Benzodiazepine Use in Opioid Maintenance Treatment Programme: Risks and Clinical Outcomes.

INTRODUCTION: The co-association of benzodiazepines and opioids is associated with an increased risk of overdose, death, and poorer psychosocial prognosis. The aim of this study is to characterize the prevalence, pattern of use, and primary clinical outcomes in benzodiazepines users in a public opioid maintenance treatment unit. MATERIAL AND METHODS: We conducted a cross-sectional study involving 236 patients treated with opioid substitutes (methadone and buprenorphine). We conducted a descriptive, bivariable, and multivariable analysis to determine clinical differences between benzodiazepines users and non-users. RESULTS: The prevalence of consumption of benzodiazepines was 25.4% (60). The benzodiazepines were obtained with a medical prescription (49.8%) or on the black market (42.6%). The most prescribed benzodiazepine was diazepam (29.1%), and the main reasons were to relieve insomnia (27.7%) or anxiety (26.9%) and to enhance the psychoactive effects of other drugs (19.7%). Regarding the clinical outcomes, we highlight: a very high prevalence of hepatitis C (51.7%); severe ongoing consumption of psychoactive drugs (73.7%); and a high rate of depression and anxiety (> 60%), significantly higher in the benzodiazepines-user group. In the multivariable analysis of benzodiazepine use, we found alcohol consumption (OR 0.482; IC 95% 0.247, 0.238) had a negative association and having hepatitis C (OR 2.544, IC 95% 1.273, 5.084) or anxiety symptoms (OR 5.591; IC 95% 2.345, 13.326) had positive associations. DISCUSSION: Our results suggest the BZD users had a complex drug addiction problem and underline the importance of adequately addressing BZD use, contemplating psychological and psychiatric approach in this particular population. CONCLUSION: Past or current use of benzodiazepines is associated with poor clinical and psychiatric outcomes. A multidisciplinary approach with a focus on infectious diseases and mental health is critical in order to enhance the treatment effectiveness and overall prognosis.

Introdução: A co-associação entre benzodiazepinas e opióides associa-se a risco aumentado de overdose, morte e pior prognóstico psicossocial. Pretendemos determinar a prevalência, o padrão de consumo e as principais co-morbilidades do uso de benzodiazepinas, em utentes sob tratamento de manutenção opióide. Material e Métodos: Conduzimos um estudo transversal, envolvendo 236 doentes tratados com substitutos opióides (metadona e buprenorfina). Realizou-se uma análise descritiva, bivariável e multivariável das características clínicas entre os usuários de benzodiazepinas e os não-usuários de benzodiazepinas. Resultados: A prevalência do uso de benzodiazepinas foi de 25,4% (60). A obtenção de benzodiazepinas foi através de prescrição médica (49,8%) ou mercado negro (42,6%). A substância mais prescrita foi o diazepam (29,1%), e as principais razões para a toma foi insónia (27,7%), ansiedade (26,9%), e para potenciar os efeitos psicoativos de outras drogas (19,7%). No que respeita aos resultados clínicos sublinhamos: prevalência elevada de hepatite C (51,7%); elevado consumo continuado de substâncias psicoativas (73,7%); elevada taxa de depressão e ansiedade (> 60%), significativamente mais elevada nos utilizadores de benzodiazepinas. Na análise multivariável para o uso de benzodiazepinas, verificámos que o consumo de álcool (OR 0,482; IC 95% 0,247, 0,238) tem associação negativa; a hepatite C (OR 2,544; IC 95% 1,273, 5,084) e a ansiedade (OR 5,591; IC 95% 2,345, 13,326) tiveram associações positivas. Discussão: Os resultados obtidos sugerem que os utilizadores de BZD têm um problema complexo de dependência de drogas e sublinham a importância de abordar adequadamente o uso de BZD, contemplando uma abordagem psicológica e psiquiátrica nesta população em particular. Conclusão: O uso de benzodiazepinas, no passado ou atualmente, associa-se a piores indicadores físicos e psiquiátricos. A abordagem multidisciplinar com foco nas doenças infeciosas e na saúde mental é uma necessidade crítica para a efetividade do tratamento e prognóstico global.

Symptom Management Among Cancer Survivors: Randomized Pilot Intervention Trial of Heart Rate Variability Biofeedback.

