Publications by authors named "Charles M Morin"

191 Publications

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: A non-inferiority randomized controlled trial.

Sleep 2021 Jul 6. Epub 2021 Jul 6.

Département d'économique, Université Laval, Québec, Canada.

Study Objectives: Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this non-inferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I).

Methods: A total of 177 cancer patients were randomized to: 1) StanCBT-I (6 face-to-face CBT-I sessions; n=59); or 2) StepCBT-I (n=118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n=65), while those with a more severe insomnia received 6 face-to-face CBT-I sessions (n=53). In both cases, patients could receive up to 3 booster sessions of CBT-I if they still had insomnia symptoms following this first step.

Results: Results indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that were not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps<.001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue and quality of life scores.

Conclusion(s): The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients.
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http://dx.doi.org/10.1093/sleep/zsab166DOI Listing
July 2021

Comorbid Insomnia and Sleep Apnea: mechanisms and implications of an underrecognized and misinterpreted sleep disorder.

Sleep Med 2021 Jun 8;84:283-288. Epub 2021 Jun 8.

Department of Child Health, University of Missouri, MO, USA.

Sleep-disordered breathing (SDB) and insomnia have long been recognized as important sleep disrupters often associated with increased morbidity and mortality. Although they are often seen as divergent conditions, mainly because their cardinal symptoms (excessive daytime sleepiness, and sleep loss) differ, these two sleep disorders present with many common symptoms, which may hinder diagnosis and treatment. In addition to possible bidirectional pathways between SDB and insomnia, other factors such as circadian timing may play a role. In this paper, we review the mechanisms, differential clinical aspects, and implications of Comorbid Insomnia and Sleep Apnea, sometimes termed COMISA.
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http://dx.doi.org/10.1016/j.sleep.2021.05.043DOI Listing
June 2021

Insomnia and circadian misalignment: an underexplored interaction towards cardiometabolic risk.

Sleep Sci 2021 Jan-Mar;14(1):55-63

Centro Cardiovascular da Universidade de Lisboa, Lisbon School of Medicine, Sleep Unit - Lisbon - Portugal.

Insomnia remains the most prevalent sleep disorder worldwide, and its pathophysiology suggests an interface with circadian rhythm sleep-wake disorders (CRSWDs). Some epidemiological studies have linked insomnia and circadian misalignment with adverse cardiometabolic outcomes, but the mechanisms underlying this relationship are still unclear. The autonomic nervous system (ANS) has been pointed out as a crucial/key mediator that triggers cardiometabolic risk. Therefore, a critical review of the literature focused on the past ten years was conducted to highlight the relationship between insomnia, circadian misalignment and cardiometabolic risk, with particular emphasis on the influence of the ANS. Shift work, as a model of circadian misalignment, was shown to increase both cardiovascular and metabolic risk and so may integrate a proof of concept on this link. Furthermore, there is good evidence from previous studies supporting that cardiac autonomic dysfunction is indeed a possible mechanism that potentiates cardiometabolic risk in insomniacs and individuals with a misalignment of the circadian timing system (e.g., shift workers), via changes in autonomic variables. Further research is however required in order to definitively establish this interactive relationship.
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http://dx.doi.org/10.5935/1984-0063.20200025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157774PMC
June 2021

Patterns of Concomitant Prescription, Over-the-Counter and Natural Sleep Aid Use over a 12-Month Period: A Population Based Study.

Sleep 2021 Jun 5. Epub 2021 Jun 5.

École de psychologie, Université Laval, Québec, QC, Canada.

Study Objectives: Concomitant patterns of sleep aid use may provide insight for understanding the transition to chronic sleep medication use. Therefore, we sought to characterize the trajectories of concomitant natural product (NP), over-the-counter (OTC), and prescribed (Rx) sleep aid use in a population-based sample over 12-months.

Methods: Self-reported data on the use of NP, OTC, and Rx sleep aids were extracted from a Canadian longitudinal study on the natural history of insomnia (N=3416, M age = 49.7±14.7 years old; 62% women) at baseline, 6 months and 12 months. Latent class growth modeling was used to identify latent class trajectories using MPlus 7. Participants completed a battery of clinical measures: Ford Insomnia Response to Stress Test, abbreviated Dysfunctional Beliefs and Attitudes about Sleep Scale, Beck Depression Inventory, Insomnia Severity Index and, the Pittsburgh Sleep Quality Index. Associations between class membership and baseline covariates were evaluated.

Results: Concurrent sleep aid use fell into six distinct latent class trajectories over a 12-month period: Minimal Use (74.5%), Rx-Dominant (11.3%), NP-Dominant (6.3%), OTC-Dominant (4.3%), Rx-NP-Dominant (2.4%), and Rx-OTC-Dominant (1.1%). The three latent classes with prominent prescribed agent use predicted greater incidence of healthcare professional consultations for their sleep (p< 0.05), poorer sleep quality (p< 0.001), elevated dysfunctional sleep beliefs (p< 0.001), and sleep reactivity (p< 0.001). Compared to the other four latent classes, clinical profiles of Rx-NP-dominant and Rx-OTC-dominant groups endorsed greater severity across measures.

Conclusions: Patterns of sleep aid use may provide insight for identifying individuals who may be vulnerable to inappropriate self-medicating practices.
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http://dx.doi.org/10.1093/sleep/zsab141DOI Listing
June 2021

Psychological Symptoms Among Evacuees From the 2016 Fort McMurray Wildfires: A Population-Based Survey One Year Later.

Front Public Health 2021 4;9:655357. Epub 2021 May 4.

Alberta Health Services, Calgary, AB, Canada.

