People with insomnia frequently underestimate the duration of their sleep compared to objective polysomnography-measured sleep duration. Cognitive behavioural therapy for insomnia (CBT-I) is the most effective treatment for insomnia and also reduces the degree of sleep underestimation. Obstructive sleep apnoea (OSA) is a highly prevalent sleep disorder characterised by frequent narrowing (hypopnoea) and closure (apnoea) of the upper airway during sleep. Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating disorder. No study has investigated subjectively (sleep diary) versus objectively (polysomnography) measured sleep discrepancies (SOSD) in individuals with COMISA before or following CBT-I. This randomised waitlist-controlled trial investigated SOSD in 145 participants with COMISA before and 6-weeks after CBT-I (n = 72) versus control (n = 73). All participants were studied prior to continuous positive airway pressure treatment for sleep apnoea. At baseline, participants underestimated their total sleep time (mean ± SD −51.9 ± 94.1 min) and sleep efficiency (−9.6 ± 18.3%), and overestimated sleep onset latency (34.5 ± 86.1 min; all p = < 0.001). Mixed models indicated a main effect of time on reduction of SOSD in both groups, but no between-group difference in the reduction of any SOSD parameters. These findings may indicate that untreated OSA contributes to a discrepancy between perceived and objective sleep parameters in people with COMISA that is not amenable to CBT-I alone (ACTRN12613001178730).
SummaryIntensive sleep retraining (ISR) is a brief behavioural treatment for sleep onset insomnia, administered in just a single overnight treatment session. This systematic review evaluates existing trials about the efficacy of intensive sleep retraining for treating insomnia, to inform whether there is enough evidence to recommend its use for clinical practice. A systematic literature search was conducted across three databases, yielding 108 results. Of these studies, three were deemed suitable for inclusion in this review. The included studies consistently reported significant reductions in insomnia symptoms following intensive sleep retraining, particularly decreases in sleep diary‐derived sleep latency and increases in total sleep time. Based on these inconclusive but promising findings, a research agenda is proffered to test intensive sleep retraining as a treatment for insomnia. Large randomised controlled trials are needed to elucidate the potential benefits of intensive sleep retraining for different populations with insomnia, as are mechanistic trials to test which components underlie its seemingly therapeutic effects. Since more practical modalities of intensive sleep retraining administration have been developed, such trials are more feasible to conduct now than ever before.
Introduction
Cognitive behavioural therapy for insomnia (CBT-I) is the recommended treatment for insomnia and improves insomnia symptoms. However, CBT-I effects on sleep-wake state discrepancy have not previously been examined in a sample of individuals with co-morbid insomnia and sleep apnoea (COMISA). This randomised controlled trial investigated the effect of CBT-I, versus no-treatment control, on sleep-wake state discrepancy in people with COMISA.
Methods
145 participants had their subjective and objective sleep parameters recorded at pre- and post-treatment via overnight sleep diaries and polysomnography.
Results
Pre-treatment, individuals with COMISA significantly (p < 0.05) underestimated their sleep duration (M min = −51.9, SD = 94.1) and sleep efficiency (M % = −9.6, SD = 18.3) and significantly (p < 0.05) overestimated sleep onset latency (M min = 34.5, SD = 86.1). Post-treatment, there were significant reductions in sleep-wake state discrepancy parameters in both groups, but no significant interaction effects to support any differences between CBT-I versus waitlist control groups (all interactions, p > 0.367).
Discussion
These findings suggest that treating the insomnia aspect of COMISA through CBT-I first may not be an effective method of reducing sleep-wake state discrepancy. This is possibly due to sleep apnoea being untreated, contributing to frequent awakenings and the discrepancy between perceived and polysomnography derived sleep parameters. Future studies could involve a COMISA group that receives treatment for their sleep apnoea symptoms before CBT-I.
Introduction
Individuals with chronic insomnia often self-report more wakefulness and less sleep than is derived from objective measures, which is called sleep-wake state discrepancy (SWSD). This study investigated associations between SWSD and clinical characteristics in older adults with sleep maintenance insomnia before and after Cognitive Behaviour Therapy (CBTi).
Method
Seventy-three adults (female=53%, mean age=63.2, SD=6.3) were recruited. Participants completed sleep diaries and wore actigraphy for one week, as well as questionnaires related to sleep quality and daytime functioning immediately before and after CBTi. SWSD was calculated as the difference between subjective (sleep diary reported) and objective (actigraphy derived) total sleep time (TST) at pre- and post-treatment.
Results
Before treatment, SWSD was not associated with age or any clinical variables, ps > .05. Following treatment, SWSD significantly reduced (p<.001), despite no improvement in objective TST, and was significantly associated with improvements in insomnia severity (r=-.57), fatigue (r=-.26), sleep self-efficacy (r=.33), and beliefs about sleep (r=-.38), ps < .05.
Discussion
These findings suggest SWSD does not correlate with any other routinely-measured clinical characteristic prior to treatment. Given the associations with treatment outcomes, the need to incorporate objective measures, in conjunction with sleep diary assessments, to determine the degree of discrepancy and therapeutically address using CBTi is warranted. Following treatment, the reduction in discrepancy was driven by sleep diary reported TST that more closely matched objective TST, which remained relatively unchanged from pre-treatment. This has important implications for CBTi and suggests improvements in the accuracy of perceived sleep is a major therapeutic mechanism.
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