bluuebunny/crossref_metadata_2025_split huggingface dataset:
0366 Understanding the mediating role of sleep improvement on anxiety symptoms using digital CBT for insomnia
Authors: Henry Alasdair , Miller Christopher , Emsley Richard , Sheaves Bryony , Freeman Daniel , Luik Annemarie , Espie Colin 
Published: May 2023

Abstract

Introduction
Insomnia has significant overlap with anxiety, and CBT for insomnia, in addition to improving sleep, leads to concomitant reductions in anxiety. Nevertheless, few studies have evaluated the anxiolytic effects of CBT for insomnia in individuals with insomnia and clinically significant anxiety symptoms or an anxiety disorder diagnosis. Large studies of digital CBT provide a prudent source to evaluate the transdiagnostic role of insomnia to reduce anxiety symptoms. Using data from two trials of dCBT for insomnia, we evaluated whether sleep is a transdiagnostic treatment target to reduce anxiety symptoms in individuals with insomnia and clinically significant anxiety.

Methods
Individual data from 2,172 participants with insomnia and clinically significant anxiety symptoms were extracted from two previously conducted randomised controlled trials of dCBT for insomnia. Participants received either dCBT or control (usual care or sleep hygiene education). Assessments were conducted at baseline, post-intervention (week 8 or 10), and follow-up (week 22 or 24). Insomnia symptoms were assessed using the Sleep Condition Indicator (SCI-8), and anxiety symptoms using the 7-item Generalized Anxiety Disorder scale (GAD-7). Mediation was evaluated using structural equation models.

Results
Compared with control, dCBT for insomnia was superior at reducing symptoms of insomnia (Hedges’ g range: 0.71-0.88; both p&lt; 0.001) and anxiety (Hedges’ g range: 0.39-0.44; both p&lt; 0.001). At post-intervention, participants in the dCBT group were significantly more likely to achieve remission (OR = 2.24 (0.30); &lt; 0.001 (1.72, 2.91)) and reliable remission (OR = 2.24 (0.30); &lt; 0.001 (1.73, 2.89)) of their anxiety. Improvements in sleep at post-intervention mediated 84% of the effect of dCBT on anxiety symptoms at follow-up.

Conclusion
Targeting insomnia symptoms via digital CBT for insomnia may be an appropriate means by which to reduce anxiety symptoms in individuals with insomnia and comorbid anxiety. These findings reinforce the transdiagnostic benefits of CBT for insomnia and digital CBT may offer an accessible first step intervention.

Support (if any)
This work was supported in part by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
0377 Sleep Health Disparities Among U.S. Military Personnel and Veterans Registered on the Burn Pit Registry
Authors: Nowakowski Sara , Razjouyan Javad , Kokonda Manasa , Christie Israel , Helmer Drew 
Published: May 2023

Abstract

Introduction
Disparities are underrecognized factors for sleep health. Additionally, there are concerns about sleep health among Veterens with exposure to burn pit smoke. This study aimed to examine the association between sex, race, and ethnicity and self-reported insomnia and sleep apnea symptoms in Veterans and active duty personnel.

Methods
Using items from the online health questionnaire of the VA/DoD Airborne Hazards and Open Burn Pit Registry administered between April 2014 and August 2022 to 320,231 Veterans and active duty personnel (age 40.1±9.2 y, 11% female, 75% white), we examined the association between sociodemographic variables (sex, race, and ethnicity) and self-reported sleep complaints (insomnia, sleep duration, sleep apnea events and snoring) in separate logistic regression models.

Results
Female sex predicted higher odds of insomnia (OR 1.3), where as male sex predicted higher odds of sleep apnea events (OR 2.6) and snoring (OR 2.4), p’s&lt;.0001. African American race predicted higher odds of sleep apnea events, snoring, insomnia and shorter sleep duration (ORs1.5-3.2, p’s&lt;.0001). Hispanic ethnicity predicted higher odds of sleep apnea events, snoring, insomnia and shorter sleep duration (ORs 1.2-1.6, p’s&lt;.0001).

Conclusion
We observed a higher prevalence of self-reported sleep complaints among Black and Hispanic compared to White Veterans and active duty personnel who completed the burn pit registry. We also found a higher prevalence of insomnia in females compared to males, while snoring and sleep apnea events were more common in males compared to females. Future research will focus on sleep health dispartities of objective sleep data extracted from polysomnography reports in the Veteran Affairs electronic medical records in Veterans on the burn pit registry.