The 2016 wildfires in Fort McMurray (Alberta, Canada) led to a massive displacement of 88,000 people and destroyed 2,400 homes. Although no direct human fatality resulted, many individuals feared for their lives or those of their loved ones. (1) To estimate the prevalence of post-traumatic stress, major depressive, insomnia, generalized anxiety, and substance use disorders in the adult population of Fort McMurray 1 year after the evacuation; (2) To identify pre-, peri-, and post-disaster correlates of mental health disorders. A phone survey using random digit sampling was used to survey evacuees. A total of 1,510 evacuees (response rate = 40.2%, 55.5% women, mean age = 44.11, SD = 12.69) were interviewed between May 9th and July 28th, 2017. Five validated scales were administered: the PTSD Symptoms Checklist (PCL-5), the Insomnia Severity Index (ISI), the depression and anxiety subscales of the Patient Health Questionnaire (PHQ-9, GAD-7), and the CAGE Substance Abuse Screening Tool. One year after the wildfires, 38% had a probable diagnosis of either post-traumatic stress, major depressive, insomnia, generalized anxiety, or substance use disorder, or a combination of these. Insomnia disorder was the most common, with an estimated prevalence of 28.5%. Post-traumatic stress, major depressive and generalized anxiety disorders were almost equally prevalent, with ~15% each. The estimated prevalence of substance use disorder was 7.9%. For all five mental health disorders, having a mental health condition prior to the fires was a significant risk factor, as well as having experienced financial stress or strain due to the economic decline already present in Fort McMurray. Five post-disaster consequences were significant predictors of four of the five disorders: decrease in work, decrease in social life, poorer current health status, increase in drug and alcohol use, and higher level of stress experienced since the fires. One year after the fires, more than one third of the evacuees had clinically significant psychological symptoms, including those of insomnia, post-traumatic stress, depression, anxiety, and substance use. This study helped identify individuals more at risk for mental health issues after a natural disaster and could guide post-disaster psychosocial support strategies.
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http://dx.doi.org/10.3389/fpubh.2021.655357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130827PMC
May 2021

ISI-3: evaluation of a brief screening tool for insomnia.

Sleep Med 2021 06 27;82:104-109. Epub 2020 Aug 27.

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.

Study Objectives: We evaluated the performance of the Insomnia Severity Index-3 (ISI-3) as a short screening tool to identify clinically significant insomnia derived from the 7-item ISI in an older primary care population.

Methods: We used results from two surveys including the 7-item ISI: Sample 1 (n = 3197) and Sample 2 (n = 247) individuals aged ≥60 years with a diagnosis of osteoarthritis from electronic health records. The 7 items were: difficulty falling asleep, difficulty staying asleep, waking too early, sleep satisfaction, sleep interference with daytime functioning, noticeability of sleep problems by others, and worry about sleep. The ISI-3 included items with highest item-total correlations to the 7-item ISI from Sample 1. A 7-item ISI score ≥15 was defined as clinically significant insomnia and served as the primary criterion for the ISI-3. We derived operating characteristics to determine the diagnostic accuracy and cut-points to maximize sensitivity and specificity for both samples.

Results: The items with the highest item-total correlations were: sleep dissatisfaction, sleep interference with daily functioning, and worry about sleep problems (r = 0.78-0.81); while difficulty falling asleep, difficulty staying asleep, waking too early and noticeability of sleep problems by others showed lower correlations (r = 0.60-0.74). The ISI-3 achieved high discriminant validity in identifying insomnia (AUC = 0.97-0.98). An ISI-3 score of ≥7 maximized sensitivity (0.94-0.97) and specificity (0.88-0.91) with kappa = 0.68-0.71, 89.1-91.5% agreement.

Conclusions: The ISI-3 can effectively screen for insomnia to trigger a more thorough diagnostic evaluation including the 7-item ISI for research or clinical purposes. Future validation studies are needed in other community and clinical populations.

Clinical Trial: This manuscript describes secondary analyses of data two National Institutes on Aging-funded clinical trials (ClinicalTrials.gov identifier: NCT01142349, NCT02946957).
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http://dx.doi.org/10.1016/j.sleep.2020.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141095PMC
June 2021

The association between high risk of sleep apnea, comorbidities, and risk of COVID-19: a population-based international harmonized study.

Sleep Breath 2021 06 28;25(2):849-860. Epub 2021 Apr 28.

Helsinki Sleep Clinic, Vitalmed Research Center, and Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland.

Purpose: Obstructive sleep apnea (OSA) may increase the risk of severe COVID-19; however, the level of potential modulation has not yet been established. The objective of the study was to determine the association between high risk of OSA, comorbidities, and increased risk for COVID-19, hospitalization, and intensive care unit (ICU) treatment.

Methods: We conducted a cross-sectional population-based web survey in adults in 14 countries/regions. The survey included sociodemographic variables and comorbidities. Participants were asked questions about COVID-19, hospitalization, and ICU treatment. Standardized questionnaire (STOP questionnaire for high risk of OSA) was included. Multivariable logistic regression was conducted adjusting for various factors.

Results: Out of 26,539 respondents, 20,598 (35.4% male) completed the survey. Mean age and BMI of participants were 41.5 ± 16.0 years and 24.0 ± 5.0 kg/m, respectively. The prevalence of physician-diagnosed OSA was 4.1% and high risk of OSA was 9.5%. We found that high risk of OSA (adjusted odds ratio (aOR) 1.72, 95% confidence interval (CI): 1.20, 2.47) and diabetes (aOR 2.07, 95% CI: 1.23, 3.48) were associated with reporting of a COVID-19 diagnosis. High risk for OSA (aOR 2.11, 95% CI: 1.10-4.01), being male (aOR: 2.82, 95% CI: 1.55-5.12), having diabetes (aOR: 3.93, 95% CI: 1.70-9.12), and having depression (aOR: 2.33, 95% CI: 1.15-4.77) were associated with increased risk of hospitalization or ICU treatment.

Conclusions: Participants at high risk of OSA had increased odds of having COVID-19 and were two times more likely to be hospitalized or treated in ICU.
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http://dx.doi.org/10.1007/s11325-021-02373-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8079162PMC
June 2021

Prevalence of sleep disturbances in patients with chronic non-cancer pain: A systematic review and meta-analysis.

Sleep Med Rev 2021 Jun 11;57:101467. Epub 2021 Mar 11.

Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address:

In individuals with chronic pain, sleep disturbances have been suggested to increase suffering, perception of pain, and to negatively affect long-term prognosis. This systematic review and meta-analysis aims to determine the pooled prevalence of sleep disturbances in chronic non-cancer pain patients with no other sleep disorders, using the patient-rated questionnaires Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI). Multiple databases were searched for studies reporting the prevalence of sleep disturbances in chronic pain patients. The meta-analysis was conducted to examine the pooled prevalence of PSQI and ISI data using the inverse-variance random-effects model and to examine mean differences in PSQI scores. The systematic search resulted in 25,486 articles and 20 were included for analysis. In 12 studies using PSQI, the pooled prevalence of sleep disturbance was 75.3% among 3597 chronic pain patients. In eight studies using ISI, the pooled prevalence was 72.9% among 2578 chronic pain patients. The meta-analysis showed a significant mean difference of 2.75 (p < 0.001) in the global PSQI score between the chronic pain group versus the non-chronic pain group. The relatively high prevalence of sleep disturbances in chronic pain patients emphasizes the importance of further characterizing the relationship between sleep and chronic pain.
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http://dx.doi.org/10.1016/j.smrv.2021.101467DOI Listing
June 2021

A very brief self-report scale for measuring insomnia severity using two items from the Insomnia Severity Index - development and validation in a clinical population.