Chronic cancer-related symptoms (stress, fatigue, pain, depression, insomnia) may be linked with sympathetic nervous system over-activation and autonomic imbalance. Decreased heart rate variability (HRV) is an indicator of autonomic dysregulation that is commonly observed among cancer survivors. HRV biofeedback (HRVB) training induces HRV coherence, which maximizes HRV and facilitates autonomic and cardiorespiratory homeostasis. This randomized, wait-list-controlled, pilot intervention trial tested the hypothesis that HRVB can improve HRV coherence and alleviate cancer-related symptoms. The intervention group (n = 17) received 4-6 weekly HRVB training sessions until participants demonstrated skill acquisition. Controls (n = 17) received usual care. Outcomes assessed at baseline and follow-up included 15-min HRV recordings (HRV Coherence Ratio), and symptoms of: stress, distress, post-traumatic stress disorder (PTSD), pain, depression, fatigue, and sleep disturbance. Linear mixed models for repeated measures were used to assess Group-by-Time interactions, pre- versus post-treatment differences in mean symptom scores, and group differences at follow-up. Mean HRV Coherence Ratios (± standard error) improved in the HRVB group at follow-up (baseline: 0.37 ± 0.05, post-intervention: 0.84 ± 0.18, p = 0.01), indicating intervention validity. Statistically significant Group-by-Time interactions indicated treatment-related improvements in HRV Coherence Ratios (p = 0.03, Pre-vs. post-treatment effect size [Cohen's d]: 0.98), sleep symptoms (p = 0.001, d = 1.19), and sleep-related daytime impairment (p = 0.005, d = 0.86). Relative to controls, the intervention group experienced trends toward improvements in stress, distress, fatigue, PTSD, and depression, although no other statistically significant Group-by-Time interactions were observed. This pilot intervention found that HRVB training reduced symptoms of sleep disturbance among cancer survivors. Larger-scale interventions are warranted to further evaluate the role of HRVB for managing symptoms in this population. Registration: NCT03692624 www.clinicaltrials.gov.

Feasibility and treatment effect of cognitive behavioral therapy for insomnia in individuals with multiple sclerosis: A pilot randomized controlled trial.

BACKGROUND: At least 40% of individuals with multiple sclerosis (MS) exercise chronic insomnia, and the prevalence is likely higher due to underdiagnosis. Poor sleep quality has been associated with increased fatigue, anxiety, depression, and risk of relapse in individuals with MS. While cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia, the treatment effect of CBT-I in people with MS is unclear. OBJECTIVE: This pilot randomized control trial (RCT) assessed the feasibility and treatment effect of CBT-I to improve sleep quality and fatigue in individuals with MS with symptoms of insomnia. METHODS: Thirty-three individuals with MS (30 females, 3 males; 30 relapsing-remitting; 3 secondary-progressive; 53.0 ± 9.4 years old) with symptoms of insomnia were randomized into one of three arms: 1. 6-week CBT-I program, 2. 6-week active control, or 3. Single session of sleep education. Participants completed surveys to assess sleep quality, fatigue, sleep self-efficacy, depression, and anxiety. RESULTS: CBT-I in individuals with MS is feasible with high retention and adherence rate. All groups experienced a large magnitude of improvement in insomnia symptoms. The CBT-I and brief education groups experienced a large magnitude of improvement in sleep quality and fatigue. Only the CBT-I group demonstrated a large magnitude of improvement in sleep self-efficacy and depression. CONCLUSION: This is the first study to prospectively demonstrates that CBT-I is feasible in people with MS and produces promising improvements in insomnia severity, sleep quality, sleep self-efficacy and comorbid symptoms of fatigue, depression, and anxiety. Future studies are needed to determine mechanisms for these improvements and expand the scope of individuals with MS who may benefit from CBT-I. Furthermore, considering the moderate to large improvements experienced by the brief education group and the limited number of CBT-I providers, a stepped-care approach warrants consideration.

Sleep hygiene in adolescents with asthma.

