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COMPARATIVE EFFICACY OF BEHAVIOR THERAPY AND COGNITIVE THERAPY AS SINGLE THERAPIES FOR INSOMNIA: A PRELIMINARY REPORT
Abstracts of 4th International Congress of WASM & 5th Conference of CSS / Sleep Medicine 12, Suppl. 1 (2011) S1–S130
intervention, which is cheap and easily available for patients suffering from insomnia. Sleep hygiene advice also improved sleep at follow-up, but increased sleep medication use. Thus, caution is warranted when sleep hygiene advice is given as a single treatment.
TEEN SLEEP, MEDIA EXPOSURES, AND PHYSICAL ACTIVITY: RESULTS FROM THE 2007 AND 2009 YOUTH RISK BEHAVIOR SURVEYS Caris Fitzgerald 1 , Erick Messias 1 , Daniel Buysse 2 . 1 University of Arkansas for Medical Sciences, United States; 2 University of Pittsburgh Sleep Medicine Institute, United States Introduction and Objectives: To quantify the association between different media exposures, vigorous physical activity, and self-reported sleep time in teens. Materials and Methods: All Youth Risk Behavioral Surveys (YRBS) with sleep data were analyzed to produce a nationally representative sample of US high-school students (2007 N=14,041, 2009 N=16,410). Media exposure was evaluated with two questions on average school day use: “How many hours of TV do you watch?” and “How many hours do you play video or computer games or use a computer for something that is not school work?” Media exposure was dichotomized into light (1hr or less/day) or heavy (3hrs or more/day). Physical activity was assessed with the question “On how many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard?” categorized as light (less then 3 days/week) or heavy (3 days or more/week). The outcome variable of self-reported sleep duration was assessed with the question: “On an average school night, how many hours of sleep do you get?” Logistic regression models were used to adjust for age, gender, race/ethnicity, presence of sadness, and substance abuse. Results: Compared to teens who reported sleeping 8 hrs/night, those reporting 4 or less hrs/night of sleep were more likely to report heavy videogame/computer use (2007 adjusted odd ratio 2.3 (95% C.I. 1.7-3.0), 2009 2.0 (95% C.I. 1.5-2.6)) while being less likely to meet recommended physical activity levels (2007 0.7 (95% C.I. 0.6-0.9), 2009 0.5 (95% C.I. 0.40.6)). TV exposure did not display significant associations with self-reported sleep in these samples. Conclusion: In these large samples of US teens, self-reported short sleep duration was associated with higher gaming/computer use, lower vigorous physical activity, and was unrelated to television watching. Acknowledgements: Center for Disease Control
DEPRESSIVE SYMPTOMATOLOGY, MEDICATION PERSISTENCE, AND ASSOCIATED HEALTH CARE COSTS IN OLDER ADULTS WITH INSOMNIA Duru Golden Uzoma. Mon Oil and Gas Medical Clinic, Nigeria Introduction and Objectives: The effect of insomnia along with the decreased cognitive functioning associated with aging is a serious concern within the elderly (65 years and older) population. We examined the association of patient health care utilization and depressive symtomatology with medication adherence in insomnia in Medicare-HMO enrolled elderly patients. Materials and Methods: This was a retrospective, longitudinal cohort study which included elderly patients (65 and older) enrolled continuously for 1-5 years in the Medicare HMO. Medication possession ratio was used to estimate the adherence in insomnia medication. Different MPR thresholds (0.8, 0.6, 0.4 and 0.2) were used to determine non adherence. Associations between depressive symptoms, medication adherence and health care costs were assessed using ordinary least square multiple regressions. Results: A total of 2068 patients with a primary diagnosis of insomnia were included in the study. Sixty percent of these patients had depressive symptomatology. The severity of comorbidity (Charlson index) was 4 and the patient perception of quality of life (Short Form-12 scores) were between 79 and 82. The prevalence of non adherence was 70% even with a low MPR of 0.2. Insomnia patients with depressive symptoms were 92% less likely to be adherent to their insomnia medications (p<0.05). After controlling other variables, we found MPR was a good predictor of total health care costs (10% increases in MPR for every 2% decrease in total health care costs, p<0.001) Conclusion: We found strong associations between depressive symtomatology, medication adherence, and health care costs in elderly patients with