Sleep Med 2021 05 16;81:365-374. Epub 2021 Mar 16.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.

Objective: To develop a very brief scale with selected items from the Insomnia Severity Index (ISI), and to investigate the psychometric properties of the proposed scale in a psychiatric sample.

Methods: Patient data from seven Cognitive Behavioral Therapy (CBT) for insomnia trials and from regular care were used in psychometric analyses (N = 280-15 653). The samples included patients screening (N = 6936) or receiving treatment (N = 1725) for insomnia and other psychiatric conditions. Six criteria relating to component structure, sensitivity to change and clinical representativeness were used to select items. Psychometric analyses for the proposed very brief scale were performed.

Results: One item representing satisfaction/dissatisfaction with current sleep pattern and one item representing interferences with daily functioning, were selected to create the 2-item ISI version. Correlations with the full scale were high at screening, pre and post, and for change (0.82-0.94). Categorical omega was ⍵ = 0.86. With a cut-off of 6 points, the scale could detect Insomnia Disorder with a sensitivity of 84% and a specificity of 76%, which was close to the full ISI showing 86% and 80% respectively.

Conclusions: The systematic psychometric evaluation based on a large sample from different contexts makes the proposed 2-item ISI version (ISI-2) a strong candidate for a very brief scale measuring insomnia, both for detecting cases and for measuring change during CBT with an overall high discriminative validity. ISI-2 is especially useful in clinical settings or population studies where there is a need to measure more than one condition at a time without overburdening patients.

Clinical Trials: Trials used in this analysis: ClinicalTrials.gov identifier: NCT01105052 (https://www.clinicaltrials.gov/ct2/show/NCT01105052) (sample b), ClinicalTrials.gov identifier: NCT01256099 (https://clinicaltrials.gov/ct2/show/NCT01256099) (sample c and d), German clinical trial (DRKS), registration ID: DRKS00008745 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008745) (sample e), ClinicalTrials.gov identifier: NCT01663844 (https://clinicaltrials.gov/ct2/show/NCT01663844) (sample f and g), ClinicalTrials.gov Identifier: NCT02743338 (https://clinicaltrials.gov/ct2/show/NCT02743338) (sample h).
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http://dx.doi.org/10.1016/j.sleep.2021.03.003DOI Listing
May 2021

Sleep, Diet and Physical Activity Among Adults Living With Type 1 and Type 2 Diabetes.

Can J Diabetes 2021 Feb 2. Epub 2021 Feb 2.

School of Nutrition, Université Laval, Québec City, Québec, Canada; Centre Nutrition, santé et société, Institute of Nutrition and Functional Foods, Université Laval, Québec City, Québec, Canada.

Objectives: Our aim in this work was to document sleep/insomnia, fruit and vegetable (FV) consumption and physical activity (PA) according to diabetes presence and type and biologic sex, as these 3 lifestyle habits may influence glycemic control and prevention of diabetes-related complications.

Methods: Adults between 18 and 64 years of age were invited to complete validated web-based self-reported questionnaires assessing sleep, insomnia, FV consumption and PA. Pregnant women and shift workers were excluded from the study.

Results: A total of 151 adults (80.1% women), of whom 54 had diabetes (type 1 [T1D], n=30; type 2 [T2D], n=24), completed the questionnaires. Sleep quality scores were significantly higher, indicating poorer sleep quality, according to diabetes presence (diabetes, 7.2±3.5; no diabetes, 5.4±3.5; p=0.0024) and type (T1D, 6.1±2.9; T2D, 8.7±3.8; p=0.0072). Sleep duration was significantly shorter among adults living with diabetes (diabetes, 7.0±1.7 hours/night; no diabetes, 7.8±1.3 hours/night; p=0.0019), regardless of type. More adults living with diabetes had moderate to severe clinical insomnia (diabetes, 25.9%; no diabetes, 10.4%; p=0.0129), especially those with T2D (T1D, 13.3%; T2D, 41.7%; p=0.0182). FV consumption and PA did not vary significantly according to diabetes presence and type. Only PA differed by biologic sex, with lower PA among women.

Conclusions: The results suggest that adults living with diabetes, especially those with T2D, are at higher risk for short and poor sleep quality, and clinical insomnia. Adults living with diabetes, especially those with T2D, should have access to effective sleep interventions to prevent complications associated with elevated glucose levels.
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http://dx.doi.org/10.1016/j.jcjd.2021.01.013DOI Listing
February 2021

Endorsement of European guideline for the diagnosis and treatment of insomnia by the World Sleep Society.

Sleep Med 2021 05 21;81:124-126. Epub 2021 Jan 21.

Harvard Medical School, Boston, MA, U.S.A.

The European guideline for the diagnosis and treatment of insomnia (1) was developed by a task force of the European Sleep Research Society, which was composed of 27 experts with clinical experience on insomnia management from different European countries and the European Insomnia Network. The guideline focused on insomnia disorder as defined by ICD-10/ICSD-3. Its starting point was the previously published guideline by the German Sleep Society, which was revised and expanded based on a review of relevant meta-analyses of insomnia therapies published through June 2016. The scope of this guideline was to provide recommendations on the treatment of chronic insomnia disorder. This guideline was selected for review by the World Sleep Society (WSS) Insomnia Task Force and the WSS International Sleep Medicine Guidelines Committee. A task force of content experts from the WSS has reviewed this guideline specifically for its relevance and applicability to the practice of sleep medicine by sleep specialists that comprise its membership.
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http://dx.doi.org/10.1016/j.sleep.2021.01.023DOI Listing
May 2021

A Portrait of Mental Health Services Utilization and Perceived Barriers to Care in Men and Women Evacuated During the 2016 Fort McMurray Wildfires.