Objective: Youth with asthma are at-risk for sleep difficulties due to nocturnal asthma symptoms. Sleep hygiene, or the ability to practice consistent sleep behaviors and habits, impacts youth sleep quality and may, as a result, influence daytime cognitive functioning. The current study sought to examine the impact sleep hygiene has on sleep quality, health-related quality of life (HRQL) and sustained attention among adolescents with asthma. It was hypothesized that worse sleep hygiene would be associated with poorer sleep quality, lower school-related and overall HRQL and worse sustained attention. Methods: Participants included 41 adolescents with persistent asthma (Mage = 14.83, SD = 1.28; 51.2% male) recruited from a pediatric pulmonology clinic. Participants completed the adolescent sleep hygiene scale (ASHS), Adolescent Sleep Wake Scale (ASWS) and the Pediatric Quality of Life Index 4.0 generic core scales (PedsQL). Participants also completed the psychomotor vigilance task (PVT), an objective test of sustained attention. Results: Higher sleep hygiene scores were related to higher reported sleep quality (ß = 0.377, p = 0.015, f2 = 0.166), higher reported school-related HRQL (ß = 0.321, p = 0.040, f2 = 0.115) and better sustained attention (ß = 0.327, p = 0.045, f2 = 0.120). Conclusions: Sleep hygiene may be an important factor in sleep quality and deficits in daytime dysfunction including sustained attention and school-related quality of life. As adolescents with asthma are at heightened risk for these outcomes associated with disturbed sleep, sleep hygiene may serve as an important domain for clinical intervention.

Meta-analysis: Exercise intervention for sleep problems in cancer patients.

BACKGROUND: Sleep problems cause physical and mental distress and may influence the survival of cancer patients. OBJECTIVES: This study aimed to explore the efficacy of exercise intervention to improve sleep in cancer patients. METHODS: Published papers from 1980 to 2018 were searched. RESULTS: The major findings included (a) exercise intervention had small positive effects on enhancing total subjective sleep quality (TSSQ; g = 0.38, 95% CI = 0.21-0.54) and objective sleep onset latency (g = 0.21, 95% CI = 0.01-0.41). (b) The characteristics in subgroups in regarding the small to large effects of an exercise programme on sleep were identified. First, the groups of a home-based exercise and a supervised exercise combined with a home-based exercise had a medium effect on TSSQ than the usual group. Second, interventions with aerobic exercise, especially the 4- to 8-week programmes and those with weekly volume of 80-149 min per week for cancer patients with ongoing or completed treatment also had a medium to large positive effect on TSSQ. Finally, patients with breast cancer and haematologic malignancies contributed a small effect in this meta-analysis. CONCLUSIONS: Maintaining regular aerobic exercises, even of different durations and weekly volumes, benefits patient sleep quality.

Effects of resistance exercise training and stretching on chronic insomnia

Objective: The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients. Methods: Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively. Results: There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group. Conclusion: Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia. Clinical trial registration: NCT01571115

Organized Social Activity, Physical Exercise, and the Risk of Insomnia Symptoms Among Community-Dwelling Older Adults.

Objectives: To compare the risk of insomnia symptoms among community-dwelling older adults who participated and did not participate in organized social activity and physical exercise. Design: Secondary data analysis of a prospective cohort study. Material and Methods: Community-dwelling older adults ≥65 years of age with no insomnia symptoms at baseline were included in the study. Participants were followed up yearly for 3 years. Insomnia symptoms, social activity, and physical exercise status of study participants were assessed at baseline and during follow-up. Results: Study participants who reported engaging in organized social activity and low-intensity physical exercise and organized social activity and high-intensity physical exercise were less likely to report insomnia symptoms during follow-up compared with those who did not engage in any activity. Conclusion: These results suggest beneficial effect of organized social activity and physical exercise in maintaining sleep quality in old age.

Description of a multifaceted intervention programme for fatigue after acquired brain injury: a pilot study.

The purpose of this pilot study was to describe and explore a group-based multifaceted intervention for patients with fatigue after acquired brain injury (ABI). We hypothesised that post-intervention changes would result in reduced fatigue, in addition to improved emotional health, sleep and attentional control. Eight subjects with traumatic brain injury (n = 3) and cerebrovascular insults (n = 5) were included. Inclusion was based upon the presence of fatigue complaints. The participants received 36 hours of intervention. Changes related to fatigue, emotional health and sleep was assessed with self-rating measures. Additionally, a neuropsychological test (Conners' Continuous Performance Test II) was included as a measure of attentional control. All subjects were assessed at baseline, post-intervention, and at 3 and 9 months follow-up. Findings indicated reduced fatigue levels (post-intervention and 3 months follow-up), anxiety (9 months follow-up), and daytime sleepiness (3 and 9 months follow-up). Pilot results suggest that multifaceted group-based interventions may have the potential to alleviate symptoms of fatigue, anxiety and sleepiness after ABI. At an individual level, a low load of psychological distress, insomnia symptoms, dysexecutive symptoms, in addition to a strong sense of self-efficacy, may be central in order to reduce levels of fatigue.