Support (if any)
This work is supported by the Department of Veteran Affairs, Veterans Health Administration, Office of Research and Development, Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413); Michael E DeBakey VAMC Bridge Grant (PI: Nowakowski); and VA Airborne Hazards and Burn Pit Center of Excellence Pilot Grant (PI:Nowakowski).
0379 A Scoping Review of Validation Studies for Commercially Available CBT-i Smartphone Applications
Authors: Mak Michael , Rahmani Armin 
Published: May 2023

Abstract

Introduction
Cognitive behavioral therapy for insomnia (CBT-I) remains the first line treatment for insomnia. CBT-I in comparison with sedative-hypnotics has similar efficacy, but with treatment durability and almost no adverse effects. Despite CBT-I being recognized as the best insomnia treatment, access remains limited. Digital CBT-I hopes to address the problem of scale, so as to deliver therapy to the masses. There are now multiple mobile applications available both on smartphone app stores, which claim to deliver evidence based CBT-i. These applications largely come at a cost and patients have to pay to access their services. The goal of this study is to review CBT-i smartphone applications to see if they are indeed validated.

Methods
We performed a search on the two most popular smartphone application platforms: Google Play and Apple Store. We used search terms: sleep, insomnia and CBT-I. We then searched for validation studies for those smartphone applications on Google Scholar. We included studies conducted in the past 10 years. Our second search consisted of reviewing PubMed and Google Scholar for validation studies for CBT-I applications. Our search terms consisted of CBT-I and smartphone, CBT-I and application and CBT-I and digital.

Results
Of the 9 validation studies that we initially found, 6 met our inclusion criteria. 3 were excluded as they did not solely use CBT-I in their applications. All 6 applications reported significant improvement in important sleep quality metrics such as sleep onset latency and total sleep time. 4 studies also reported on a subjective improvement in quality of sleep. 2 studies looked at populations with comorbidities including cannabis use disorder and epilepsy. Both studied again found improvement in sleep quality in those specific populations. There were concerning patterns of bias found amongst the reviewed studies. 3/6 investigators had direct relationships with companies which designed and marketed the applications.

Conclusion
dCBT-I offers an opportunity to increase accessibility to therapy. There are only a limited number of studies which have examined the effectiveness of the applications on the market. There remains serious concerns about the risk of bias and the quality of validation studies which claim to confirm the effectiveness of these applications.

Support (if any)
0381 Adverse Childhood Experiences Associated with Adult Sleep Duration, Control Over Sleep, and Daytime Sleepiness
Authors: Rasmussen Elizabeth , Ricketts Emily , Joyce Daniel , Mensah-Osman Taylor , Gorovoy Suzanne , Granados Karla , Prather Aric , Hale Lauren , Branas Charles , Rojo-Wissar Darlynn , Grandner Michael 
Published: May 2023

Abstract

Introduction
Adverse childhood events have been linked with many mental and physical health risks, but less work has explored nighttime and daytime sleep problems, especially inability to control sleep.

Methods
Data were obtained from the Sleep and Healthy Activity, Diet, Environment, and Socialization (SHADES) study of N=1007 adults aged 22-60 years recruited from communities in southeastern Pennsylvania. Adverse childhood experiences were defined as a self-reported history of child abuse, parent divorce, parent death, parent with depression, parent with anxiety disorder, and childhood poverty (yes/no). Habitual sleep duration was assessed in hours, daytime sleepiness was assessed with the Epworth Sleepiness Scale (ESS), and control over sleep was assessed with the Brief Index of Sleep Control (BRISC). Covariates included age, sex, race/ethnicity, and education. Additional models included depression severity, assessed using a modified version of the Patient Health Questionnaire-9.

Results
History of child abuse was associated with 23 fewer minutes of nighttime sleep (p=0.001), and parent anxiety was associated with 15 fewer minutes (p=0.048). When depression was added to the model, the effects for sleep duration were attenuated (15.3 minutes, p=0.03). No other relationships were observed. Regarding control over nighttime sleep, decreased sense of control was reported by those who experienced child abuse (B=-0.4, p&lt; 0.0005), parent divorce (B=-0.1, p=0.035), and parent depression (B=-0.2, p=0.02). After adjusting for depression, the relationship with child abuse was attenuated but maintained (B=-0.2, p&lt; 0.0005). Elevated ESS scores were seen in those who reported child abuse (B=4.7, p&lt; 0.0005), parent depression (B=4.3, p&lt; 0.0005), and parent anxiety (B=3.9, p&lt; 0.0005). After adjusting for depression, relationships were attenuated but maintained for child abuse (B=2.0, p=0.02), parent depression (B=2.2, p=0.004), and parent anxiety (B=2.2, p=0.017).