Adm Policy Ment Health 2021 Feb 28. Epub 2021 Feb 28.

School of Psychology, Université Laval, Québec, QC, Canada.

This study examines the influence of gender on mental health services utilization and on perceived barriers to treatment one year after the 2016 Fort McMurray wildfires. Data was collected through a phone survey from May to July 2017 (N = 1510). Participants were English-speaking evacuees aged 18 and older. Mental health services utilization and barriers to mental health care were assessed with the Perceived Need for Care questionnaire. Probable diagnoses of posttraumatic stress disorder, depression and insomnia were assessed with validated self-report questionnaires. Multiple logistic regressions confirmed that gender was a significant predictor of services utilization, after controlling for associated sociodemographic variables and presence of probable diagnoses. Women were respectively 1.50, 1.55 and 1.86 times more likely than men to receive information, medication and psychological help. Self-reliance was the most frequently reported reason for not receiving help, and motivational barriers, such as pessimism and stigma, were reported in a higher proportion than structural barriers, including nonresponse and finance. No significant gender differences were found in the types of perceived barriers to services. Among the Fort McMurray fire evacuees, mental health services utilization was similar to other studies on natural disaster victims, and higher in women than in men. Efforts to increase services utilization in natural disaster victims should focus on motivational barriers and offering treatments fostering people's autonomy, such as online treatments.
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http://dx.doi.org/10.1007/s10488-021-01114-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914389PMC
February 2021

A Prevention Program for Insomnia in At-risk Adolescents: A Randomized Controlled Study.

Pediatrics 2021 03;147(3)

Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry and.

Objectives: To prevent the future development of insomnia in at-risk adolescents.

Methods: A randomized controlled trial comparing 4 weekly insomnia prevention program with a nonactive control group. Subjects were assessed at baseline, postintervention, and 6 and 12 months after intervention. Assessors were blinded to the randomization. Analyses were conducted on the basis of the intention-to-treat principles.

Results: A total of 242 adolescents with family history of insomnia and subthreshold insomnia symptoms were randomly assigned to an intervention group ( = 121; mean age = 14.7 ± 1.8; female: 51.2%) or control group ( = 121; mean age = 15.0 ± 1.7; female: 62.0%). There was a lower incidence rate of insomnia disorder (both acute and chronic) in the intervention group compared with the control group (5.8% vs 20.7%; = .002; number needed to treat = 6.7; hazard ratio = 0.29; 95% confidence interval: 0.12-0.66;  = .003) over the 12-month follow-up. The intervention group had decreased insomnia symptoms ( = .03) and reduced vulnerability to stress-related insomnia ( = .03) at postintervention and throughout the 12-month follow-up. Decreased daytime sleepiness ( = .04), better sleep hygiene practices ( = .02), and increased total sleep time ( = .05) were observed at postintervention. The intervention group also reported fewer depressive symptoms at 12-month follow-up ( = .02) compared with the control group.

Conclusions: A brief cognitive behavioral program is effective in preventing the onset of insomnia and improving the vulnerability factors and functioning outcomes.
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http://dx.doi.org/10.1542/peds.2020-006833DOI Listing
March 2021

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial.

JAMA Intern Med 2021 Apr;181(4):530-538

Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle.

Importance: Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

Objective: To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

Design, Setting, And Participants: This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

Interventions: Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

Main Outcomes And Measures: The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

Results: Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

Conclusions And Relevance: In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

Trial Registration: Clinical Trials.gov Identifier: NCT02946957.
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http://dx.doi.org/10.1001/jamainternmed.2020.9049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900930PMC
April 2021

Cognitive behavioral therapy for insomnia in patients with chronic pain - A systematic review and meta-analysis of randomized controlled trials.

Sleep Med Rev 2021 Feb 2;60:101460. Epub 2021 Feb 2.

Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada. Electronic address:

Several randomized controlled trials have implemented cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid insomnia and chronic pain. This systematic review and meta-analysis investigated the effectiveness of CBT-I on patient-reported sleep, pain, and other health outcomes (depressive symptoms, anxiety symptoms, and fatigue) in patients with comorbid insomnia and chronic non-cancer pain. A systematic literature search was conducted using eight electronic databases. Upon duplicate removal, 6374 records were screened against the inclusion criteria. Fourteen randomized controlled trials were selected for the review, with twelve (N = 762 participants) included in the meta-analysis. At post-treatment, significant treatment effects were found on global measures of sleep (standardized mean difference = 0.89), pain (0.20), and depressive symptoms (0.44). At follow-up (up to 12 mo), CBT-I significantly improved sleep (0.56). Using global measures of sleep, we found a probability of 81% and 71% for having better sleep after CBT-I at post-treatment and final follow-up, respectively. The probability of having less pain after CBT-I at post-treatment and final follow-up was 58% and 57%, respectively. There were no statistically significant effects on anxiety symptoms and fatigue at either assessment point. Future trials with sufficient power, longer follow-up periods, and inclusion of CBT for pain components are warranted.
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http://dx.doi.org/10.1016/j.smrv.2021.101460DOI Listing
February 2021

A systematic analysis of ICSD-3 diagnostic criteria and proposal for further structured iteration.

Sleep Med Rev 2021 Jan 26;58:101439. Epub 2021 Jan 26.

Sleep Clinic, University Hospital of Bordeaux, 33 076 Bordeaux, France; USR CNRS 3413 SANPSY, University Hospital of Bordeaux, 33 076 Bordeaux, France. Electronic address:

The main objective of this theoretical review is to systematically analyze the type of International Classification of Sleep Disorders-3 (ICSD-3) diagnostic criteria by labeling each of them in order to propose an overview of the way in which the diagnostic criteria are organized. Labeling of diagnostic criteria using a rigorous iterative process of "aggregation" and "generalization" was conducted and inter-rater reliability calculation (Cohen's Kappa with three raters) was calculated. 241 criteria from 43 main sleep disorders of the ICSD-3 were labeled into nine types (Clinical manifestation 86.0% of sleep disorders, Objective markers 53.5%, Distress 30.2%, Disability 30.2%, Duration 30.2%, Frequency 58.1%, Age in 18.6%, Exclusion condition 81.4% and Associated condition 34.8%), with a high inter-rater reliability (Cohen's Kappa = 0.85). This analysis assumes that the structuring of the ICSD-3 diagnostic criteria is based on the Harmful Dysfunction Analysis (HDA). Some criteria correspond to the dysfunction part of the HDA while others refer to the harmful part. However, the approach does not seem to be homogeneous across the nosological classification. The use of a structured definition of sleep disorder and a framework to organize the ICSD diagnostic criteria is discussed with regard to the reliability and validity of criteria for diagnosing sleep disorders.
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http://dx.doi.org/10.1016/j.smrv.2021.101439DOI Listing
January 2021

Complementary and alternative treatments for insomnia/insomnia -depression-anxiety symptom cluster: Meta-analysis of English and Chinese literature.