Effects of resistance exercise training and stretching on chronic insomnia.

OBJECTIVE: The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients. METHODS: Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively. RESULTS: There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group. CONCLUSION: Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia. CLINICAL TRIAL REGISTRATION: NCT01571115.

Revealing the Neural Mechanisms Underlying the Beneficial Effects of Tai Chi: A Neuroimaging Perspective.

Tai Chi Chuan (TCC), a traditional Chinese martial art, is well-documented to result in beneficial consequences in physical and mental health. TCC is regarded as a mind-body exercise that is comprised of physical exercise and meditation. Favorable effects of TCC on body balance, gait, bone mineral density, metabolic parameters, anxiety, depression, cognitive function, and sleep have been previously reported. However, the underlying mechanisms explaining the effects of TCC remain largely unclear. Recently, advances in neuroimaging technology have offered new investigative opportunities to reveal the effects of TCC on anatomical morphologies and neurological activities in different regions of the brain. These neuroimaging findings have provided new clues for revealing the mechanisms behind the observed effects of TCC. In this review paper, we discussed the possible effects of TCC-induced modulation of brain morphology, functional homogeneity and connectivity, regional activity and macro-scale network activity on health. Moreover, we identified possible links between the alterations in brain and beneficial effects of TCC, such as improved motor functions, pain perception, metabolic profile, cognitive functions, mental health and sleep quality. This paper aimed to stimulate further mechanistic neuroimaging studies in TCC and its effects on brain morphology, functional homogeneity and connectivity, regional activity and macro-scale network activity, which ultimately lead to a better understanding of the mechanisms responsible for the beneficial effects of TCC on human health.

Effect of Rehabilitation on Sleep Quality After Ablation for Atrial Fibrillation: Data From a Randomized Trial.

BACKGROUND: Low sleep quality is common in patients with atrial fibrillation (AF). Positive effects of cardiac rehabilitation on patients treated for AF with ablation have been found, but whether cardiac rehabilitation affects sleep quality is unknown. The objectives of this study were to investigate (1) differences in sleep quality between cardiac rehabilitation and usual care groups and (2) whether other factors could affect sleep quality. METHODS: From the randomized CopenHeartRFA trial, 210 patients treated for AF with ablation were included. A rehabilitation program consisting of physical exercise and psychoeducational consultations was tested. Sleep quality was measured with the Pittsburg Sleep Quality Index (PSQI) questionnaire before intervention and at the end of intervention. Anxiety, depression, and European Heart Rhythm Association scores were assessed. RESULTS: No difference between groups in sleep quality was found (PSQI global mean [SD] score, 6.60 [3.61] points for the cardiac rehabilitation group [n = 83] and 6.08 [3.60] points for the usual care group [n = 90]; P = .34), although improvements in sleep quality were noted in both groups. Sleep latency, duration, and efficiency were significant by type of AF at 1 month. Anxiety, depression, and higher European Heart Rhythm Association scores at 4 months were associated with a higher PSQI global mean score at the end of intervention. CONCLUSION: The rehabilitation program showed no effect on sleep quality. A large proportion of patients reported poor sleep quality, and patients reporting anxiety, depression, or AF symptoms described worse sleep quality compared with patients who did not experience anxiety, depression, or AF symptoms. More research in the field is warranted.

Changes in subcortical resting-state functional connectivity in patients with psychophysiological insomnia after cognitive-behavioral therapy: Changes in resting-state FC after CBT for insomnia patients.

