Background Poor sleep, including insomnia, is common among patients with heart failure (HF). However, little is known about the efficacy of interventions for insomnia in this population. Prior to developing interventions, there is a need for better understanding of patient perceptions about insomnia and its treatment. Objectives To evaluate HF patients’ perceptions about 1) insomnia and its consequences; 2) predisposing, precipitating, and perpetuating factors for insomnia; 3) self-management strategies and treatments for insomnia; and 4) preferences for insomnia treatment. Methods The study, guided by the “3 P” model of insomnia, employed a parallel convergent mixed methods design in which we obtained qualitative data through focus groups and quantitative data through questionnaires (sleep quality, insomnia severity, dysfunctional beliefs and attitudes about sleep; sleep-related daytime symptoms and functional performance). Content analysis was used to evaluate themes arising from the focus group data, and descriptive statistics were used to analyze the quantitative data. The results of both forms of data collection were compared and synthesized. Results HF patients perceived insomnia as having a negative impact on daytime function and comorbid health problems, pain, nocturia, and psychological factors as perpetuating factors. They viewed use of hypnotic medications as often necessary but disliked negative daytime side effects. They used a variety of strategies to manage their insomnia, but generally did not mention their sleep concerns to physicians whom they perceived as not interested in sleep. Conclusions HF patients believe insomnia is important and multi-factorial. Behavioral treatments, such as Cognitive Behavioral Therapy, for insomnia may be efficacious in modifying perpetuating factors and likely to be acceptable to patients.

Background: Chronic insomnia is common among patients with heart failure (HF) and may contribute to fatigue and poor function. However, to date there have been no randomized controlled trials focused on treatment of insomnia or daytime symptoms in this population. Objective: The purpose of this study was to examine the preliminary effi cacy, feasibility, and acceptability of a selfmanagement intervention (cognitive behavioral therapy [CBT-I]) for insomnia among patients with stable HF. Methods: We conducted a pilot randomized controlled trial (RCT) in which patients with stable Class I-III HF (n = 25/52.1% women; mean age = 59 ± 14.8 years) were randomized in groups to CBT-I (n = 29) or an attention control condition (HF self-management with sleep hygiene; n = 19). Participants completed 2 weeks of wrist actigraphy, the insomnia severity index, and measures of fatigue, depression, sleepiness, and functional performance at baseline and follow-up. We computed the size of the effects on the dependent variables and used MANOVA to evaluate the effects of CBT-I on insomnia and fatigue. Results: CBT-I was feasible and acceptable and had a statistically signifi cant effect on insomnia and fatigue, while controlling for the effects of comorbidity and age. Conclusions: CBT-I has short-term effi cacy as a treatment for chronic insomnia among patients with stable HF. Future studies are needed to address its sustained effects. Keywords: self-management, heart failure, insomnia, cognitive behavioral therapy, sleep, fatigue, depression Citation: Redeker NS, Jeon S, Andrews L, Cline J, Jacoby D, Mohsenin V. Feasibility and effi cacy of a self-management intervention for insomnia in stable heart failure. J Clin Sleep Med 2015;11(10):1109 -1119 .pii: jc-00335-14 http://dx.doi.org/10.5664/jcsm.5082 H eart failure (HF), a disabling chronic condition that affl icts over fi ve million Americans, 1 is associated with excess morbidity and mortality, comorbidity, poor daytime function, and high symptom burden. Almost 75% of HF patients report poor sleep.2,3 Insomnia, characterized by diffi culty initiating and maintaining sleep, early morning awakenings, non-restorative sleep, and daytime dysfunction, occurs in 25% to 56% of HF patients, 2-5 who report higher rates than "healthy" controls 2 and the general population. Chronic insomnia contributes to incident HF and death. 6 It is distressing and associated with symptoms, such as fatigue, nocturnal dyspnea, depression, anxiety, pain, and excessive daytime sleepiness, poor quality of life, and decrements in functional performance. 3,5,[7][8][9][10][11][12][13] Health care providers frequently attribute sleep disturbance, including insomnia symptoms, to the pathophysiology (e.g., fl uid congestion) and symptoms of HF itself (e.g., nocturnal dyspnea, nocturia) or to sleep disordered breathing that occurs in about half the population.14 However, sleep disordered breathing does not consistently explain insomnia, self-reported sleep quality, or fatigue; and insomnia was closely associated with...

Lack of knowledge about psychosis, a condition oftentimes associated with serious mental illness, may contribute to disparities in mental health service use. Psychoeducational interventions aimed at improving psychosis literacy have attracted significant attention recently, but few have focused on the growing numbers of ethnic and linguistic minorities in countries with large immigrant populations, such as the United States. This paper reports on two studies designed to evaluate the effectiveness of a DVD version of La CLAve, a psychoeducational program that aims to increase psychosis literacy among Spanish-speaking Latinos. Study 1 is a randomized control study to test directly the efficacy of a DVD version of La CLAve for Spanish-speakers across a range of educational backgrounds. Fifty-seven medical students and 68 community residents from Mexico were randomly assigned to view either La CLAve or a psychoeducational program of similar length regarding caregiving. Study 2 employed a single-subjects design to evaluate the effectiveness of the DVD presentation when administered by a community mental health educator. Ninety-three Spanish-speakers from San Diego, California completed assessments both before and after receiving the DVD training. Results from these two studies indicate that the DVD version of La CLAve is capable of producing a range of psychosis literacy gains for Spanish-speakers in both the United States and Mexico, even when administered by a community worker. Thus, it has potential for widespread dissemination and use among underserved communities of Spanish-speaking Latinos and for minimizing disparities in mental health service use, particularly as it relates to insufficient knowledge of psychosis.

Improvement in dysfunctional sleep-related cognitions is an important mechanism for CBT-I effects among HF patients who are especially vulnerable to poor sleep and high symptom burden.

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