Conclusion
Adverse childhood events may lead to sleep/wake dysregulation, including less sleep at night, more sleepiness during the day, and decreased sense of control over sleep ability. Future efforts might focus on increasing control over nighttime sleep and reducing daytime sleepiness.

Support (if any)
0387 Burden of insomnia among Alzheimer's patients: variations in comorbidities and healthcare utilization in Medicaid enrollees
Authors: Chekani Farid , Sharma Manvi , Goswami Swarnali , Mirchandani Kirti 
Published: May 2023

Abstract

Introduction
Sleep disturbance contributes to the burden of Alzheimer’s disease (AD), specifically among vulnerable patients with behavioral symptoms and multiple comorbidities. Limited information exists regarding the characteristics associated with insomnia among patients with AD. This study describes medical conditions and healthcare utilization among patients with AD and insomnia.

Methods
This retrospective cohort study used MarketScan® Multi-State Medicaid Database 2016-2020 and included adults aged ≥ 50 with newly diagnosed AD. Index date was the earliest medical or pharmacy claim date for insomnia within 3 months prior to 12 months post AD date. For comparison, non-insomnia cohort was selected based on propensity score 1:1 matching. Comorbid conditions and behavioral symptoms (BS) - including agitation aggression, psychotic symptoms, and mood disorders – and delirium were measured in the 12-month baseline period and were compared across insomnia and non-insomnia cohorts using chi-square tests. Healthcare utilization was assessed in 12-month post-index date (follow-up period).

Results
Among patients with incident AD, significantly higher proportions of individuals with comorbidities were detected in insomnia (N=3,904) vs. non-insomnia (N=3,904) cohorts in 12-month baseline period, i.e., hypertension (76.2% vs. 71.2%, p &lt; 0.001), diabetes (35% vs. 32.9%, p=0.05), valvular disease (11.6% vs. 9.8%, p=0.01), delirium (5.1% vs. 3.7%, p=0.002) and BS (62.4% vs. 46%, p&lt; 0.0001). The proportion of patients with BS during follow-up was higher in the insomnia cohort (76.18%) in comparison to the non-insomnia cohort (53.53%). In the follow-up, proportion of inpatient, emergency room and physician office visits were 34.5%, 49.8%, 45.6% in insomnia and 30.7%, 42.5%, 41.2% in non-insomnia cohorts respectively. Mean (SD) inpatient length-of-stay was 3.2 (9.62) days for insomnia and 2.6 (8.52) days for non-insomnia cohorts respectively.

Conclusion
The study results indicate that major comorbidities and behavioral symptoms are highly prevalent among insomnia patients with AD. Insomnia is associated with higher utilization rates when healthcare use is compared between insomnia and non-insomnia patients. Optimization of insomnia treatment is crucial for the disease management in AD patients.

Support (if any)
Funding for this research was provided by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Rahway, NJ, USA.
0397 Efficacy of second-stage clinician-led CBTI in non-responders to digital CBTI: Is alleviation of cognitive arousal a mechanism?
Authors: Sagong Chaewon , Kalmbach David , Cheng Philip , Fellman-Couture Cynthia , Iqal Justin , Ruprich Melissa , Bayoneto Alec , Peterson Edward , Roth Thomas , Drake Christopher 
Published: May 2023

Abstract

Introduction
Cognitive-behavioral therapy for insomnia (CBTI) is first-line treatment for insomnia, but a provider shortage limits access. eHealth technology can increase access to behavioral interventions, and digital CBTI (fully automated programs) are effective. However, &gt;50% of digital CBTI patients do not remit, and non-remission is linked to undertreated cognitive arousal, a central feature of insomnia. In a randomized controlled trial, we randomized digital CBTI non-remitters to second-stage clinician-led CBTI or control. We evaluated whether second-stage CBTI effectively reduced insomnia and depression, and tested whether reductions in cognitive arousal mediated these effects.