STUDY OBJECTIVES: To examine the resting-state functional connectivity (FC) between subcortical regions in relation to whole-brain activity in patients with psychophysiological insomnia (PI) and changes following cognitive-behavioral therapy for insomnia (CBTi). METHODS: The FC between subcortical seed regions (caudate, putamen, pallidum, amygdala, thalamus, and hippocampus) and whole-brain voxels were compared between the PI group (n = 13, mean age: 51.0 ± 10.2 years) and good sleepers (GS, n = 18, mean age: 42.7 ± 12.3 years). Also, in the PI group, FC was compared before and after 5 weeks of CBTi. RESULTS: Compared to the GS group, the PI group exhibited stronger FC between the thalamus and prefrontal cortex and between the pallidum and precuneus but weaker FC between the pallidum and angular gyrus, the caudate and orbitofrontal cortex, and the hippocampus and fusiform gyrus. After CBTi, the PI group exhibited decreased FC between the thalamus and parietal cortex, the putamen and motor cortices, and the amygdala and lingual gyrus, but increased FC between the caudate and supramarginal gyrus, the pallidum and orbitofrontal cortex, and the hippocampus and frontal/parietal gyri. CONCLUSIONS: The present findings demonstrate different FC in PI patients compared to GS and provide insight into the neurobiological rationale for CBTi.

Home-based multidimensional survivorship programmes for breast cancer survivors.

BACKGROUND: The prognosis and survival rate of women with breast cancer have significantly improved worldwide. Effective home-based multidimensional programmes for breast cancer survivors have gained an ever greater emphasis in survivorship care to maximise women's quality of life for their successful transition to rehabilitation and normal life. It is important to summarise the best available evidence to evaluate the effects of home-based multidimensional survivorship programmes on quality of life in women within 10 years of the completion of surgery or adjuvant cancer therapy for breast cancer, or both. OBJECTIVES: To assess the effects of home-based, multidimensional survivorship (HBMS) programmes on maintaining or improving the quality of life in breast cancer survivors. SEARCH METHODS: In April 2016 we searched the Cochrane Breast Cancer Specialised Register, CENTRAL, PubMed, Embase, CINAHL Plus, PsycINFO, Web of Science, and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. We also screened reference lists of all identified studies and contacted study authors. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of HBMS programmes in maintaining or improving quality of life in women with stages 0 to 3 breast cancer who completed primary cancer treatment (surgery or adjuvant cancer therapy, or both) up to 10 years earlier. We considered studies where the interventions included more than one of the following listed components: educational (such as information provision and self-management advice), physical (such as exercise training and resistance training) and psychological (such as counselling and cognitive therapies), to constitute a multidimensional programme. Interventions had to be allowed to be carried out at home. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligible studies for inclusion, and performed quality assessment and extracted relevant data of the included studies. Quality of life was the primary outcome of the review. MAIN RESULTS: We included 22 RCTs and four quasi-RCTs on 2272 participants. We categorised the intervention components into four groups: educational and psychological; educational and physical; physical and psychological; and educational, physical and psychological. Most of the studies used usual care (routine medical follow-up services) as the comparator. A few studies used a lower level or different type of intervention (e.g. stress management or exercise) or attention control as the comparator.We used the Functional Assessment of Cancer Therapy-Breast (FACT B), European Organisation for Research and Treatment of Cancer Quality of Life C30 (EORTC C30), Quality of Life (QoL) Breast Cancer, and SF36 questionnaires to assess quality of life. HBMS programmes may increase breast cancer-specific quality of life and global quality of life immediately after the intervention, as measured by FACT-B and EORTC C30 (FACT-B: mean difference (MD) 4.55, 95% confidence interval (CI) 2.33 to 6.78, 7 studies, 764 participants; EORTC: MD 4.38, 95% CI 0.11 to 8.64, 6 studies; 299 participants; moderate-quality evidence). There was no evidence of a difference in quality of life as measured by QoL-Breast Cancer or SF-36 (QoL-Breast Cancer: MD 0.42, 95% CI -0.02 to 0.85, 2 studies, 111 participants, very low-quality evidence; physical composite score SF36: MD 0.55, 95% CI -3.52 to 4.63, 2 studies, 308 participants, low-quality evidence).We observed a similar pattern at one to three months after the intervention: FACT-B (MD 6.10, 95% CI 2.48 to 9.72, 2 studies, 426 participants), EORTC-C30 (MD 6.32, 95% CI 0.61 to 12.04, 2 studies; 172 participants) and QoL-Breast Cancer (MD 0.45, 95% CI -0.19 to 1.09, 1 study, 61 participants). At four to six months and 12 months, there was no evidence of a difference in quality of life between groups (four to six months: EORTC - MD 0.08, 95% CI -7.28 to 7.44, 2 studies; 117 participants; SF-36 - MD -1.05, 95% CI -5.60 to 3.51, 2 studies, 308 participants; 12 months: EORTC - MD 2.04, 95% CI -9.91 to 13.99, 1 study; 57 participants).Functional status was incorporated into the quality of life subscale findings. HBMS programmes may decrease anxiety (MD of Hospital Anxiety and Depression Scale (HADS) -1.01, 95% CI -1.94 to -0.08, 5 studies, 253 participants, low-quality evidence) compared to control immediately after the intervention but the effect did not persist at four to six months. There was no evidence of improvements in depression immediately after HBMS (MD of HADS -1.36, 95% CI -2.94 to 0.22, 4 studies, 213 participants, low-quality evidence) or at follow-up. HBMS programmes may also decrease fatigue (MD -1.11, 95% CI -1.78 to -0.45, 3 studies, 127 participants; low-quality evidence) and insomnia (MD -1.81, 95% CI -3.34 to -0.27, 3 studies, 185 participants, low-quality evidence).None of the included studies reported service needs and utilisation and cost of care, and therefore the effect of HBMS programmes on healthcare utilisation and cost is unknown. Due to the variations in assessment methods of adherence among the eight studies, we could not combine the results for meta-analysis. We synthesised the results narratively, with the reported adherence rates of 58% to 100%. AUTHORS' CONCLUSIONS: The results of this systematic review and meta-analysis revealed that HBMS programmes in breast cancer survivors appear to have a short-term beneficial effect of improving breast cancer-specific quality of life and global quality of life as measured by FACT-B and EORTC-C30, respectively. In addition, HBMS programmes are associated with a reduction in anxiety, fatigue and insomnia immediately after the intervention. We assessed the quality of evidence across studies as moderate for some outcomes, meaning that we are fairly confident about the results, while we assessed other outcomes as being low-quality, meaning that we are uncertain about the result.