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insomnia. Disease and risk management programs in managed care settings should be used to optimize the medication adherence in the elderly. Acknowledgements: Elisha Stephen
MONTHLY FLUCTUATIONS OF SLEEP AND INSOMNIA SYMPTOMS OVER THE COURSE OF A YEAR IN A POPULATION-BASED SAMPLE Mélanie LeBlanc, Charles Morin, Lynda Bélanger, Hans Ivers, Marie-Andrée Côté. Université Laval, Canada Introduction and Objectives: The longitudinal course of insomnia is not well documented. Most studies examining temporal fluctuations of symptoms have used yearly assessment intervals. The objective of this study was to document the course of insomnia symptoms and sleep quality by examining their fluctuations over shorter (i.e., monthly) intervals for one year. Materials and Methods: Participants were 100 adults (mean age = 49.9 years; 66% women) selected from a larger sample enrolled in a longitudinal study of insomnia. They completed 12 monthly telephone interviews assessing sleep and insomnia symptoms, use of sleep aids, stressful life events, and physical and mental health problems for the previous month. Of a potential 1200 interviews, 1121 (94.3%) were completed. Participants were classified in one of three groups based on data collected at each assessment: good sleepers (GS; n= 42 at baseline), insomnia symptoms (SYMP; n= 34 at baseline), and insomnia syndrome (SYND; n= 24 at baseline). Results: There were significant fluctuations of sleep/insomnia symptoms over time, with 66% of the participants changing status at least once over the 12 assessments (GS, 50%, SYND, 58.3%, and SYMP, 91.2%). On average, the sleep status of an individual changed 2.58 times over the 12 monthly assessments. Individuals with SYMP changed status significantly more frequently (3.41) than GS (1.93), but not more than SYND (2.54). Moreover, 83% of individuals with SYMP at baseline reported improved sleep (i.e., became GS) at least once over the year, compared to 29.4% who reported sleep worsening (i.e., became SYND). Among GS, risks of developing insomnia symptoms and syndrome over the subsequent months were respectively 14.4% and 3.2%. Conclusion: Repeated assessment of sleep and insomnia symptoms showed significant variability over monthly intervals. These findings highlight the importance of conducting assessment at shorter than the usual yearly interval in order to capture more reliably the course of insomnia over time. Acknowledgements: Research supported by Canadian Institutes of Health Research grant (#42504)
COMPARATIVE EFFICACY OF BEHAVIOR THERAPY AND COGNITIVE THERAPY AS SINGLE THERAPIES FOR INSOMNIA: A PRELIMINARY REPORT Charles M. Morin 1 , Allison Harvey 2 , Lynda Bélanger 1 , Simon Beaulieu-Bonneau 1 , Émilie Fortier-Brochu 1 , Polina Eidelman 2 , Lisa Talbot 2 . 1 Université Laval, Canada; 2 University of California, United States Introduction and Objectives: Considerable evidence speaks for the efficacy of cognitive-behavior therapy (CBT) for insomnia. Yet, the unique contribution of its components remains poorly understood. This presentation summarizes preliminary results from a randomized controlled trial assessing the relative efficacy and contribution of cognitive therapy (CT) and behavior therapy (BT), compared to full CBT, for improving nighttime sleep and daytime functioning. Materials and Methods: 186 adults with chronic insomnia were recruited. This report comprises the first 100 participants (63% women; age = 38.8 years, insomnia duration = 