Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients

Primary care is often the place where patients with depression and comorbid insomnia seek treatment. The experience of comorbid insomnia with depression can have a significant impact on the efficacy of other depression treatments and exacerbate depressive symptoms. Using the empirically based Cognitive-Behavioral Treatment for Insomnia (CBT-I) to target the comorbid experience of insomnia in patients with depression can help improve sleep and potentially modify some depressive symptoms. Additional rationale for such an approach includes that a positive therapeutic experience may enhance engagement with or adherence to other psychotherapeutic interventions. Although other brief CBT-I interventions have been developed for primary care, none of them were actually delivered to depressed patients or implemented in primary care. Therefore, this paper describes a brief CBT-I intervention that was designed to be delivered in 4 sessions lasting from 15 to 45 minutes each within a primary care setting to depressed veterans. A case study is provided along with sample materials used in this intervention. In addition, we share implementation tips based on our experiences and feedback from eight veterans who have completed the intervention to date. Overall, the intervention was generally well received and suggests that the intervention may be feasibly delivered in a primary care setting.     

Psychometric Properties and the Predictive Validity of the Insomnia Daytime Worry Scale: A Pilot Study

The relationship between presleep worry and insomnia has been investigated in previous studies, but less attention has been given to the role of daytime worry and symptoms of insomnia. The aims of the current study were (a) to assess the psychometric properties of a novel scale measuring insomnia-specific worry during daytime and (b) to examine whether levels of daytime worry predict severity of insomnia symptoms. Participants (N = 353) completed the Insomnia Daytime Worry Scale (IDWS) and the Insomnia Severity Index. An explorative principal-axis factor analysis extracted two factors from the IDWS, accounting for 70.5% of the variance. The IDWS demonstrated good reliability. The total score of IDWS and both factors predicted levels of insomnia severity in two separate hierarchical regression analyses. This preliminary evidence suggests that the IDWS is a valid and reliable scale to measure daytime worry in insomnia.     

Measuring depression at the end of life: is the Hamilton Depression Rating Scale a valid instrument?

Depression at the end of life is a common mental health issue with serious implications for quality of life and decision making. This study investigated the reliability and validity of one of the most frequently used measures of depression, the Hamilton Depression Rating Scale (HAM-D) in 422 patients with terminal cancer admitted to a palliative care hospital. The HAM-D demonstrated high reliability and concurrent validity with depression diagnosis, based on Structured Clinical Interview for DSM-IV Axis I Disorders, non-patient research version (SCID-I/NP Depression Module). Receiver Operating Characteristic (ROC) analyses generated an area under the curve of .91, indicating high sensitivity and specificity. The HAM-D strongly correlated with several measures of distress (e.g., hopelessness, desire for hastened death, and suicidal ideation). Factor analysis generated 4 factors (anxiety, depressed mood, insomnia, and somatic symptoms), accounting for 42% of the variance. Implications for assessing depression in this population are discussed.     

Attempts to control unwanted thoughts in the night: development of the thought control questionnaire-insomnia revised (TCQI-R)

The attempted control of intrusive, uncontrollable thoughts has been implicated in the maintenance of a range of psychological disorders. The current paper describes the refinement of the Thought Control Questionnaire Insomnia (TCQI; Behav. Cogn. Psychoth. 29 (2001)) through its administration to a sample (n=385) including good sleepers and individuals with insomnia. Several items with poor psychometric properties were discarded, resulting in a 35-item revised TCQI. Factor analysis revealed six factors; aggressive suppression, cognitive distraction, reappraisal, social avoidance, behavioural distraction, and worry. The attempted management of unwanted thoughts was compared across individuals with insomnia and good sleepers, and the impact of these strategies on sleep quality, anxiety and depression was investigated. With the exception of cognitive distraction, individuals with insomnia, relative to good sleepers, more frequently used every thought control strategy. The strategies of aggressive suppression and worry, in particular, appeared to be unhelpful, with the use of these strategies predicting sleep impairment, anxiety and depression. The strategy of cognitive distraction appeared to be helpful, with the use of this strategy predicting better sleep quality.     

Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM): Scale Development,Reliability, and Validity

Empathy has been shown to affect the quality of care by enhancing the physician–patient relationship and promoting effective communication. In this study, the newly developed Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM), designed to assess empathy and confrontation in physician–patient interactions, were subjected to preliminary psychometric testing. Particular attention was paid to face validity, reliability, sensitivity, and practicality. A total of 118 volunteers were asked to assess transcribed interactions between physicians and a standardized patient using the REM. In order to assess the convergent validity of the REM, the Motivational Interviewing Treatment Integrity Code (MITI) and the Behavior Change Counseling Index (BECCI) were used. Factor analysis identified two subscales, reflecting empathy and confrontation. Interrater reliability coefficients for items ranged from r = .82 to .97; Cronbach’s alphas for the two subscales were .89 and .88, respectively. The convergent validity was supported by substantial correlations between the REM scores and the MITI scores and by significant correlations between the REM scores and the BECCI score. The REM demonstrated good psychometric properties suggesting the rating scales might be useful in clinical practice, research endeavors, and medical education. Further research is necessary to assess the test-retest reliability as well as the predictive validity of this instrument.     

Distinguishing rumination from worry in clinical insomnia

Research has found that repetitive thought processes, such as worry and rumination, play an important role in several disorders; however, these cognitive processes have not yet been examined in insomnia. This study explores rumination and worry in insomnia by examining: 1) whether those high and low on rumination and worry differ on subjective sleep measures, and 2) whether rumination and worry are distinct processes in insomnia. Participants (N = 242) were diagnosed with an insomnia disorder by sleep experts. Participants completed measures of worry and rumination and maintained a 2-week daily sleep log. Results of a multivariate analysis of variance found no main effect of worry; although high and low ruminators differed on several sleep log indices, including sleep efficiency, wakefulness after sleep onset and sleep quality. Factor analysis supported the idea that rumination and worry are separate constructs. Whereas previous research has focused on worry in insomnia, these findings suggest that rumination is important for understanding sleep disturbance. Further, although rumination and worry are both repetitive thought processes, these results indicate that they are distinct processes within insomnia and should be treated as such. The results are discussed with respect to treatment implications for Cognitive Behavioural Therapy for Insomnia.     

Cognitive-Behavioral Therapy for Insomnia Co-Morbid with Hearing Impairment: A Randomized Controlled Trial

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.     

Brief Behavioral Treatment for Insomnia vs. Cognitive Behavioral Therapy for Insomnia: Results of a Randomized Noninferiority Clinical Trial Among Veterans

The goal of this study was to compare a brief behavioral treatment for insomnia (BBTI), which has fewer sessions (4), shorter duration (< 30–45 minutes), and delivers treatment in-person plus phone calls to cognitive behavioral therapy for insomnia (CBTI), which has 5 in-person sessions. The hypothesis was BBTI would be noninferior to CBTI. The Reliable Change Index was used to establish a noninferiority margin (NIM) of 3.43, representing the maximum allowable difference between groups on the pre-post Insomnia Severity Index change (ΔISI). Sixty-three veterans with chronic insomnia were randomized to either BBTI or CBTI and veterans in both groups had significant reductions of their insomnia severity per the ISI and improved their sleep onset latency, total wake time, sleep efficiency, and sleep quality per sleep diaries. While CBTI had a larger pre-post ΔISI, this was not significantly different than ΔISI BBTI and was less than the NIM. However, the 95% confidence interval of the between group pre-post ΔISI extended beyond the NIM, and thus BBTI was inconclusively noninferior to CBTI. Limitations, such as small sample size and high rate of dropout, indicate further study is needed to compare brief, alternative yet complementary behavioral insomnia interventions to CBTI. Still, evidence-based brief and flexible treatment options will help to further enhance access to care for veterans with chronic insomnia, especially in non-mental-health settings like primary care.     

Association Between Insomnia and Quality of Life: An Exploratory Study Among Software Engineers

Insomnia is a major public health challenge. Due to its high prevalence and impact on health in recent years it has attracted attention of health care providers. The concept of quality of life (QOL) has gained importance as an outcome measure in sleep disturbed people. This study aims to determine the prevalence of insomnia among software engineers as the job related stress is considered very high. Ninety-one software engineers aged between 21 and 45 from a software developing company in Mysore formed the study population. Insomnia Screening Questionnaire and SF 36 Health Survey Questionnaire were used to elicit information about sleep quality and quality of life respectively. Sleep status among the subjects was as follows: 20.9% severe insomnia, 35.2% mild insomnia and 43.9% normal sleeper. Mean scores for SF 36 and those for physical and mental health were considerably lower among severe insomniacs. Software engineers run at the risk of developing insomnia, those with severe insomnia had poor QOL in comparison with the others. Quality of sleep among software engineers needs special attention since they are prone to develop sleep disturbances.     