Psychological interventions that target sleep reduce pain catastrophizing in knee osteoarthritis.

Pain catastrophizing is a significant risk factor for patients with knee osteoarthritis (KOA) and thus is a target for many psychological interventions for pain. This study examined if interventions targeting sleep found to be effective in improving sleep in KOA also reduce pain catastrophizing measured as a trait through the pain catastrophizing scale and measured as a daytime and nocturnal state through daily diaries. Secondary analyses were conducted on data collected as part of a randomized controlled trial assessing the effectiveness of cognitive behavioral therapy for insomnia in patients with KOA at 5 different time points: pretreatment, midtreatment and posttreatment and at 3- and 6-month follow-up. One hundred patients diagnosed with KOA and insomnia were randomized to receive either 8 sessions of cognitive behavioral therapy for insomnia or a placebo intervention of behavioral desensitization. Multilevel modeling revealed that both intervention groups showed a significant reduction pretreatment to posttreatment in all 3 measures of pain catastrophizing and maintained stable levels through the 6-month follow-up. Increased sleep continuity early in treatment (pretreatment to midtreatment), but not reductions in pain, was associated with a reduction in trait and nocturnal catastrophizing later in treatment (midtreatment to posttreatment). These results suggest that short interventions focusing on sleep can significantly reduce pain catastrophizing even in a clinical population with low baseline levels of catastrophizing, possibly through improving sleep continuity.

Fatigue in the first year after traumatic brain injury: course, relationship with injury severity, and correlates.

The objectives of this study were to document the evolution of fatigue in the first year after traumatic brain injury (TBI), and to explore correlates of fatigue. Participants were 210 adults who were hospitalised following a TBI. They completed questionnaires 4, 8, and 12 months post-injury, including the Multidimensional Fatigue Inventory (MFI). Participants with severe TBI presented greater mental and physical fatigue, and reduced activity compared to participants with moderate TBI. For all MFI subscales except reduced motivation, the general pattern was a reduction of fatigue levels over time after mild TBI, an increase of fatigue after severe TBI, and stable fatigue after moderate TBI. Fatigue was significantly associated with depression, insomnia, cognitive difficulties, and pain at 4 months; the same variables and work status at 8 months; and depression, insomnia, cognitive difficulties, and work status at 12 months. These findings suggest that injury severity could have an impact on the course of fatigue in the first year post-TBI. Depression, insomnia, and cognitive difficulties remain strong correlates of fatigue, while for pain and work status the association with fatigue evolves over time. This could influence the development of intervention strategies for fatigue, implemented at specific times for each severity subgroup.