12.8 years). They were randomly assigned to one of three 8-week treatment conditions: BT (n=32), CT (n=33), or CBT (n=35). Main end points were insomnia severity, measured by the Insomnia Severity Index (ISI), completed at baseline, mid, and end of treatment, and remission defined as an ISI score below 8. Results: Between-group differences were assessed using mixed model analyses. A significant interaction effect was observed for insomnia severity. Simple effects for treatment conditions were significant only at posttreatment (p=0.003). Pairwise comparisons revealed significant differences between CBT (M=6.58) and the other conditions (M=9.46 for each), p=0.0007, but there was no significant difference between BT and CT. Remission rates were also significantly different at post-treatment, F(2,79) = 4.34, p=0.02; there was a higher remission rate in CBT (72.4%) relative to CT (33.3%) and
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Abstracts of 4th International Congress of WASM & 5th Conference of CSS / Sleep Medicine 12, Suppl. 1 (2011) S1–S130
BT (49.7%), but these latter conditions did not differ significantly from each other (p=0.20). Conclusion: These results provide evidence about the efficacy of CT and BT as single therapies for chronic insomnia. Further results on their unique contribution with regard to nighttime and daytime functioning parameters are awaited. This dismantling study should improve our understanding of the mechanisms underlying the efficacy of CBT for insomnia and enhance its efficacy and efficiency. Acknowledgements: Research supported by the National Institute of Mental Health (MH79188)
EFFECTS OF COGNITIVE BEHAVIORAL THERAPY FOR STRESS-INDUCED SLEEP DISTURBANCE AND HYPERAROUSAL Shun Nakajima 1 , Isa Okajima 2 , Masaki Nakamura 2 , Akira Usui 3 , Shingo Nishida 2 , Kenichi Hayashida 4 , Yuichi Inoue 1 . 1 Development of Somnology, Tokyo Medical University, Japan; 2 Japan Somnology Center, Neuropsychiatric Institute, Japan; 3 The Faculty of Health Science Technology, Bunkyo Gakuin University, Japan; 4 Sleep and Stress Clinic, Japan Introduction and Objectives: Stress-induced hyperarousal is thought to play a role on the onset and relapse of insomnia. Although effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I) has been established, there has been no research to clearly demonstrate whether or not CBT-I is effective for stress-induced hyperarousal. This study was planned to clarify this issue. Materials and Methods: There were 63 participants with primary insomnia who visited the outpatient clinic of Japan Somnology Center. All the participants were assigned to (1) a six-sessions of CBT-I simultaneous with pharmaceutical treatment (CBT-I group; n= 34, 70% female, mean age: 49.4±14.7 years) or (2) treatment as usual (TAU; n=29, 62% female, mean age: 43.2±16.1 years) by sleep disorder physicians in an open-label manner. Both groups completed questionnaires assessing the stress-induced sleep disturbance and hyperarousal (Ford Insomnia Response to Stress Test: FIRST) and the insomnia symptom (Pittsburgh Sleep Quality Index: PSQI; Athens Insomnia Scale: AIS) both at the baseline and at the end of the treatment. Results: There were significant group x time interaction on all scales by using a repeated-measures ANOVA (FIRST: F(1,55) = 4.95, p<0.05, PSQI: F(1,58) = 22.91, p<0.001, AIS: F(1,60) = 13.16, p<0.001, respectively). The scores of the FIRST decreased at the end of the treatment in both groups and between groups at the end of the treatment. Significant decrease in the score of the FIRST was observed only in CBT-I group. The rates of change after the treatment of CBT-I were larger than that of TAU (FIRST: d = 0.59, PSQI: d=1.23, AIS: d=0.92). Conclusion: These results showed that CBT-I improves not only insomnia symptoms but also stress-induced hyperarousal. Intervention targeting maladaptive coping with insomnia is likely to reduce the stress-induced hyperarousal (Mendoza et al., 2010), possibly leading to preventing the relapse of insomnia.