Methods
207 patients whose insomnia did not remit with digital CBTI presented to second-stage therapy. Patients were randomized to clinician-led CBTI or sleep education control via telemedicine. Study outcomes included insomnia (insomnia severity index, ISI), depression (quick inventory of depressive symptomatology self-report 16-item survey, QIDS-SR16), and three indices of cognitive arousal (pre-sleep arousal scale’s cognitive factor [PSASC], perseverative thinking questionnaire [PTQ], and daytime insomnia symptoms response scale [DISRS]).

Results
Before second-stage therapy, all patients reported clinically significant insomnia (ISI≥10), 13.0% reported moderate depression, and 69.5% reported high cognitive arousal. Step 2 CBTI patients, relative to Controls, reported larger decreases in ISI (-6.43±4.31 vs -2.58±4.83, t=6.05, p&lt;.001, Cohen’s d=.84). At posttreatment, 56.3% of Step 2 CBTI patients remitted (ISI≤7) relative to just 16.3% of Controls (Χ2=35.77, p&lt;.001, RR=3.45). CBTI patients reported larger reductions in depression relative to control, which was a small-to-medium effect (-2.63±3.11 vs -1.11, t=3.15, p=.002, Cohen’s d=.44). Contrary to hypotheses, Step 2 CBTI did not reduce cognitive arousal relative to Control as measured by the PSASC (p=.195), PTQ (p=.840), and DISRS (p=.643).

Conclusion
Clinician-led CBTI is effective for alleviating symptoms of insomnia and comorbid depression in insomnia patients who do not initially remit with digital CBTI. Contrary to hypotheses, reducing cognitive arousal did not mediate treatment effects. As most insomnia non-remitters present to second-stage therapy with high cognitive arousal, alternative approaches that better target cognitive arousal symptoms may represent viable second-stage therapy options for insomnia.

Support (if any)
This RCT (NCT03322774) was supported by NIMH R01-MH122636.
0398 Efficacy of Suvorexant for Insomnia Disorder in Patients with Poorly-Controlled Type 2 Diabetes
Authors: Winkelman John , Wipper Benjamin , Zackon Jordana , Hoeppner Bettina 
Published: May 2023

Abstract

Introduction
Sleep disturbance is a common and underappreciated feature of diabetes and sleep may contribute to glycemic control in patients with type two diabetes (T2D). We conducted a randomized placebo-controlled 3-month trial to examine the efficacy of suvorexant in improving sleep and other aspects of health in patients with suboptimally-controlled type 2 diabetes and insomnia.

Methods
This double-blind, randomized placebo-controlled 3-month trial was conducted using the sequential parallel comparison design (SPCD). Sixty-nine poorly-controlled T2D patients (HbA1c≥6.5) were randomized to placebo and/or suvorexant (10-20 mg). The primary outcome was subjective total sleep time (STST), and secondary outcomes were Insomnia Severity Index (ISI) score and wake time after sleep onset (WASO). Exploratory outcomes included sleep efficiency, hemoglobin A1c (HbA1c), and C-reactive protein (CRP). Exploratory analyses were conducted on relationships of sleep and diabetes outcomes.

Results
There were no significant improvements in STST, ISI, or WASO among patients taking suvorexant compared to those taking placebo. There were also no significant changes in any of the exploratory endpoints. Improvements in sleep were associated with improvements in both objective (i.e. HbA1c) and subjective (i.e. Diabetes Distress Scale) measures of diabetes, across treatment assignments.

Conclusion
Our negative findings for suvorexant efficacy for insomnia in poorly-controlled T2D may be related to inadequate sample size or due to the complex and multiple contributions to insomnia in this patient population. The associations of improved sleep with improvements in diabetes-related metrics across groups highlights the importance of identifying and treating sleeping difficulties in this population.

Support (if any)
This research was funded by an investigator-initiated grant from Merck Pharmaceuticals.
0402 Factors associated with subjective sleep problem and treatment willingness in sleep clinic patients
Authors: Bae Hyoeun , Lee Sujin , Kim Jee Hyun , Joo Eun Yeon 
Published: May 2023

Abstract

Introduction
Insomnia clinic physicians often encounter patients with discrepancy between subjective and objective sleep problem. This study aimed to investigate factors that attributed to patients’ perception of sleep disturbances and treatment willingness, which were practical in determining diagnostic and treatment direction.