Comparative Effectiveness of Three Occupational Therapy Sleep Interventions: A Randomized Controlled Study.

Although sleep intervention is within the domain of occupational therapy, few studies exist supporting practice. Effectiveness of three sleep interventions was compared: Dreampad Pillow®, iRest® meditation, and sleep hygiene. Twenty-nine participants were randomly assigned to the Dreampad Pillow® ( n = 10), iRest® meditation ( n = 9), and sleep hygiene ( n = 10) groups. In Phase 1, all participants used a 7-day sleep hygiene regimen to reduce poor sleep habits. In Phase 2 (14 days), 10 participants used the Dreampad Pillow® and sleep hygiene, nine used the iRest meditation and sleep hygiene, and 10 continued sleep hygiene only. At intervention-end, the iRest meditation group experienced statistically greater time asleep than both the Dreampad Pillow® ( p < .006, d = 1.87) and sleep hygiene groups ( p < .03, d = 1.80). The Dreampad Pillow® group experienced statistically fewer nighttime awakenings than the iRest® meditation ( p < .04, d = -1.53) and sleep hygiene ( p < .004, d = -1.43) groups. No differences were found between groups in perceived sleep quality, length of time needed to fall asleep, and fatigue level next day. This study provides support for sleep interventions within occupational therapy's domain.

Validation study of the Italian version of the Insomnia Severity Index (ISI).

To test the factorial structure of the Italian version of the Insomnia Severity Index (ISI) using a confirmatory approach and to assess its psychometric properties. ISI questionnaire was completed by 272 patients (average age 41.28, range 18-73) with insomnia diagnosis performed by a sleep medicine physician and retrospectively enrolled in the study. All patients underwent Cognitive Behavioral Treatment for Insomnia (CBT-I) and completed sleep diaries before starting the treatment. Data from sleep diaries were analyzed for assessing concurrent validity of the ISI. Confirmatory factor analysis (CFA) for ordinal Likert-type items was applied to compare four competing models proposed in the literature. 244 patients, out of the 272, completed the ISI at the end of CBT-I. A comparison of ISI score before and after treatment was performed. The CFA analysis confirmed the presence of three main factors conceptualized as severity and impact of the disease along with sleep satisfaction. Significant correlations of the first three items of the questionnaire, investigating three different subtypes of insomnia, and the subjective measures from the sleep diaries were found, thus supporting the concurrent validity of the test. Sleep efficiency (SE) had a significant inverse correlation with the severity and satisfaction factors and with ISI's total score. After CBT-I treatment, a significant reduction of ISI's scores was observed, thus confirming the effectiveness of the CBT-I treatment. The internal reliability coefficient was 0.75. The ISI questionnaire maintains good psychometric properties in the Italian version, thus confirming that this instrument is reliable for detecting insomnia severity and identifying patients' symptoms.

Randomized Controlled Pilot Trial of Behavioral Insomnia Treatment for Chronic Migraine With Comorbid Insomnia.