THE NATURE AND PREVALENCE OF MIDDLE-OF-THE-NIGHT USE OF PRESCRIPTION HYPNOTICS Thomas Roth 1 , Patricia Berglund 2 , Victoria Shahly 3 , Alicia C. Shillington 4 , Judith J. Stephenson 5 , Denise Cooke 6 , Nikhilesh Singh 6 , Ronald Kessler 3 . 1 Henry Ford Hospital, United States; 2 Institute for Social Research, University of Michigan, United States; 3 Department of Health Care Policy, Harvard Medical School, United States; 4 Epi-Q, Inc., United States; 5 HealthCore, Inc., United States; 6 Transcept Pharmaceuticals, Inc., United States Introduction and Objectives: Middle-of-the-night (MOTN) awakening with difficulty returning to sleep is common and associated with significant adverse consequences. Given that there are no FDA-approved hypnotics with an indication for MOTN use and no data on safety and efficacy of medications when used in the MOTN, a study was undertaken to assess the prevalence and nature of off-label MOTN hypnotic use. Materials and Methods: 1,927 subjects, ages 18-64yrs, who received a hypnotic prescription in the past year, were randomly sampled from 120,000 eligible members of a large commercial health plan (>34 million lives). Respondents with a history of MOTN hypnotic use who reported never using a hypnotic twice in the same night (n=209), plus a weighted sample
of at-bedtime only users (n=303), were studied further with additional questions. Results: 20.1% of the 1,927 subjects reported using hypnotics indicated for use during MOTN awakening at least some of the time – 11.5% never used hypnotics twice in the same night and 9.0% did – and 79.5% used them at bedtime only. Of those studied further, 43.0% of MOTN and 28.0% of bedtime users reported MOTN awakening as their biggest sleep problem. Of those reporting MOTN insomnia as their biggest sleep problem, 51.5% reported MOTN use. 81.7% used hypnotics MOTN on their own initiative, 12.1% under doctors’ direction, and 5.2% were not sure. 69.5% of MOTN users had a MOTN dosing rule to determine when during the night to take the medication: average MOTN use time was 6 hours before having to arise. Hypnotics taken MOTN and at-bedtime were essentially the same with the three most commonly used drugs being zolpidem, eszopiclone and temazepam. Conclusion: Despite the absence of any clinical information supporting MOTN use, a number of non-geriatric patients with a prescription hypnotic use it off-label in the middle of the night. Acknowledgements: Funded by Transcept Pharmaceuticals, Inc., Pt. Richmond, CA.
ENHANCED USE-DEPENDENT PLASTICITY IN PRIMARY INSOMNIA Rachel Marie E. Salas, Joseph Galea, Gabriela Cantarero, Richard Allen, Charlene Gamaldo, Michael Smith, Barbara Lam, Pablo Celnik. Johns Hopkins, United States Introduction and Objectives: Healthy sleep provides favorable conditions for neuroplasticity and memory consolidation. Primary Insomnia patients (PIP) report cognitive and memory impairment. Investigations, focused on neuropsychological and behavioral measures, showed inconsistent deficits in memory and learning. It is unknown if PIP are able to exhibit use dependent plasticity (UDP) changes resulting from motor training, one of the initial steps in the formation of motor memories and motor skill development. Here, we tested the ability of PIP to sustain UDP using a TMS paradigm. Furthermore, because an imbalance of excitatory and inhibitory influences are likely in PI, we also studied GABA and glutamate. Additionally, we evaluated sleep spindles on polysomnography. Materials and Methods: PIP (n=18; 57.8±1.5;12F) and Good Sleepers (GS) (n=10; 60.4±3.4;7F), underwent training consisting of thumb movements at 1 Hz for 30min. TMS was applied over M1 to elicit consistent thumbmovements before and after training. A training target zone (TTZ) was defined as a window of ±20° centered on the mean direction of training movements. The percentage of TMS-evoked thumb movements falling within the TTZ was calculated for baseline, p1, and p2. In addition, glutamate (ICF) and GABA (SICI and LICI) were assessed. An algorithm detected fast and slow spindles and quantified their characteristics. Results: PIP showed increased UDP relative to GS as reflected by increased movements falling within the TTZ during p1 (p=0.02). There were no differences in SICI or LICI between groups. However, PIP demonstrated increased ICF compared to GS. PIP also demonstrated increased fast spindle densities. Conclusion: The main finding of this study is that PIP experienced an enhanced ability to sustain UDP resulting from motor training which was associated with increased intracortical facilitation in PIP. Results suggest that PIP may have an enhanced capacity to undergo UDP changes possibly due to increased glutamatergic mechanisms. PIP also demonstrated increased fast spindles, potentially related to UDP. Acknowledgements: Supplement to Novel Strategies to Enhance Motor Function After Stroke (RO1 HD053793-SA1)
THE ROLE OF ANDROGEN-DEPRIVATION THERAPY AND HOT FLASHES IN THE EVOLUTION OF INSOMNIA IN PATIENTS WITH PROSTATE CANCER Josée Savard, Séverine Hervouet, Hans Ivers. Université Laval, Canada Introduction and Objectives: Androgen-deprivation therapy leads to nocturnal hot flashes and nocturia which may both disturb sleep. As part of a larger longitudinal study, this investigation aimed to: (1) compare the evolution of rates of insomnia in patients receiving ADT + radiotherapy (ADT-RTH) to patients receiving RTH only; and (2) assess the mediating role of hot flashes and urinary symptoms in the relationship between ADT and insomnia. Materials and Methods: Sixty men scheduled to receive RTH for prostate
intervention, which is cheap and easily available for patients suffering from insomnia. Sleep hygiene advice also improved sleep at follow-up, but increased sleep medication use. Thus, caution is warranted when sleep hygiene advice is given as a single treatment.
