Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women.

OBJECTIVES: In the United States, Black women are disproportionately afflicted with prenatal insomnia. Although cognitive-behavioral therapy for insomnia (CBTI) may represent a strategy to reduce disparities in insomnia, racial minorities attend fewer healthcare appointments and have poorer outcomes from prenatal care and mental health treatment relative to white patients. The present study examined differences in treatment engagement and patient-reported outcomes in non-Hispanic Black and white pregnant women receiving digital CBTI. METHODS: Secondary analysis of 39 pregnant women with clinical insomnia who received digital CBTI. Treatment engagement was operationalized as the number of sessions completed (≥4 considered an adequate dose). Treatment outcomes were assessed using the Insomnia Severity Index (ISI; insomnia) and Pittsburgh Sleep Quality Index (PSQI; global sleep disturbance). RESULTS: Black women were 4 times more likely than white women to discontinue CBTI before receiving an adequate dose (8.3% vs. 33.3%). Regarding treatment outcomes, white women reported a mean reduction of 5.75 points on the ISI and a reduction of 3.33 points on the PSQI (Cohen's dz = 1.10-1.19). By comparison, Black women reported reductions of 2.13 points on the ISI and 1.53 points on the PSQI, which were statistically non-significant. Differences in treatment engagement did not account for the disparities in patient-reported outcomes. CONCLUSIONS: During pregnancy, Black women completed fewer CBTI sessions and experienced poorer treatment outcomes in response to digital CBTI relative to white women. Enhancements to insomnia therapy and its digital delivery may improve adherence and outcomes in Black pregnant women.

Application of Continuous Positive Airway Pressure for Thoracic Respiratory Motion Management: An Assessment in a Magnetic Resonance Imaging-Guided Radiation Therapy Environment.

PURPOSE: Patient tolerability of magnetic resonance (MR)-guided radiation treatment delivery is limited by the need for repeated deep inspiratory breath holds (DIBHs). This volunteer study assessed the feasibility of continuous positive airway pressure (CPAP) with and without DIBH for respiratory motion management during radiation treatment with an MR-linear accelerator (MR-linac). METHODS AND MATERIALS: MR imaging safety was first addressed by placing the CPAP device in an MR-safe closet and configuring a tube circuit via waveguide to the magnet bore. Reproducibility and linearity of the final configuration were assessed. Six healthy volunteers underwent thoracic imaging in a 0.35T MR-linac, with one free breathing (FB) and 2 DIBH acquisitions being obtained at 5 pressures from 0 to 15 cm-H2O. Lung and heart volumes and positions were recorded; repeatability was assessed by comparing 2 consecutive DIBH scans. Blinded reviewers graded images for motion artifact using a 3-point grading scale. Participants completed comfort and perception surveys before and after imaging sessions. RESULTS: Compared with FB alone, FB-10, FB-12, and FB-15 cm H2O significantly increased lung volumes (+23%, +34%, +44%; all P <.05) and inferiorly displaced the heart (0.86 cm, 0.96 cm, 1.18 cm; all P < . 05). Lung volumes were significantly greater with DIBH-0 cm H2O compared with FB-15 cm H2O (+105% vs +44%, P = .01), and DIBH-15 cm H2O yielded additional volume increase (+131% vs +105%, P = .01). Adding CPAP to DIBH decreased lung volume differences between consecutive breath holds (correlation coefficient 0.97 at 15 cm H2O vs 0.00 at 0 cm H2O). The addition of 15 cm H2O CPAP reduced artifact scores (P = .03) compared with FB; all DIBH images (0-15 cm H2O) had less artifact (P < .01). CONCLUSIONS: This work demonstrates the feasibility of integrating CPAP in an MR-linac environment in healthy volunteers. Extending this work to a larger patient cohort is warranted to further establish the role of CPAP as an alternative and concurrent approach to DIBH in MR-guided radiation therapy.

Insomnia, Short Sleep, And Snoring In Mid-To-Late Pregnancy: Disparities Related To Poverty, Race, And Obesity.

OBJECTIVE: To characterize sleep habits and parameters among women in mid-to-late pregnancy and to identify disparities associated with poverty, race, and obesity. DESIGN: Cross-sectional. SETTING: Large multi-site health system in Metro Detroit. PARTICIPANTS: A total of 267 pregnant women (27.3% non-Hispanic black; gestational age: 27.99±1.20 weeks) completed online surveys on sleep quality, insomnia symptoms, sleep aid use, signs/symptoms of sleep-disordered breathing, and sociodemographics. Body mass index (BMI) and patient insurance were derived from medical records. RESULTS: As high as 76.2% of the women reported global sleep disturbance, 30.6% endorsed snoring, 24.3% sleep <6 hrs/night, and over half screened positive for clinical insomnia. Yet, only 3.4% of the women reported an insomnia diagnosis and 3.0% reported a sleep apnea diagnosis. In unadjusted models, poverty, Medicaid coverage, self-identifying as black, and obesity before and during pregnancy (BMI ≥ 35) were associated with a wide range of sleep problems. However, adjusted models revealed specificity. Poverty was uniquely related to increased insomnia symptoms and trouble sleeping due to bad dreams. Obesity before pregnancy was related to poor sleep quality, snoring, sleep aids, and short sleep. Black women reported shorter sleep duration than white women but differed on no other sleep parameters. CONCLUSION: Clinical signs of insomnia and sleep-disordered breathing are common in mid-to-late pregnancy, but most cases go undetected. Problematic sleep disproportionately affects women in poverty, who self-identify as black, and who are obese before pregnancy. Poverty-related sleep issues are linked to insomnia, obesity-related disparities center on sleep-related breathing and medication use, and racial disparities relate to short sleep.