BACKGROUND: Migraine frequently co-occurs with and is triggered by sleep disturbance, particularly insomnia, and the large majority of patients with chronic migraine (CM) have comorbid insomnia. Limited evidence suggests that behavioral regulation of sleep may reduce migraine frequency, but studies to date have not assessed the viability of stimulus control and sleep restriction interventions or included objective measurement of sleep parameters. The aim of this study, thus, was to pilot-test the efficacy of a brief behavioral insomnia intervention for adults with CM and comorbid insomnia; headache diaries and actigraphy were included to assess outcomes throughout the trial. METHODS: This randomized parallel-arm pilot trial recruited adults with both CM and comorbid insomnia. Participants were randomly assigned to three 30-minute biweekly sessions of cognitive-behavioral therapy for insomnia (CBTi) or control treatment. Participants were blinded to treatment and control conditions to control for outcome expectations. Each treatment condition involved training in and daily practice in 5 instructions/skills. The CBTi group learned and practiced skills pertaining to stimulus control and sleep restriction. The control intervention was the same as used by Calhoun and Ford (2007) and involved training in and daily practice of skills pertaining to keeping a consistent food/liquid intake, range of motion exercises, and acupressure. Participants provided outcome data via daily headache diaries, actigraphy, and self-report measures. The primary outcome was reduction in headache frequency at 2 weeks post-treatment and 6-week follow-up; secondary outcomes included other headache parameters, objective actigraphic and subjective changes in sleep, and treatment effect sizes and perceived credibility. Generalized estimating equations with a binomial logit link and inverse probability weights were used to assess the primary outcome among the intent-to-treat sample, and repeated measures generalized linear models were used to assess changes in secondary outcomes after controlling for baseline values. RESULTS: The intent-to-treat analyses included 31 adults (M age = 30.8 [12.9] years; 90.3% female; 80.6% white) with CM and comorbid insomnia. Both interventions yielded reductions in headache frequency at post-treatment (26.9% reduction for CBTi vs. 36.2% for control) and follow-up (48.9% for CBTi vs. 25.0% for control). At follow-up the odds of experiencing headache were 60% lower for CBTi than for control treatment, indicative of a large effect size that did not reach statistical significance after Bonferroni correction for assessing two primary endpoints (odds ratio: 0.40; 95% CI: 0.17, 0.91; P = .028). CBTi produced significantly larger increases than control treatment in total sleep time and sleep efficiency as quantified by actigraphy, as well as in self-reported insomnia severity. Adherence was high and treatments were perceived as credible without differences between groups, but the control group experienced a higher rate of dropouts. No adverse events were reported. CONCLUSIONS: Behavioral treatment of comorbid insomnia in individuals with CM produced large reductions in headache frequency, though some improvement in headache occurred with a behavioral intervention not focused on modifying sleep. Among the CBTi group only, both headache frequency and sleep parameters continued to improve after treatment, suggesting the presence of enduring effects over time. Directly treating insomnia using components of stimulus control and sleep restriction holds promise for reducing comorbid migraine. Development of and comparison to a truly inert pseudotherapy control presents unique challenges that future studies should address.

[REASONS AND CONSEQUENCES OF SOMATOFORM DISORDERS IN CHILDREN AND ADOLESCENTS].

The aim of our study was to find the reason of various forms of somatoform disorders (phobias, behavioral disorders, insomnia, tics, stuttering, enuresis, encopresis) in children and adolescents of various social status for diagnosis and treatment. We have examined 202 patients who referred to our clinic from 2012-2016. The age range was 2-18 years. After examination we have concluded the following recommendations: - to implement neuropsychological rehabilitation in order to stimulate mental development; - to work with speech therapist to improvement the speech; - to work individually with psychotherapist to improve the behavior; - to train the parent to manage the behavior at home; - to give the personal card containing information about exercises, games and puzzles to stimulate the development and in some cases to give individual educational program; - to give separate information to parents and in some cases to teachers of kindergartens and schools.

Implementing Computer-Based Psychotherapy Among Veterans in Outpatient Treatment for Substance Use Disorders.

OBJECTIVE: Computer-based psychotherapy interventions (CBPIs) are increasingly offered as first-level access to evidence-based mental health treatment. However, their implementation has not been evaluated in public-sector outpatient settings. METHODS: An evidence-based CBPI for insomnia was implemented with provider and patient education sessions, on-site Internet access, and clinician telephone support. Persons receiving care at a Veterans Health Administration substance abuse treatment clinic were screened for chronic insomnia and offered CBPI access. The feasibility of this strategy was evaluated in a pre-post design, which assessed engagement and completion rates, participant-reported acceptability, and clinical outcomes. RESULTS: Of 100 veterans referred, 51 enrolled in the program, of whom 22 (43%) completed all sessions, 13 (26%) partially completed the program, and 16 (31%) did not engage. There were no statistically significant differences between these three groups in baseline characteristics. In the total sample, Insomnia Severity Index (ISI) scores decreased (improved) by 32% (mean±SD of 6.3±6.2 points, t=6.82, df=44, p<.001). Veterans who completed all six sessions displayed clinically and statistically significant improvements on the ISI compared with those who did not engage, as shown in a regression analysis that controlled for baseline insomnia severity, time between assessments, and sedative-hypnotic medication use (F=3.87, df=4 and 40, p≤.004). Among all participants, 67% agreed that they would engage in another CBPI in the future. When questioned about potential barriers, 36% of the full sample endorsed a preference for face-to-face therapy. CONCLUSIONS: A strategy of brief provider and patient education, on-site Internet access, and telephone support was feasible and effective for implementing CBPIs in outpatient substance abuse treatment settings for veterans.