TEEN SLEEP, MEDIA EXPOSURES, AND PHYSICAL ACTIVITY: RESULTS FROM THE 2007 AND 2009 YOUTH RISK BEHAVIOR SURVEYS Caris Fitzgerald 1 , Erick Messias 1 , Daniel Buysse 2 . 1 University of Arkansas for Medical Sciences, United States; 2 University of Pittsburgh Sleep Medicine Institute, United States Introduction and Objectives: To quantify the association between different media exposures, vigorous physical activity, and self-reported sleep time in teens. Materials and Methods: All Youth Risk Behavioral Surveys (YRBS) with sleep data were analyzed to produce a nationally representative sample of US high-school students (2007 N=14,041, 2009 N=16,410). Media exposure was evaluated with two questions on average school day use: “How many hours of TV do you watch?” and “How many hours do you play video or computer games or use a computer for something that is not school work?” Media exposure was dichotomized into light (1hr or less/day) or heavy (3hrs or more/day). Physical activity was assessed with the question “On how many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard?” categorized as light (less then 3 days/week) or heavy (3 days or more/week). The outcome variable of self-reported sleep duration was assessed with the question: “On an average school night, how many hours of sleep do you get?” Logistic regression models were used to adjust for age, gender, race/ethnicity, presence of sadness, and substance abuse. Results: Compared to teens who reported sleeping 8 hrs/night, those reporting 4 or less hrs/night of sleep were more likely to report heavy videogame/computer use (2007 adjusted odd ratio 2.3 (95% C.I. 1.7-3.0), 2009 2.0 (95% C.I. 1.5-2.6)) while being less likely to meet recommended physical activity levels (2007 0.7 (95% C.I. 0.6-0.9), 2009 0.5 (95% C.I. 0.40.6)). TV exposure did not display significant associations with self-reported sleep in these samples. Conclusion: In these large samples of US teens, self-reported short sleep duration was associated with higher gaming/computer use, lower vigorous physical activity, and was unrelated to television watching. Acknowledgements: Center for Disease Control
DEPRESSIVE SYMPTOMATOLOGY, MEDICATION PERSISTENCE, AND ASSOCIATED HEALTH CARE COSTS IN OLDER ADULTS WITH INSOMNIA Duru Golden Uzoma. Mon Oil and Gas Medical Clinic, Nigeria Introduction and Objectives: The effect of insomnia along with the decreased cognitive functioning associated with aging is a serious concern within the elderly (65 years and older) population. We examined the association of patient health care utilization and depressive symtomatology with medication adherence in insomnia in Medicare-HMO enrolled elderly patients. Materials and Methods: This was a retrospective, longitudinal cohort study which included elderly patients (65 and older) enrolled continuously for 1-5 years in the Medicare HMO. Medication possession ratio was used to estimate the adherence in insomnia medication. Different MPR thresholds (0.8, 0.6, 0.4 and 0.2) were used to determine non adherence. Associations between depressive symptoms, medication adherence and health care costs were assessed using ordinary least square multiple regressions. Results: A total of 2068 patients with a primary diagnosis of insomnia were included in the study. Sixty percent of these patients had depressive symptomatology. The severity of comorbidity (Charlson index) was 4 and the patient perception of quality of life (Short Form-12 scores) were between 79 and 82. The prevalence of non adherence was 70% even with a low MPR of 0.2. Insomnia patients with depressive symptoms were 92% less likely to be adherent to their insomnia medications (p<0.05). After controlling other variables, we found MPR was a good predictor of total health care costs (10% increases in MPR for every 2% decrease in total health care costs, p<0.001) Conclusion: We found strong associations between depressive symtomatology, medication adherence, and health care costs in elderly patients with
S5
insomnia. Disease and risk management programs in managed care settings should be used to optimize the medication adherence in the elderly. Acknowledgements: Elisha Stephen
