patients, but more efficient use of EMS agencies' resources could lead to cost savings that could offset intervention implementation costs. The other 3 aims (health, patient satisfaction, and provider satisfaction) were reported inconsistently in these studies and need to be addressed further. Given the small number of heterogeneous studies reviewed, the potential for CP-MIH interventions to comprehensively address the Quadruple Aim is still unclear, and more research on these programs is needed.

Intraindividual sleep variability and its association with insomnia identity and poor sleep.

OBJECTIVE: Insomnia identity refers to the conviction that one has insomnia, which can occur independently of poor sleep. Night-to-night variability in sleep (termed intraindividual variability [IIV]) may contribute to insomnia identity yet remain undetected via conventional mean analyses. This study compared sleep IIV across four subgroups: noncomplaining good sleepers (NG), complaining poor sleepers (CP), complaining good sleepers (CG), and noncomplaining poor sleepers (NP). METHODS: This study analyzed 14 days of sleep diary data from 723 adults. Participants were classified according to presence/absence of a sleep complaint and presence/absence of poor sleep. A 2 × 2 multivariate analysis of covariance (MANCOVA) was performed to explore differences on five measures of sleep IIV: intraindividual standard deviation in total sleep time (iSD TST), sleep onset latency (iSD SOL), wake after sleep onset (iSD WASO), number of nightly awakenings (iSD NWAK), and sleep efficiency (iSD SE). RESULTS: MANCOVA revealed significant main effects of poor sleep, sleep complaint, and their interaction on sleep IIV. Poor sleepers exhibited greater IIV across all sleep parameters compared to good sleepers. Similarly, individuals with a sleep complaint exhibited greater IIV compared to individuals with no complaint. The interaction revealed that iSD SOL was significantly greater among CP than NP, and iSD NWAK was significantly greater among CG than NG. CONCLUSIONS: Greater night-to-night variability in specific sleep parameters was present among complaining versus noncomplaining sleepers in good and poor sleep subgroups. These findings suggest certain aspects of sleep consistency may be salient for treatment-seeking individuals based on their quantitative sleep status.

Multilevel modeling of chronotype and weekdays versus weekends to predict nonrestorative sleep.

Nonrestorative sleep, a form of subjective sleep disturbance that has been largely neglected in the literature, is newly accessible to researchers via the validated restorative sleep questionnaire (RSQ). The daily version of the RSQ allows for analysis of within-subjects variation in restorative sleep across repeated samplings, and such day-to-day regularity in sleep variables has been highlighted as an important new direction for research. The present study used a sophisticated statistical approach, multilevel modeling, to examine the contributions of circadian chronotype, calendar day of questionnaire completion (weekends versus weekdays), and their interaction in explaining both interindividual and intraindividual variance in restorative sleep. Analyses were conducted using an archival dataset of college undergraduates who continuously completed daily RSQs over a 14-day sampling period. In the final multilevel model, possessing an evening type predicted lower restorative sleep between subjects, while sampling on weekdays predicted lower restorative sleep within subjects. Furthermore, a cross-level interaction was observed, such that the difference in restorative sleep on weekends versus weekdays was more pronounced among those with greater evening circadian preference. All of the effects were maintained after accounting for the significant influence of gender (women had less restorative sleep than men). These results are theoretically consistent with findings that evening types display stronger disparities in sleep schedules across free and workdays (i.e., social jet lag), and attest to the usefulness of multilevel models for statistically investigating how stable traits interact with factors that vary day to day (e.g., work or school schedules) in influencing sleep outcomes.

The role of perceived sleep norms in subjective sleep appraisals and sleep-related illness behavior.

The present investigation sought to extend extant research on subjective sleep complaints by examining their relation to perceived sleep norms. Results from two studies showed that individuals' distress and illness behavior in response to symptoms of fatigue and non-restorative sleep was influenced by their perceptions of peer norms for those symptoms. Individuals who believed they experienced a greater degree of fatigue and non-restorative sleep than their peers reported more distress arising from those symptoms, and were also more likely to seek social support and medical treatment for them. Furthermore, participants who scored higher in neuroticism were more likely to believe they experienced worse fatigue and non-restorative sleep than their peers, and thus reported higher symptom-related distress, and higher likelihood of engaging in illness behaviors. These results provide preliminary evidence of the clinical relevance of perceived norms in the way individuals respond to and manage sleep related problems.

Association between chronotype and nonrestorative sleep in a college population.

Nonrestorative sleep (NRS), characterized by a lack of refreshment upon awakening, has received little attention in the sleep literature even though it can occur and cause impairment apart from other sleep difficulties associated with insomnia. The Restorative Sleep Questionnaire (RSQ) is one of the first validated self-report instruments for investigating NRS severity, presenting new opportunities to explore what factors predict and perhaps contribute to unrefreshing sleep. The present study sought to determine whether inherent circadian preference for morning or evening activity, known as chronotype, predicted restorative sleep in 164 college undergraduates who completed daily RSQs over 2 weeks. The participants who endorsed greater orientation to evening activity on the morningness-eveningness questionnaire reported significantly less average restorative sleep across their full sampling period, and this association was maintained after accounting for demographic factors, number of sleep-relevant psychiatric and medical diagnoses, sleep diary parameters, self-reported status as an insomniac and ratings of sleep quality. When analyses were conducted separately for weekday and weekend RSQ scores, eveningness predicted NRS independently of extraneous variables only during the workweek, not during Saturday and Sunday. These findings have implications for the developing conceptualization of NRS, and continue the work of elucidating the interconnections between common sleep disturbances and the circadian system.