Increased GABA levels in persons with insomnia may reflect an allostatic response to chronic hyperarousal. The preserved, negative relationship between GABA and time awake after sleep onset supports this notion, indicating that the possible allostatic response is adaptive.

Background Former sleep studies among non-treatment seeking chronic cocaine users had captured polysomnographic changes for as long as three weeks of abstinence. Methods 20 cocaine dependent participants, randomized to placebo in an ongoing clinical trial, received 12 days of inpatient substance abuse treatment followed by 6 weeks of outpatient cognitive behavioral therapy. Polysomnographic recording was performed on consecutive nights during the 1st and 2nd inpatient and 3rd and 6th outpatient weeks. Number of days abstinent was determined from thrice weekly urine toxicology and self-report. Polysomnographic sleep was compared between study week 1 and 2, using paired t-tests. Trajectory of total sleep time (TST) was modeled both as a linear and a quadratic function of days abstinent. Results Despite reporting an improvement in overall sleep quality, polysomnographic sleep worsened from week 1 to 2. Among all participants, TST and stage 2 sleep time decreased, while REM sleep latency increased. Among participants who began the study with a positive urine test, there was also a decrease in REM and a trend for decreased slow wave sleep. TST compared to number of days abstinent (up to 54 days) was best fit with a quadratic model (p = 0.002), suggesting the possibility of an improvement in total sleep time with extended abstinence. Conclusions This is the first polysomnographic characterization of sleep in a large sample of cocaine users in treatment. Present findings confirm earlier results of poor and deteriorating sleep early in abstinence, and raise the possibility of improvement after an extended abstinence.

Objective To describe the sleep patterns of early cocaine abstinence in chronic users by polysomnographic and subjective measures. Methods 28 cocaine-dependent participants (ages 24-55) underwent polysomnographic sleep (PSG) recording on the 1st, 2nd and 3rd weeks of abstinence on a research dedicated inpatient facility. Objective measures of total sleep time, total REM time, slow wave sleep, sleep efficiency and a subjective measure (sleep quality) along with demographic data were collected from three different long term research studies over a five year period. Data were reanalyzed to allow greater statistical power for comparisons. Results Progressive weeks of abstinence had main effects on all assessed PSG sleep measures showing decreased total sleep time, REM sleep, stage 1 and 2 sleep, and sleep efficiency; increases in sleep onset and REM latencies and a slight increase in slow-wave sleep time were also present. Total sleep time and slow wave sleep were negatively associated with years of cocaine use. Total sleep time was positively associated with the amount of current ethanol use. Sex differences were found with females having more total REM time and an increase at a near significance level in slow wave sleep. Subjective measures were reported as improving with increasing abstinence over the same time period. Conclusions Chronic cocaine users show a general deterioration in objective sleep measures over a three-week period despite an increase in subjective overall sleep quality providing further evidence for “occult insomnia” during early cocaine abstinence.

Background Abstinence from chronic cocaine use is associated with abnormal sleep architecture. As sleep abnormalities are associated with clinical outcome in alcohol dependence, we hypothesized a similar relationship in cocaine dependence. Methods We report data from a cocaine self-administration study (N=12) and the placebo arm of a randomized clinical trial (N=20). Self-administration participants underwent three cocaine self-administration sessions during a three-week inpatient stay. Treatment participants underwent two weeks of inpatient followed by six weeks of outpatient treatment including once-weekly cognitive behavioral therapy. Measurements included polysomnography from early and late in abstinence during the inpatient stays. Clinical outcomes included amount of cocaine self-administered, urine tests, and self-reported use and withdrawal symptoms. Results Change in slow-wave sleep from early to late abstinence (ΔSWS; p=0.05), late abstinence rapid eye movement sleep (REM; p=0.002), and late abstinence total sleep time (p=0.02) were negatively correlated with the amount of cocaine self-administered. Early abstinence REM was positively correlated with withdrawal symptoms (p=0.02). Late abstinence REM was positively correlated with percent negative urines and maximum consecutive number of days abstinent (both p<0.001). ΔSWS was positively correlated with percent negative urines (p=0.03) and participants with increased SWS had greater percent negative urines (p=0.008) and maximum consecutive number of days abstinent (p=0.009). Conclusions Correlations between sleep deficits and amount of cocaine self-administered, clinical outcomes, and severity of withdrawal symptoms underscore the relevance of sleep in clinical outcomes in the treatment of cocaine dependence.