MONTHLY FLUCTUATIONS OF SLEEP AND INSOMNIA SYMPTOMS OVER THE COURSE OF A YEAR IN A POPULATION-BASED SAMPLE Mélanie LeBlanc, Charles Morin, Lynda Bélanger, Hans Ivers, Marie-Andrée Côté. Université Laval, Canada Introduction and Objectives: The longitudinal course of insomnia is not well documented. Most studies examining temporal fluctuations of symptoms have used yearly assessment intervals. The objective of this study was to document the course of insomnia symptoms and sleep quality by examining their fluctuations over shorter (i.e., monthly) intervals for one year. Materials and Methods: Participants were 100 adults (mean age = 49.9 years; 66% women) selected from a larger sample enrolled in a longitudinal study of insomnia. They completed 12 monthly telephone interviews assessing sleep and insomnia symptoms, use of sleep aids, stressful life events, and physical and mental health problems for the previous month. Of a potential 1200 interviews, 1121 (94.3%) were completed. Participants were classified in one of three groups based on data collected at each assessment: good sleepers (GS; n= 42 at baseline), insomnia symptoms (SYMP; n= 34 at baseline), and insomnia syndrome (SYND; n= 24 at baseline). Results: There were significant fluctuations of sleep/insomnia symptoms over time, with 66% of the participants changing status at least once over the 12 assessments (GS, 50%, SYND, 58.3%, and SYMP, 91.2%). On average, the sleep status of an individual changed 2.58 times over the 12 monthly assessments. Individuals with SYMP changed status significantly more frequently (3.41) than GS (1.93), but not more than SYND (2.54). Moreover, 83% of individuals with SYMP at baseline reported improved sleep (i.e., became GS) at least once over the year, compared to 29.4% who reported sleep worsening (i.e., became SYND). Among GS, risks of developing insomnia symptoms and syndrome over the subsequent months were respectively 14.4% and 3.2%. Conclusion: Repeated assessment of sleep and insomnia symptoms showed significant variability over monthly intervals. These findings highlight the importance of conducting assessment at shorter than the usual yearly interval in order to capture more reliably the course of insomnia over time. Acknowledgements: Research supported by Canadian Institutes of Health Research grant (#42504)
COMPARATIVE EFFICACY OF BEHAVIOR THERAPY AND COGNITIVE THERAPY AS SINGLE THERAPIES FOR INSOMNIA: A PRELIMINARY REPORT Charles M. Morin 1 , Allison Harvey 2 , Lynda Bélanger 1 , Simon Beaulieu-Bonneau 1 , Émilie Fortier-Brochu 1 , Polina Eidelman 2 , Lisa Talbot 2 . 1 Université Laval, Canada; 2 University of California, United States Introduction and Objectives: Considerable evidence speaks for the efficacy of cognitive-behavior therapy (CBT) for insomnia. Yet, the unique contribution of its components remains poorly understood. This presentation summarizes preliminary results from a randomized controlled trial assessing the relative efficacy and contribution of cognitive therapy (CT) and behavior therapy (BT), compared to full CBT, for improving nighttime sleep and daytime functioning. Materials and Methods: 186 adults with chronic insomnia were recruited. This report comprises the first 100 participants (63% women; age = 38.8 years, insomnia duration = 12.8 years). They were randomly assigned to one of three 8-week treatment conditions: BT (n=32), CT (n=33), or CBT (n=35). Main end points were insomnia severity, measured by the Insomnia Severity Index (ISI), completed at baseline, mid, and end of treatment, and remission defined as an ISI score below 8. Results: Between-group differences were assessed using mixed model analyses. A significant interaction effect was observed for insomnia severity. Simple effects for treatment conditions were significant only at posttreatment (p=0.003). Pairwise comparisons revealed significant differences between CBT (M=6.58) and the other conditions (M=9.46 for each), p=0.0007, but there was no significant difference between BT and CT. Remission rates were also significantly different at post-treatment, F(2,79) = 4.34, p=0.02; there was a higher remission rate in CBT (72.4%) relative to CT (33.3%) and
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Abstracts of 4th International Congress of WASM & 5th Conference of CSS / Sleep Medicine 12, Suppl. 1 (2011) S1–S130
BT (49.7%), but these latter conditions did not differ significantly from each other (p=0.20). Conclusion: These results provide evidence about the efficacy of CT and BT as single therapies for chronic insomnia. Further results on their unique contribution with regard to nighttime and daytime functioning parameters are awaited. This dismantling study should improve our understanding of the mechanisms underlying the efficacy of CBT for insomnia and enhance its efficacy and efficiency. Acknowledgements: Research supported by the National Institute of Mental Health (MH79188)