Sleep Med Rev 2021 Jan 23;58:101445. Epub 2021 Jan 23.

School of Psychology, Université Laval, Quebec City, Quebec, Canada; Centre d'étude des troubles du sommeil, Centre de recherche de l'Institut universitaire en santé mentale de Québec, Quebec City, Québec, Canada.

This study systematically reviewed randomized controlled trials (RCT), published in English or Chinese, investigating the effect of complementary and alternative medicines (CAM) on significant insomnia/poor sleep quality and accompanying depression and/or anxiety symptoms. A meta-analysis was completed by calculating within-group effect size (ES) of each CAM treatment on sleep, depression and/or anxiety measures. Moderating analyses of study quality, language, treatment duration and presence of physical diseases were conducted to evaluate their impact on ESs. Between-group ES of CAM (vs. non-specific/placebo controls) were computed among high-quality studies. From an initial pool of 5047 articles, a total of 72 studies were included in the meta-analysis (44 in English; 28 in Chinese). All CAM modalities yielded significant, moderate to large effect sizes on sleep, depression, and anxiety symptoms yet with high heterogeneity. Significant between-group differences on sleep measures were found only between mindfulness-based treatment and non-specific/placebo controls. Chinese literature are associated with larger ESs. Future study should examine the presence and nature of the active components in different CAM approaches.
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http://dx.doi.org/10.1016/j.smrv.2021.101445DOI Listing
January 2021

Healthcare workers' sleep and mood disturbances during COVID-19 outbreak in an Iranian referral center.

Sleep Breath 2021 Feb 13. Epub 2021 Feb 13.

Université Laval, École de Psychologie, Pavillon F.A.S., Québec, Québec, G1K 7P4, Canada.

Purpose: This study aimed to assess the frequency of sleep and mood disturbances, and their association with COVID-like symptoms in healthcare workers (HCWs) with and without positive Coronavirus RT-PCR in a corona referral center.

Methods: This study was a cross-sectional, anonymous survey of adult HCWs. Data collection was performed in May and June 2020, while governmental restrictions were in place. The participants completed the forms including six separate parts: personal and occupational information, Insomnia Severity Index (ISI), Generalized Anxiety Disorder-7 (GAD-7), Patient's Health Questionnaire (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and COVID-like symptoms and Coronavirus RT-PCR status.

Results: Among the 372 HCW participants, 245 (66%) were women and  mean age was 34.5 ± 7.1 years (age range 23 to 58). The mean scores of all questionnaires except ISI were significantly higher in the HCWs with positive Coronavirus RT-PCR than another group (PSQI, 9 ± 3.4 vs. 6.9 ± 3.1; GAD-7, 9.8 ± 3.6 vs. 7.9 ± 5.3; PHQ-9, 12.8 ± 6.1 vs. 9.5 ± 6.4, P < 0.05; and ISI, 13.8 ± 5.3 vs. 12.3 ± 6 P = 0.163). Positive association between COVID-like symptoms and sleep and mood disturbances was found in the group without a positive test result. Analysis of questionnaires showed higher scores in the group directly involved except for ISI (P < 0.001 and P = 0.053 respectively).

Conclusions: During the COVID-19 pandemic, the HCWs in this sample experienced a high rate of sleep and mood disturbances. There was also a strong association between sleep and mood disturbances and COVID-like symptoms in the group without a positive RT-PCR result. With all this considered, effective psychological support for HCWs during crisis seems to be necessary.
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http://dx.doi.org/10.1007/s11325-021-02312-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881749PMC
February 2021

Pandémie COVID-19, sommeil et séquelles psychologiques: au nom du Réseau canadien du sommeil et des rythmes circadiens* et de la Société canadienne du sommeil*.

Can J Psychiatry 2020 Dec 23:706743720980262. Epub 2020 Dec 23.

École de psychologie, 204255Université Laval, Québec, Canada.

Les données recueillies lors de crises et tragédies passées prouvent que les problèmes de sommeil survenant durant ou peu de temps après un événement traumatique sont reliés à une probabilité accrue de développer des symptômes psychiatriques durables. Or la pandémie COVID-19 et ses conséquences à moyen et long-terme combinent plusieurs facteurs de risque pour le sommeil, tant pour les intervenants de la santé que la population générale. Notre relevé mensuel des publications scientifiques qui combinent COVID-19 et sommeil/insomnie entre janvier et juillet 2020 révèle un taux de croissance comparable pour les articles qui portent plus précisément sur la santé mentale mais aucune ne porte sur les résultats d'une intervention. Nous proposons qu'il faille agir rapidement sur les difficultés de sommeil en cette période de pandémie afin de protéger l'équilibre psychologique individuel à moyen et long terme, d'autant plus que les outils nécessaires à la prévention de l'insomnie, sa détection et son traitement sont à la portée de tous les professionnels de la santé mentale.
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http://dx.doi.org/10.1177/0706743720980262DOI Listing
December 2020

Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial.

Braz J Psychiatry 2020 Dec 18. Epub 2020 Dec 18.

Ambulatório de Sono, Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil.

Objective: To evaluate a protocol for acceptance and commitment therapy-based behavioral intervention for insomnia (ACT-BBI-I) in adults compared to cognitive behavioral therapy for insomnia (CBT-I).

Methods: Forty-five adults with chronic insomnia were randomized to ACT-BBI-I or CBT-I. Both interventions were performed in six weekly group sessions. The common treatment elements in both protocols included stimulus control and sleep restriction. CBT-I is focused on the cognitive restructuring of maladaptive beliefs about sleep and the daytime effects of insomnia. ACT-BBI-I focuses on therapeutic processes of acceptance, availability, values, defusion, and commitment. The results were evaluated through the following instruments: a sleep diary, the Insomnia Severity Index, the Epworth Sleepiness Scale, the Hospital Anxiety and Depression Scale, the Acceptance and Action Questionnaire-II, and the Dysfunctional Beliefs and Attitudes about Sleep scale.