Psychometric properties of the Insomnia Catastrophizing Scale (ICS) in a large community sample

ABSTRACT

The purpose was to investigate the psychometric properties of the Insomnia Catastrophizing Scale (ICS) including factorial validity and internal consistency as well as discriminative and convergent validity. Associations with sleep parameters and daytime impairment are also examined. Drawn from a randomly selected sample of the general population, 1615 participants completed a survey on insomnia-related nighttime and daytime symptoms, health outcomes and psychological processes, including the ICS. A one-factor solution was supported for both the nighttime catastrophizing (11 items) and daytime catastrophizing (6 items) subscales. Both subscales displayed high internal consistencies (α > 0.90) and accounted for 59.1–70.1% of the variance. The insomnia disorder group had significantly higher scores than participants without insomnia on the two subscales and on the individual items. Cutoffs were established for both subscales with acceptable sensitivity and specificity. Both subscales displayed adequate convergent validity with measures indexing worry, cognitive pre-sleep arousal and anxiety. The two subscales were also significantly associated with nighttime and daytime insomnia symptoms. The ICS is a reliable and valid scale for the assessment of insomnia-related catastrophizing. Future research is needed to examine the test-retest reliability and treatment sensitivity of the ICS.     

A multigroup confirmatory factor analysis of the Patient Health Questionnaire-9 among English- and Spanish-speaking Latinas

Depression is a significant problem for ethnic minorities that remains understudied partly due to a lack of strong measures with established psychometric properties. One screening tool, the Patient Health Questionnaire-9 (PHQ-9), which was developed for use in primary care has also gained popularity in research settings. The reliability and validity of the PHQ-9 has been well established among predominantly Caucasian samples, in addition to many minority groups. However, there is little evidence regarding its utility among Hispanic Americans, a large and growing cultural group in the United States. In this study, we investigated the reliability and structural validity of the PHQ-9 in Hispanic American women. A community sample of 479 Latina women from southern California completed the PHQ-9 in their preferred language of English or Spanish. Cronbach's alphas suggested that there was good internal consistency for both the English- and Spanish-language versions. Structural validity was investigated using multigroup confirmatory factor analysis. Results support a similar one-factor structure with equivalent response patterns and variances among English- and Spanish-speaking Latinas. These results suggest that the PHQ-9 can be used with confidence in both English and Spanish versions to screen Latinas for depression.     

Insomnia: Neurophysiological and NeuropsychologicalApproaches

Insomnia is a symptom, a syndrome and a comorbid disorder. Its diagnosis relies on subjective reports from the afflicted individual and is defined as difficulties in initiating sleep, maintaining sleep, waking up too early or non-restorative sleep. However, insomnia and especially, primary insomnia, has received much attention in insomnia research with the use of objective measures. Insomnia, its peculiarities, most frequent subtypes and two most prominent models will first be briefly introduced. Then, insomnia will be reviewed according to results obtained with the use of neurophysiological measures as basic/traditional as polysomnography to more sophisticated ones such as power spectral analysis, neuroimaging, cyclic alternating patterns and event-related potentials. In addition, a review of the discrepancies between subjective and objective reports of cognitive alterations through neuropsychological testing is offered. The need to combine measures is then highlighted in conclusion.     

个体相对剥夺感问卷在大学生群体的信效度检验

翻译与修订个体相对剥夺感问卷(Personal Relative Deprivation Scale,PRDS),并在大学生群体中进行了信效度检验。探索性因子分析结果显示,原问卷中两个反向计分的项目在主因子载荷很低,删除这两个项目后的PRDS-3各项目鉴别力良好; 探索性因子分析和验证性因子分析均显示PRDS-3符合单维度结构; PRDS-3重测信度为0.89,在不同样本间的内部一致性系数为0.77-0.81; PRDS-3得分与相对剥夺感、经济相对剥夺感、焦虑、压力、抑郁、攻击性等效标具有中高程度的相关关系(r>0.4,p<0.01)。PRDS-3得分与社会比较倾向的能力维度显著相关(r=0.46,p<0.01),且能部分地中介能力社会比较倾向对物质主义和生活满意度的影响。综上,可以认为,中文版PRDS-3信效度指标良好,符合测量学要求,可作为相对剥夺感的评估工具。     

Practical Guidance for Targeting Insomnia in Primary Care Settings

Insomnia is among the most prevalent conditions in primary care. Despite the development of well-established, evidence-based cognitive and behavioral interventions for insomnia, they are not typically applied in primary care environments. One method for improving primary care delivery of these interventions is to integrate behavioral health providers as a service delivery team member in this environment. The population health focus and time-limited appointments of primary care require that these well-established interventions are adapted for effective implementation in primary care. Using a case example, we describe practical methods of delivering these interventions in the primary care setting.     