EFFECTS OF COGNITIVE BEHAVIORAL THERAPY FOR STRESS-INDUCED SLEEP DISTURBANCE AND HYPERAROUSAL Shun Nakajima 1 , Isa Okajima 2 , Masaki Nakamura 2 , Akira Usui 3 , Shingo Nishida 2 , Kenichi Hayashida 4 , Yuichi Inoue 1 . 1 Development of Somnology, Tokyo Medical University, Japan; 2 Japan Somnology Center, Neuropsychiatric Institute, Japan; 3 The Faculty of Health Science Technology, Bunkyo Gakuin University, Japan; 4 Sleep and Stress Clinic, Japan Introduction and Objectives: Stress-induced hyperarousal is thought to play a role on the onset and relapse of insomnia. Although effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I) has been established, there has been no research to clearly demonstrate whether or not CBT-I is effective for stress-induced hyperarousal. This study was planned to clarify this issue. Materials and Methods: There were 63 participants with primary insomnia who visited the outpatient clinic of Japan Somnology Center. All the participants were assigned to (1) a six-sessions of CBT-I simultaneous with pharmaceutical treatment (CBT-I group; n= 34, 70% female, mean age: 49.4±14.7 years) or (2) treatment as usual (TAU; n=29, 62% female, mean age: 43.2±16.1 years) by sleep disorder physicians in an open-label manner. Both groups completed questionnaires assessing the stress-induced sleep disturbance and hyperarousal (Ford Insomnia Response to Stress Test: FIRST) and the insomnia symptom (Pittsburgh Sleep Quality Index: PSQI; Athens Insomnia Scale: AIS) both at the baseline and at the end of the treatment. Results: There were significant group x time interaction on all scales by using a repeated-measures ANOVA (FIRST: F(1,55) = 4.95, p<0.05, PSQI: F(1,58) = 22.91, p<0.001, AIS: F(1,60) = 13.16, p<0.001, respectively). The scores of the FIRST decreased at the end of the treatment in both groups and between groups at the end of the treatment. Significant decrease in the score of the FIRST was observed only in CBT-I group. The rates of change after the treatment of CBT-I were larger than that of TAU (FIRST: d = 0.59, PSQI: d=1.23, AIS: d=0.92). Conclusion: These results showed that CBT-I improves not only insomnia symptoms but also stress-induced hyperarousal. Intervention targeting maladaptive coping with insomnia is likely to reduce the stress-induced hyperarousal (Mendoza et al., 2010), possibly leading to preventing the relapse of insomnia.
THE NATURE AND PREVALENCE OF MIDDLE-OF-THE-NIGHT USE OF PRESCRIPTION HYPNOTICS Thomas Roth 1 , Patricia Berglund 2 , Victoria Shahly 3 , Alicia C. Shillington 4 , Judith J. Stephenson 5 , Denise Cooke 6 , Nikhilesh Singh 6 , Ronald Kessler 3 . 1 Henry Ford Hospital, United States; 2 Institute for Social Research, University of Michigan, United States; 3 Department of Health Care Policy, Harvard Medical School, United States; 4 Epi-Q, Inc., United States; 5 HealthCore, Inc., United States; 6 Transcept Pharmaceuticals, Inc., United States Introduction and Objectives: Middle-of-the-night (MOTN) awakening with difficulty returning to sleep is common and associated with significant adverse consequences. Given that there are no FDA-approved hypnotics with an indication for MOTN use and no data on safety and efficacy of medications when used in the MOTN, a study was undertaken to assess the prevalence and nature of off-label MOTN hypnotic use. Materials and Methods: 1,927 subjects, ages 18-64yrs, who received a hypnotic prescription in the past year, were randomly sampled from 120,000 eligible members of a large commercial health plan (>34 million lives). Respondents with a history of MOTN hypnotic use who reported never using a hypnotic twice in the same night (n=209), plus a weighted sample
of at-bedtime only users (n=303), were studied further with additional questions. Results: 20.1% of the 1,927 subjects reported using hypnotics indicated for use during MOTN awakening at least some of the time – 11.5% never used hypnotics twice in the same night and 9.0% did – and 79.5% used them at bedtime only. Of those studied further, 43.0% of MOTN and 28.0% of bedtime users reported MOTN awakening as their biggest sleep problem. Of those reporting MOTN insomnia as their biggest sleep problem, 51.5% reported MOTN use. 81.7% used hypnotics MOTN on their own initiative, 12.1% under doctors’ direction, and 5.2% were not sure. 69.5% of MOTN users had a MOTN dosing rule to determine when during the night to take the medication: average MOTN use time was 6 hours before having to arise. Hypnotics taken MOTN and at-bedtime were essentially the same with the three most commonly used drugs being zolpidem, eszopiclone and temazepam. Conclusion: Despite the absence of any clinical information supporting MOTN use, a number of non-geriatric patients with a prescription hypnotic use it off-label in the middle of the night. Acknowledgements: Funded by Transcept Pharmaceuticals, Inc., Pt. Richmond, CA.