Results: Both interventions had a significant positive impact on sleep patterns, insomnia, anxiety, beliefs about sleep, and psychological flexibility. All improvement was maintained at the 6-month follow-up.

Conclusion: The results suggest that integrating principles of ACT with behavioral techniques may be useful for treating insomnia. Further research should identify whether the principles of ACT result in added effectiveness compared to behavioral components alone.

Clinical Trial Registration: RBR-7nc5wq.
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http://dx.doi.org/10.1590/1516-4446-2020-0947DOI Listing
December 2020

Smartphone-Based Virtual Agents to Help Individuals With Sleep Concerns During COVID-19 Confinement: Feasibility Study.

J Med Internet Res 2020 12 18;22(12):e24268. Epub 2020 Dec 18.

USR 3413 SANPSY, University of Bordeaux, Bordeaux, France.

Background: The COVID-19 crisis and consequent confinement restrictions have caused significant psychosocial stress and reports of sleep complaints, which require early management, have increased during recent months. To help individuals concerned about their sleep, we developed a smartphone-based app called KANOPEE that allows users to interact with a virtual agent dedicated to autonomous screening and delivering digital behavioral interventions.

Objective: Our objective was to assess the feasibility of this app, in terms of inclusion rate, follow-up rate, perceived trust and acceptance of the virtual agent, and effects of the intervention program, in the context of COVID-19 confinement in France.

Methods: The virtual agent is an artificial intelligence program using decision tree architecture and interacting through natural body motion and natural voice. A total of 2069 users aged 18 years and above downloaded the free app during the study period (April 22 to May 5, 2020). These users first completed a screening interview based on the Insomnia Severity Index (ISI) conducted by the virtual agent. If the users were positive for insomnia complaints (ISI score >14), they were eligible to join the 2-stage intervention program: (1) complete an electronic sleep diary for 1 week and (2) follow personalized sleep recommendations for 10 days. We collected and analyzed the following measures: sociodemographic information, ISI scores and sleep/wake schedules, and acceptance and trust of the agent.

Results: Approximately 76% (1574/2069) of the app users completed the screening interview with the virtual agent. The virtual agent was well accepted by 27.4% (431/1574) of the users who answered the acceptance and trust questionnaires on its usability, satisfaction, benevolence, and credibility. Of the 773 screened users who reported sleep complaints (ISI score >14), 166 (21.5%) followed Step 1 of the intervention, and only 47 of those (28.3%) followed Step 2. Users who completed Step 1 found that their insomnia complaints (baseline mean ISI score 18.56, mean ISI score after Step 1 15.99; P<.001) and nocturnal sleep quality improved significantly after 1 week. Users who completed Step 2 also showed an improvement compared to the initial measures (baseline mean ISI score 18.87, mean ISI score after Step 2 14.68; P<.001). Users that were most severely affected (ISI score >21) did not respond to either intervention.

Conclusions: These preliminary results suggest that the KANOPEE app is a promising solution to screen populations for sleep complaints and that it provides acceptable and practical behavioral advice for individuals reporting moderately severe insomnia.
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http://dx.doi.org/10.2196/24268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752183PMC
December 2020

Profile of Somryst Prescription Digital Therapeutic for Chronic Insomnia: Overview of Safety and Efficacy.

Authors:
Charles M Morin

Expert Rev Med Devices 2020 Dec 2;17(12):1239-1248. Epub 2020 Dec 2.

School of Psychology, Laval University , Quebec City, Canada.

: Prescription digital therapeutics (PDTs) represent a new class of software-based medical devices authorized by the Food and Drug Administration (FDA) to treat disease. Somryst™, the first PDT for treating chronic insomnia, delivers cognitive behavioral therapy for insomnia (CBT-I) via a mobile application. CBT-I is the guideline-recommended, first-line treatment for chronic insomnia, but availability of CBT-I therapists is limited. Somryst addresses this need by providing asynchronous access to CBT-I treatment. As a contactless therapeutic medium, Somryst is also an ideal option when face-to-face therapy is not available or recommended for safety reasons (e.g. because of possible exposure to the SARS-CoV-2 virus). : This review summarizes the mechanisms of action and technical features of Somryst, and describes safety and effectiveness data from the randomized trials on which FDA clearance was based. : Somryst demonstrates robust clinical efficacy with a favorable benefit-to-risk profile for treating adults with chronic insomnia. FDA clearance was based on data from 2 clinical trials of the first-generation web-based CBT-I platform Sleep Healthy Using the Internet (SHUTi). Somryst, and PDTs in general, are promising devices to address the need for greater accessibility to effective therapies.
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http://dx.doi.org/10.1080/17434440.2020.1852929DOI Listing
December 2020

Sleep and circadian problems during the coronavirus disease 2019 (COVID-19) pandemic: the International COVID-19 Sleep Study (ICOSS).

J Sleep Res 2021 02 12;30(1):e13206. Epub 2020 Nov 12.

Centre d'étude des troubles du sommeil, École de psychologie, Institut universitaire en santé mentale, Centre de recherche CERVO, Université Laval, Quebec, QC, Canada.

This protocol paper describes the development of an international collaboration to survey several thousand adults from different countries around the world about their sleep during the coronavirus disease 2019 (COVID-19) pandemic. It is based on the development of a harmonised survey with 50 questions (106 different items) on sleep habits and sleep symptoms that permit comparability of information. The harmonised questionnaire may be used in anonymous cross-sectional surveys, and the instruments within the questionnaire may also be used in prospective studies and clinical studies. The aim was to develop a questionnaire to sample a variety of sleep-wake disorders and other symptoms likely to be caused by prolonged social confinement or by having had COVID-19. The questionnaire was designed to be: (a) simple and, (b) free to use, for research purposes, (c) multilingual, and (d) comprehensive. It can be completed in <30 min. By the end of June 2020, the survey questionnaire had been administered in Austria, Canada, China, Finland, France, Germany, Hong Kong, Italy, Japan, Norway, Poland, Sweden, UK and USA. Research questions to be addressed by the pooled data derived from the participating sites focus on describing the nature and rates of various sleep and circadian rhythms symptoms, as well as their psychological and medical correlates, that arise at various points during the COVID-19 pandemic.
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http://dx.doi.org/10.1111/jsr.13206DOI Listing
February 2021

Incidence, Persistence, and Remission Rates of Insomnia Over 5 Years.

