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      Cognitive behavioural therapy for insomnia reduces sleep apnoea severity: a randomised controlled trial


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          Insomnia and obstructive sleep apnoea (OSA) frequently co-occur and may be causally related through sleep fragmentation and/or hyperarousal mechanisms. Previous studies suggest that OSA treatment can improve insomnia severity. However, the effect of insomnia treatment on OSA severity has not been investigated. We performed a randomised controlled trial to investigate the effect of cognitive behavioural therapy for insomnia (CBTi) on OSA severity, controlling for potential sleep-stage and posture effects.

          145 patients with comorbid insomnia (International Classification of Sleep Disorders, 3rd Edn) and untreated OSA (apnoea–hypopnoea index (AHI) ≥15 events·h −1 sleep) were randomised to a four-session CBTi programme or to a no-treatment control. Overnight sleep studies were completed pre- and post-treatment to measure AHI, arousal index and sleep architecture, to investigate the effect of intervention group, time, sleep stage (N1–3 or REM) and posture (supine or nonsupine) on OSA severity.

          The CBTi group showed a 7.5 event·h −1 greater AHI difference (mean (95% CI) decrease 5.5 (1.3–9.7) events·h −1, Cohen's d=0.2, from 36.4 events·h −1 pre-treatment) across sleep-stages and postures, compared to control (mean increase 2.0 (−2.0–6.1) events·h −1, d=0.01, from 37.5 events·h −1 at pre-treatment; interaction p=0.012). Compared to control, the CBTi group also had a greater reduction in total number (mean difference 5.6 (0.6–10.6) greater overall reduction; p=0.029) and duration of nocturnal awakenings (mean difference 21.1 (2.0–40.3) min greater reduction; p=0.031) but showed no difference in the arousal index, or sleep architecture.

          CBTi consolidates sleep periods and promotes a 15% decrease in OSA severity in patients with comorbid insomnia and OSA. This suggests that insomnia disorder may exacerbate OSA and provides further support for treating insomnia in the presence of comorbid OSA.


          Cognitive behavioural therapy for insomnia consolidates sleep periods and promotes a 15% decrease in obstructive sleep apnoea severity in patients with comorbid insomnia and sleep apnoea https://bit.ly/3e4iPgB

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          Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.

          To quantify and compare potential benefits (subjective reports of sleep variables) and risks (adverse events and morning-after psychomotor impairment) of short term treatment with sedative hypnotics in older people with insomnia. Medline, Embase, the Cochrane clinical trials database, PubMed, and PsychLit, 1966 to 2003; bibliographies of published reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies. Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over with insomnia and otherwise free of psychiatric or psychological disorders. 24 studies (involving 2417 participants) with extractable data met inclusion and exclusion criteria. Sleep quality improved (effect size 0.14, P 0.05), and reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001) in people using any sedative compared with placebo. Improvements in sleep with sedative use are statistically significant, but the magnitude of effect is small. The increased risk of adverse events is statistically significant and potentially clinically relevant in older people at risk of falls and cognitive impairment. In people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.
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            In the past few years it has become increasingly clear that insomnia is a chronic disease that interacts with many other medical conditions. As our ability to examine complex physiological activity during sleep has increased, additional evidence continues to suggest that insomnia is associated with inappropriate physiological arousal. It is now known that patients with primary insomnia have increased high-frequency EEG activation, abnormal hormone secretion, increased whole body and brain metabolic activation, and elevated heart rate and sympathetic nervous system activation during sleep. This activation can be measured throughout the day and night and is chronic. Other research suggests that insomnia, probably based upon the associated chronic physiologic arousal, is associated with increased risk for medical disorders such as depression, hypertension, or cardiac disease. An animal model that has used odor stress to produce poor sleep in rats has identified specific activated brain sites similar to those found in human brain metabolic studies to suggest that insomnia is a state in which sleep and arousal systems are both simultaneously active. The animal studies have also shown that the inappropriate arousal can be blocked by lesions in the limbic and arousal systems. It is hoped that these findings can be extended to identify new compounds that improve insomnia by acting at these sites of abnormal brain activation. Published by Elsevier Ltd.
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              Sleep and psychiatric disorders. A meta-analysis.

              We reviewed the literature on sleep in psychiatric disorders and evaluated the data by meta-analysis, a statistical method designed to combine data from different studies. A total of 177 studies with data from 7151 patients and controls were reviewed. Most psychiatric groups showed significantly reduced sleep efficiency and total sleep time, accounted for by decrements in non-rapid eye movement sleep. Rapid eye movement sleep time was relatively preserved in all groups, and percentage of rapid eye movement sleep was increased in affective disorders. Reduction in rapid eye movement sleep latency was seen in affective disorders but occurred in other categories as well. Although no single sleep variable appeared to have absolute specificity for any particular psychiatric disorder, patterns of sleep disturbances associated with categories of psychiatric illnesses were observed. Overall, findings for patients with affective disorders differed most frequently and significantly from those for normal controls.

                Author and article information

                ERJ Open Res
                ERJ Open Res
                ERJ Open Research
                European Respiratory Society
                April 2020
                17 May 2020
                : 6
                : 2
                : 00161-2020
                [1 ]The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
                [2 ]The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Education Psychology and Social Work, Flinders University, Adelaide, Australia
                [3 ]Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
                [4 ]Institute for Social Science Research, The University of Queensland, Brisbane, Australia
                [5 ]Thoracic Program, The Prince Charles Hospital, Brisbane, Australia
                Author notes
                Alexander Sweetman, Adelaide Institute for Sleep Health: a Centre of Research Excellence, Flinders University, College of Medicine and Public Health, Bedford Park, 5042, Australia. E-mail: alexander.sweetman@ 123456flinders.edu.au
                Author information
                Copyright ©ERS 2020

                This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

                : 1 April 2020
                : 3 April 2020
                Funded by: National Health and Medical Research Council, open-funder-registry 10.13039/501100000925;
                Award ID: APP1049591; Treating insomnia comorbid with obstru
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