Phenotypes of sleeplessness: stressing the need for psychodiagnostics in the assessment of insomnia

Insomnia is a too general term for various subtypes that might have different etiologies and therefore require different types of treatment. In this explorative study we used cluster analysis to distinguish different phenotypes in 218 patients with insomnia, taking into account several factors including sleep variables and characteristics related to personality and psychiatric comorbidity. Three clusters emerged from the analysis. The ‘moderate insomnia with low psychopathology’-cluster was characterized by relatively normal personality traits, as well as normal levels of anxiety and depressive symptoms in the presence of moderate insomnia severity. The ‘severe insomnia with moderate psychopathology’-cluster showed relatively high scores on the Insomnia Severity Index and scores on the sleep log that were indicative for severe insomnia. Anxiety and depressive symptoms were slightly above the cut-off and they were characterized by below average self-sufficiency and less goal-directed behavior. The ‘early onset insomnia with high psychopathology’-cluster showed a much younger age and earlier insomnia onset than the other two groups. Anxiety and depressive symptoms were well above the cut-off score and the group consisted of a higher percentage of subjects with comorbid psychiatric disorders. This cluster showed a ‘typical psychiatric’ personality profile. Our findings stress the need for psychodiagnostic procedures next to a sleep-related diagnostic approach, especially in the younger insomnia patients. Specific treatment suggestions are given based on the three phenotypes.     

A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility,Acceptability, and Potential Efficacy

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28–55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = −0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = −1.1, p = .001), sleep onset latency (d = −0.6, p = .021), global sleep quality (d = −0.9, p = .002), and depression symptoms (d = −0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.     

Cross-ethnic Applicability of the Gender-based Attitudes Toward Marriage and Child Rearing Scales

The reliability and validity of Hoffman and Kloska’s (1995) Gender-based Attitudes toward Marital Roles (GATMR) and Gender-based Attitudes toward Child Rearing (GATCR) were assessed for a sample of Mexican American mothers and fathers (n = 167) of fifth-grade children in a large metropolitan area in the southwestern United States. Factor analysis was conducted, and the results suggest that the 6-item GATMR is conceptually distinct and reliable for this ethnic group. Correlation of GATMR scores for mothers and fathers with divisions of family labor suggest good validity. A 5-item revised GATCR demonstrated modest reliability and good construct validity. The value of these scales for work with Mexican American families is noted. Theoretical implications for gender socialization are explored, and suggestions for further research are offered. This research was supported by Grant # MH 54154-01A2 from the National Institute of Mental Health.     

幼儿教师工作投入问卷的编制

本研究旨在编制适合我国幼儿教师职业特点的工作投入问卷。在文献综述的基础上,根据访谈(N=24)和开放式问卷调查(N=72),编制了问卷的项目;根据探索性因素分析(N=516),抽取了四个因素,即工作愉悦、工作价值、工作责任和工作专注;根据验证性因素分析及信效度检验(N=720),考察了问卷的主要心理测量学指标,均符合要求。幼儿教师工作投入问卷共有21个项目,结构和信效度良好,可以作为幼儿教师工作投入的测评工具。     

中小学教师工作重塑问卷的编制

在文献分析和专家评定的基础上,从重塑的对象与方式出发,通过半结构化访谈和问卷调查,编制了初始的中小学教师工作重塑问卷。通过探索性因素分析和验证性因素分析对初始问卷进行修订,最终形成的正式问卷包含五个维度：任务重塑、角色重塑、关系重塑、技能重塑和认知重塑。结果表明,中小学教师工作重塑问卷具有较高的内部一致性信度、重测信度以及较好的内容效度、结构效度和效标效度。该问卷的心理测量学指标良好,可以作为我国中小学教师工作重塑的测量工具。     

Treating Primary Insomnia: Clinical Effectiveness and Predictors of Outcomes on Sleep,Daytime Function and Health-Related Quality of Life

Primary insomnia, as defined by DSM-IV-TR, refers to a persistent sleep disturbance which is not connected to a current psychiatric or physical condition, but significantly impairs social and occupational functioning. This study explored the impact of Cognitive Behavioral Therapy for Insomnia (CBT-i) on sleep, daytime functioning and health-related quality of life (HRQoL). Next, we investigated which factors predicted positive treatment outcome by examining demographics, insomnia characteristics, baseline levels of daytime function, HRQoL, sleep-disruptive beliefs and psychological health on post-treatment sleep quality, daytime function and HRQoL. 138 consecutive primary insomnia patients completed questionnaires pre- and post-treatment and at 6 months follow-up. After CBT-i, robust clinical improvements were observed in sleep, daytime function and HRQoL, regardless of age, gender, type or duration of the complaint. Patients with pre-treatment severe insomnia, pronounced daytime impairment and low psychological well-being benefited most.