ENHANCED USE-DEPENDENT PLASTICITY IN PRIMARY INSOMNIA Rachel Marie E. Salas, Joseph Galea, Gabriela Cantarero, Richard Allen, Charlene Gamaldo, Michael Smith, Barbara Lam, Pablo Celnik. Johns Hopkins, United States Introduction and Objectives: Healthy sleep provides favorable conditions for neuroplasticity and memory consolidation. Primary Insomnia patients (PIP) report cognitive and memory impairment. Investigations, focused on neuropsychological and behavioral measures, showed inconsistent deficits in memory and learning. It is unknown if PIP are able to exhibit use dependent plasticity (UDP) changes resulting from motor training, one of the initial steps in the formation of motor memories and motor skill development. Here, we tested the ability of PIP to sustain UDP using a TMS paradigm. Furthermore, because an imbalance of excitatory and inhibitory influences are likely in PI, we also studied GABA and glutamate. Additionally, we evaluated sleep spindles on polysomnography. Materials and Methods: PIP (n=18; 57.8±1.5;12F) and Good Sleepers (GS) (n=10; 60.4±3.4;7F), underwent training consisting of thumb movements at 1 Hz for 30min. TMS was applied over M1 to elicit consistent thumbmovements before and after training. A training target zone (TTZ) was defined as a window of ±20° centered on the mean direction of training movements. The percentage of TMS-evoked thumb movements falling within the TTZ was calculated for baseline, p1, and p2. In addition, glutamate (ICF) and GABA (SICI and LICI) were assessed. An algorithm detected fast and slow spindles and quantified their characteristics. Results: PIP showed increased UDP relative to GS as reflected by increased movements falling within the TTZ during p1 (p=0.02). There were no differences in SICI or LICI between groups. However, PIP demonstrated increased ICF compared to GS. PIP also demonstrated increased fast spindle densities. Conclusion: The main finding of this study is that PIP experienced an enhanced ability to sustain UDP resulting from motor training which was associated with increased intracortical facilitation in PIP. Results suggest that PIP may have an enhanced capacity to undergo UDP changes possibly due to increased glutamatergic mechanisms. PIP also demonstrated increased fast spindles, potentially related to UDP. Acknowledgements: Supplement to Novel Strategies to Enhance Motor Function After Stroke (RO1 HD053793-SA1)
THE ROLE OF ANDROGEN-DEPRIVATION THERAPY AND HOT FLASHES IN THE EVOLUTION OF INSOMNIA IN PATIENTS WITH PROSTATE CANCER Josée Savard, Séverine Hervouet, Hans Ivers. Université Laval, Canada Introduction and Objectives: Androgen-deprivation therapy leads to nocturnal hot flashes and nocturia which may both disturb sleep. As part of a larger longitudinal study, this investigation aimed to: (1) compare the evolution of rates of insomnia in patients receiving ADT + radiotherapy (ADT-RTH) to patients receiving RTH only; and (2) assess the mediating role of hot flashes and urinary symptoms in the relationship between ADT and insomnia. Materials and Methods: Sixty men scheduled to receive RTH for prostate