JAMA Netw Open 2020 11 2;3(11):e2018782. Epub 2020 Nov 2.

École de psychologie, Université Laval, Québec, Québec, Canada.

Importance: Insomnia is a significant public health problem, but there is little information on its natural history.

Objective: To assess the incidence, persistence, and remission rates of insomnia over a 5-year naturalistic follow-up period.

Design, Setting, And Participants: This cohort study included participants with and without sleep problems selected from the adult population in Canada from August 2007 to June 2014. Participants completed an annual survey about their sleep and health status for 5 consecutive years.

Exposure: Using validated algorithms, participants were classified at each assessment as being good sleepers (n = 1717), having an insomnia disorder (n = 538), or having subsyndromal insomnia (n = 818).

Main Outcomes And Measures: Survival analyses were used to derive incidence rates of new insomnia among the subgroup of good sleepers at baseline and persistence and remission rates among those with insomnia at baseline. Sleep trajectories were examined by looking at year-person transitions between each consecutive year summed over the 5-year follow-up period. All inferential analyses were weighted according to normalized sampling weights.

Results: The sample included 3073 adults (mean [SD] age, 48.1 [15.0] years; range, 18.0-95.0 years; 1910 [62.2%] female). Overall, 13.9% (95% CI, 11.0%-17. 5%) of initial good sleepers developed an insomnia syndrome during the 5-year follow-up period, and incidence rates were higher among women than among men (17.6% [95% CI, 13.6%-22.7%] vs 10.1% [95% CI, 6.6%-15.3%; χ2  = 4.43; P = .03). A total of 37.5% (95% CI, 32.6%-42.5%) of participants with insomnia at baseline reported insomnia persisting at each of the 5 annual follow-up times. For subsyndromal insomnia, rates were 62.5% at 1 year to 26.5% at 5 years. For syndromal insomnia, rates were 86.0% at 1 year to 59.1% at 5 years. Conversely, remission rates among those with subsyndromal insomnia were almost double the rates among those with an insomnia syndrome at 1 year (37.5% [95% CI, 31.7%-44.0%] vs 14.0% [95% CI, 9.3%-20.8%]), 3 years (62.7% [95% CI, 56.7%-68.7%] vs 27.6% [95% CI, 20.9%-35.9%]), and 5 years (73.6% [95% CI, 68.0%-78.9%%] vs 40.9% [95% CI, 32.7%-50.4%]). Yearly trajectories showed that individuals who were good sleepers at baseline were 4.2 (95% CI, 3.51-4.89) times more likely to stay good sleepers in the subsequent year, but once they developed insomnia, they were equally likely to report symptoms (47% probability) than to return to a good sleeper status (53% probability) 1 year later. Similarly, those with an insomnia syndrome at any given assessment were more likely (adjusted odds ratio, 1.60; 95% CI, 1.19-2.60) to remain in that status (persistence) than to improve (remittance) at the next assessment; even among those who improved, the odds of relapse were greater (adjusted odds ratio, 2.04; 95% CI, 1.23-3.37) than those to improve in the following year.

Conclusions And Relevance: The findings suggest that insomnia is often a persistent condition. Considering the long-term adverse outcomes associated with persistent insomnia, these findings may have important implication for the prognosis and management of insomnia.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.18782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648256PMC
November 2020

Advancing a value framework for sleep: Update on economic aspects of cognitive-behavioral treatments for insomnia.

Sleep Med Rev 2020 12 16;54:101387. Epub 2020 Sep 16.

Université Laval, École de psychologie, Québec City, Québec, Canada.

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http://dx.doi.org/10.1016/j.smrv.2020.101387DOI Listing
December 2020

The European Portuguese version of the insomnia severity index.

J Sleep Res 2021 02 30;30(1):e13198. Epub 2020 Sep 30.

Faculty of Psychology and Educational Sciences, University of Coimbra (FPCE-UC), Coimbra, Portugal.

Insomnia is the most prevalent sleep complaint, but remains largely an unidentified public health issue. The Insomnia Severity Index (ISI) is a brief self-report questionnaire to assess insomnia, long-established both in clinical and research settings. The present study aimed to analyse the reliability, validity, and accuracy of the ISI European Portuguese version. After the translation protocol, 1,274 participants (65.54% female), with a mean (SD, range) age of 37.52 (16.82, 18-95) years, completed the ISI. This sample included 250 patients with insomnia from a Sleep Medicine Centre, presenting a diagnosis of insomnia disorder (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; International Classification of Sleep Disorders, Third Edition), and 1,024 individuals from the community. A group of 30 patients with obstructive sleep apnea (OSA) was also recruited. Cronbach's α was 0.88 (internal consistency), and corrected item-total correlations ranged from 0.56 to 0.83. An exploratory factor analysis (oblique rotation) revealed a two-factor solution for both clinical and community samples. The ISI total score significantly differentiated insomnia disorder, no insomnia, and OSA subgroups with a large effect size (η  = 0.42). The correlation between ISI and Pittsburgh Sleep Quality Index supported concurrent validity (0.82), and discriminant validity was confirmed by a moderate correlation between ISI and Beck Depression Inventory Second Edition (0.32). The area under the curve was 0.88, and the optimal cut-off to detect clinical insomnia was 14 (82.1% sensitivity, 79.5% specificity). In conclusion, the Portuguese version of the ISI is a reliable and valid measure of insomnia in clinical and non-clinical populations. Our present study also contributes to relevant data for the international literature regarding the cut-off score of the scale for the detection of clinical insomnia.
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http://dx.doi.org/10.1111/jsr.13198DOI Listing
February 2021

Video cognitive-behavioral therapy for insomnia in cancer patients: A cost-effective alternative.

Psychooncology 2021 01 9;30(1):44-51. Epub 2020 Sep 9.

Department of Economics, Université Laval, Quebec City, Quebec, Canada.

Objective: Despite its high prevalence, cancer-related insomnia typically remains untreated because of a lack of access to cognitive-behavioral therapy for insomnia (CBT-I), the treatment of choice for this condition. While face-to-face CBT-I appears to be optimal in terms of efficacy, self-administered formats may be more cost-effective. The goal of this secondary analysis of a randomized clinical trial was to compare the cost-effectiveness of a professionally-based CBT-I (PCBT-I) to that of a video-based CBT-I (VCBT-I).