Methods
This study was a cross-sectional study, data collected from November 2018 to October 2022 in sleep clinic of tertiary university-affiliated hospital. Adults older than 19 who underwent sleep questionnaires and polysomnography (PSG) were included (n=3,239). Demographic data and sleep-related factors (alcohol, caffeine, exercise, education, job, marital status, comorbidity) were collected. Subjects were categorized into four groups by questionnaire answers (Do you think you have sleep problem? Do you want treatment for sleep problem? -group 1, neither; group 2, no sleep problem but want treatment; group 3, yes sleep problem without treatment willing; group 4, both yes.) and compared.

Results
Group 2 had higher percentage of job, snoring, witnessed apnea, worry about sleep, sleep maintenance problem than group 1. Group 3 had less job, sleep maintenance problem, daytime dysfunction, worry about sleep than group 4 (p&lt; 0.05). Majority of no sleep problem groups were revealed to be normal (group 1: 28.0%, 2: 28.5%) or OSA (group 1: 63,7%, 2: 63.1%), while yes sleep problem groups were relatively higher combined insomnia and OSA (COMISA) (group 3: 20.0%, 4: 23.8%) or insomnia (group 3: 11.1%, 4: 15.3%) by PSG. OSA patients in group 2 showed more witnessed apnea and worry about sleep than group 1. COMISA patients in group 3 had less daytime dysfunction than group 4. However, PSG parameters were not significantly different among groups.

Conclusion
This study found that social need and subjective sleep maintenance problem are key factors that lead patients to regard their sleep as problematic or seek for treatment. In particular, patients with suspected OSA need to be instructed to get sleep study since sleep apnea severity do not affect treatment willingness and they had the lowest insight of their sleep problem. For those complaining of no or mild problem yet seeks for treatment, focusing on relieving misperceived worries about sleep is needed.

Support (if any)
0408 Insomnia, hypersomnia, and depression in buprenorphine treated opioid use disorder subjects
Authors: Krishnamurthy Venkatesh , Freet Christopher , Yadav Sanjay , del Tredici Sonya , Vgontzas Alexandros , Bixler Edward , Fernandez-Mendoza Julio 
Published: May 2023

Abstract

Introduction
Sleep disturbances and depression are highly prevalent in Opioid use disorder subjects treated with buprenorphine. However, the association between sleep disturbances such as insomnia/hypersomnia and depression in the above patient population is not known. The aim of the study is to examine the association between sleep disturbances including insomnia and hypersomnia with depressive disorders in buprenorphine treated opioid use disorder (OUDB) subjects.

Methods
We studied 92 OUDB (38±11.2y, 49% female, 9% minority) at the Recovery, Advocacy, Empowerment and Service program (RASE) and Internal Medicine clinics of Wellspan (York, PA). Subjects completed the Patient Health Questionaire-9 (PHQ-9), Insomnia Severity Index (ISI), Epworth sleepiness scale (ESS), and opioid craving scale (OCS). Depression was defined as a PHQ 9 score ≥ 10, insomnia with an ISI score of &gt;15 and excessive daytime sleepiness (EDS) with an ESS score of &gt;10. Binary logistic regression analysis evaluated the likelihood of OUDB subjects having depression in relation to insomnia, excessive daytime sleepiness (EDS), opioid craving, duration of opioid use, duration since last use of any illegal substance, number of rehabilitation treatments and buprenorphine dosage.

Results
No differences between in OUDB subjects with (n=47) and without (n=34) depression were observed in age, duration of opioid dependence, duration of buprenorphine treatment, number of rehabilitation treatments or time since last use of any illegal substance. Subjects with depression had significantly higher ISI (18.2±4.2 verus11.8±6.6, p&lt; 0.01), ESS (11.2±4.7 versus 8.2±4.1, p&lt; 0.01 ) scores and a trend towards higher OCS score (3.2±4.1 verus1.9±2.2, p=0.056) as compared to those without depression. The odds of depression associated with Insomnia and EDS were 8.5 (95%CI=2.3-31.2) and 4.4 (95%CI=1.1-17) times respectively in this patient population.

Conclusion
Insomnia and hypersomnia are highly associated with depression in buprenorphine treated OUDBs patients. Insomnia and hypersomnia needs to be evaluated early and receive targeted treatment during early abstinence in order to prevent relapse in this patient population.

Support (if any)
This project is supported by the Junior Faculty Development Program, Penn State College of Medicine