Objective To determine whether the increase in slow-wave sleep associated with modafinil treatment in chronic cocaine users mediates improved clinical outcomes. Method 57 cocaine dependent participants were randomized to receive modafinil 400mg or placebo daily during a period of inpatient treatment followed by six weeks of outpatient treatment. Participants underwent polysomnographic sleep recording during inpatient treatment prior to and after starting modafinil. Outpatient treatment consisted of weekly cognitive behavioral therapy. Contingency management was used to promote participation in treatment and research demands, including thrice weekly visits during the outpatient phase for urine toxicology screens and other assessments. The primary clinical outcome was the percent of urine toxicology screens that were negative for cocaine. Results Modafinil treatment was associated with a higher mean percentage (52% vs. 26%) of cocaine-free urine screens (p=0.02) and an increase in N3 sleep time (p=0.002). The change in N3 sleep time mediated the higher rate of cocaine-free urine screens. Modafinil treatment was also associated with more consecutive days abstinent during outpatient treatment, greater survival of abstinence, higher daily rates of abstinence, and less sleep degradation typically associated with abstinence from chronic cocaine use. Conclusions Morning-dosed modafinil improves slow-wave sleep in abstinent cocaine users in the inpatient setting, and this effect is a statistical mediator of improved clinical outcomes associated with continued modafinil treatment. The high rates of abstinence achieved in this trial suggest that promoting healthy sleep physiology in an inpatient setting may be important in the effective treatment of cocaine dependence.

Activity in the prefrontal cortex may distinguish the meta-awareness experienced during lucid dreams from its absence in normal dreams. To examine a possible relationship between dream lucidity and prefrontal task performance, we carried out a prospective study in 28 high school students. Participants performed the Wisconsin Card Sort and Iowa Gambling tasks, then for one week kept dream journals and reported sleep quality and lucidity-related dream characteristics. Participants who exhibited a greater degree of lucidity performed significantly better on the task that engages the ventromedial prefrontal cortex (the Iowa Gambling Task), but degree of lucidity achieved did not distinguish performance on the task that engages the dorsolateral prefrontal cortex (the Wisconsin Card Sort Task), nor did it distinguish self-reported sleep quality or baseline characteristics. The association between performance on the Iowa Gambling Task and lucidity suggests a connection between lucid dreaming and ventromedial prefrontal function.

Study Objectives: Insomnia, though quite common in the general population, is especially prevalent among individuals with co-occurring mental illnesses, patients whose condition can be further exacerbated by insomnia and vice versa. For individuals taking one or more psychotropic medications, cognitive behavioral therapy for insomnia (CBT-I), the gold standard in insomnia treatment, is a particularly favorable option (vis-à-vis pharmacotherapy). However, CBT-I can be inaccessible for persons with low socioeconomic status, a group that includes many with psychiatric diagnoses. Computer-based delivery of CBT-I (cb-CBT-I) has the potential to be a cost-effective tool that could greatly improve accessibility for this at-risk demographic. Methods: Thirty-four participants with insomnia who were currently engaged in mental health care treatment were randomized to an active control group (sleep diary group; n = 16) or cb-CBT-I (n = 18) during weekly outpatient sessions over the course of 6 w. All participants completed sleep and activity logs at each appointment, whereas those in the cb-CBT-I group also completed one session of the cb-CBT-I program each week. Results: cb-CBT-I treatment was associated with lower scores (improved sleep) on the Pittsburgh Sleep Quality Index (PSQI). Post hoc tests demonstrated a between groups difference at week 6 (p = 0.02), with a statistically significant decrease in PSQI scores in the cb-CBT-I group (p = 0.0006) but not in the sleep diary group (p = 0.35). Conclusions: cb-CBT-I improves sleep in individuals with insomnia and co-occurring mental illness. The significant improvements on the PSQI suggest that implementing a cb-CBT-I treatment in a community mental health center would be a simple and effective treatment for improving sleep over a short period of time. Commentary: A commentary on this article appears in this issue on page 161. Keywords: behavioral health integration, CBT, CBT-I, collaborative care, insomnia, technology-assisted care delivery Citation: Feuerstein S, Hodges SE, Keenaghan B, Bessette A, Foreselius E, Morgan PT. Computerized cognitive behavioral therapy for insomnia in a community health setting.

Modafinil, a wake-promoting agent used to treat sleep disorders, is thought to enhance cognition. Although modafinil has shown promise as a pharmacotherapy for the treatment of cocaine dependence, it is unknown to what extent cognitive effects may play a role in such treatment. We examined the effect of modafinil on the Balloon Analogue Risk Task (BART), a behavioral measure in which higher scores are purported to reflect a greater propensity for risk-taking. Thirty cocaine dependent individuals, enrolled in a randomized clinical trial of modafinil 400mg (n=12) versus placebo (n=18), were administered the BART during the second week of inpatient treatment for cocaine dependence. A comparison cohort of healthy participants (n=19) performed the BART under similar conditions. Modafinil treatment was associated with significantly higher BART scores (p=0.01), which were comparable to scores in healthy persons. BART scores in placebo treated participants were much lower than previously reported in healthy participants, and lower than those observed in the comparison cohort. As propensity toward risk taking is typically associated with higher BART scores as well as increased risk for substance use, our findings may reflect a novel aspect of cognitive impairment related to chronic cocaine use. Notably, the low BART scores reflect highly suboptimal performance on the task, and the observed effect of modafinil may indicate a normalization of this impairment and have implications for treatment outcome.