Methods: A total of 161 women with breast cancer received six weekly, individual CBT-I sessions (PCBT-I; n = 81) or a 60-minutes animated video +6 short booklets (VCBT-I; n = 80). Participants completed the Insomnia Severity Index (ISI) and provided information to calculate treatment costs.

Results: Total per patient treatment costs were 5.5 times greater for PCBT-I ($1298.90) than VCBT-I ($234.36; P < .0001). Both at posttreatment and 3-month follow-up, the ISI reduction was greater in PCBT-I than VCBT-I, but these differences were not significant (P = .09 and P = .24, respectively). In contrast, the cost-effectiveness ratio was significantly more advantageous for VCBT-I than PCBT-I. Compared to VCBT-I, each reduction of 1 unit on the ISI produced by PCBT-I was associated with a treatment cost that was significantly greater at posttreatment ($186.95 CAD vs $44.87 CAD; P = .001) and follow-up ($154.76 vs $24.97, P = .005).

Conclusions: Although CBT-I is slightly less efficacious when self-administered, it constitutes a much more cost-effective alternative than face-to-face CBT-I and represents an extremely valuable option in settings where monetary and human resources required to administer CBT-I are not available or sufficient.
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http://dx.doi.org/10.1002/pon.5532DOI Listing
January 2021

Sleep and circadian rhythm in response to the COVID-19 pandemic.

Can J Public Health 2020 10 22;111(5):654-657. Epub 2020 Jul 22.

Université de Montréal, Montreal, QC, Canada.

This commentary highlights the critical role of sleep as a public health issue, particularly during a stressful life period such as the COVID-19 pandemic, and provides evidence-based practical guidelines to manage sleep disturbances during this crisis. The COVID-19 pandemic and the imposed social confinement have produced significant stress, anxiety, and worries about health and the fear of being infected, jobs and financial problems, and uncertainty about the future. The incidence of sleep disturbances has also increased dramatically during this period. Aside from stress and anxiety, two other factors are likely to contribute to increased sleep disturbances during this crisis. First, alterations of our daily routines such as arising at a specific time, showing up at work, eating, exercising, and engaging in social and leisure activities at relatively fixed times are all important timekeepers for our sleep-wake cycles to remain synchronized with the day (light) and night (dark) cycles. Alterations of these timekeepers, combined with reduced daylight exposure, also essential to keep our biological clock synchronized, are likely to disrupt sleep and circadian rhythms. Sleep plays a fundamental role for mental and physical health, and adequate sleep duration and quality are essential for coping with major life events such as the COVID-19 pandemic. Public health education is warranted to keep the population well informed about the importance of sleep and healthy sleep practices in order to cope with the pandemic and prevent or minimize long-term adverse outcomes.
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http://dx.doi.org/10.17269/s41997-020-00382-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375451PMC
October 2020

Effectiveness of Sequential Psychological and Medication Therapies for Insomnia Disorder: A Randomized Clinical Trial.

JAMA Psychiatry 2020 Nov;77(11):1107-1115

University of Colorado, Denver.

Importance: Despite evidence of efficacious psychological and pharmacologic therapies for insomnia, there is little information about what first-line treatment should be and how best to proceed when initial treatment fails.

Objective: To evaluate the comparative efficacy of 4 treatment sequences involving psychological and medication therapies for insomnia and examine the moderating effect of psychiatric disorders on insomnia outcomes.

Design, Setting, And Participants: In a sequential multiple-assignment randomized trial, patients were assigned to first-stage therapy involving either behavioral therapy (BT; n = 104) or zolpidem (zolpidem; n = 107), and patients who did not remit received a second treatment involving either medication (zolpidem or trazodone) or psychological therapy (BT or cognitive therapy [CT]). The study took place at Institut Universitaire en Santé Mentale de Québec, Université Laval, Québec City, Québec, Canada, and at National Jewish Health, Denver, Colorado, and enrollment of patients took place from August 2012 through July 2017.

Main Outcomes And Measures: The primary end points were the treatment response and remission rates, defined by the Insomnia Severity Index total score.

Results: Patients included 211 adults (132 women; mean [SD] age, 45.6 [14.9] years) with a chronic insomnia disorder, including 74 patients with a comorbid anxiety or mood disorder. First-stage therapy with BT or zolpidem produced equivalent weighted percentages of responders (BT, 45.5%; zolpidem, 49.7%; OR, 1.18; 95% CI, 0.60-2.33) and remitters (BT, 38.03%; zolpidem, 30.3%; OR, 1.41; 95% CI, 0.75-2.65). Second-stage therapy produced significant increases in responders for the 2 conditions, starting with BT (BT to zolpidem, 40.6% to 62.7%; OR, 2.46; 95% CI, 1.14-5.30; BT to CT, 50.1% to 68.2%; OR, 2.09; 95% CI, 1.01-4.35) but no significant change following zolpidem treatment. Significant increase in percentage of remitters was observed in 2 of 4 therapy sequences (BT to zolpidem, 38.1% to 55.9%; OR, 2.06; 95% CI, 1.04-4.11; zolpidem to trazodone, 31.4% to 49.4%; OR, 2.13; 95% CI, 0.91-5.00). Although response/remission rates were lower among patients with psychiatric comorbidity, treatment sequences that involved BT followed by CT or zolpidem followed by trazodone yielded better outcomes for patients with comorbid insomnia. Response and remission rates were well sustained through the 12-month follow-up.

Conclusions And Relevance: Behavioral therapy and zolpidem medication produced equivalent response and remission rates. Adding a second treatment produced an added value for those whose insomnia failed to remit with initial therapies.

Trial Registration: ClinicalTrials.gov Identifier: NCT01651442.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.1767DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344835PMC
November 2020

The acute effects of the COVID-19 pandemic on insomnia and psychological symptoms.

Sleep Med 2021 01 6;77:346-347. Epub 2020 Jun 6.

Université de Montréal, Hôpital Du Sacré-Cœur de Montréal, Canada; Centre D'étude Avancée en Médecine Du Sommeil, Hôpital Du Sacré-Cœur de Montréal, Canada.

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http://dx.doi.org/10.1016/j.sleep.2020.06.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274952PMC
January 2021