Reducing Cognitive Arousal and Sleep Effort Alleviates Insomnia and Depression in Pregnant Women with DSM-5 Insomnia Disorder Treated with a Mindfulness Sleep Program

Overview

Journal Sleep Adv

Date 2023 Aug 30

PMID 37645455

Authors

David A Kalmbach

Philip Cheng

Anthony N Reffi

Jason C Ong

Leslie M Swanson

Colin A Espie

Grace M Seymour

Mika Hirata

Olivia Walch

DAngela S Pitts

Thomas Roth

Christopher L Drake

Affiliations

Soon will be listed here.

Abstract

Objectives: Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depression via a mindfulness sleep program for pregnant women.

Methods: Secondary analysis from a proof-of-concept trial of 12 pregnant women with DSM-5 insomnia disorder who were treated with Perinatal Understanding of Mindful Awareness for Sleep (PUMAS), which places behavioral sleep strategies within a mindfulness framework. Data were collected across eight weekly assessments: pretreatment, six sessions, and posttreatment. Measures included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC), and the Glasgow sleep effort scale (GSES). We used linear mixed modeling to test cognitive arousal and sleep effort as concurrent and prospective predictors of insomnia and depression.

Results: Most patients reported high cognitive arousal before PUMAS (75.0%), which decreased to 8.3% after treatment. All insomnia remitters reported low cognitive arousal after treatment, whereas half of nonremitters continued reporting high cognitive arousal. Both nocturnal cognitive arousal and sleep effort were associated with same-week changes in insomnia throughout treatment, and sleep effort yielded a prospective effect on insomnia. Lower levels of nocturnal cognitive arousal and sleep effort prospectively predicted reductions in depression.

Conclusions: The present study offers preliminary evidence that reducing sleep effort and nocturnal cognitive arousal may serve as key mechanisms for alleviating insomnia and depression via mindfulness-based insomnia therapy. ClinicalTrials.gov ID: NCT04443959.

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References

Sedov I, Tomfohr-Madsen L . Trajectories of Insomnia Symptoms and Associations with Mood and Anxiety from Early Pregnancy to the Postpartum. Behav Sleep Med. 2020; 19(3):395-406. DOI: 10.1080/15402002.2020.1771339. View

Felder J, Epel E, Neuhaus J, Krystal A, Prather A . Efficacy of Digital Cognitive Behavioral Therapy for the Treatment of Insomnia Symptoms Among Pregnant Women: A Randomized Clinical Trial. JAMA Psychiatry. 2020; 77(5):484-492. PMC: 6990703. DOI: 10.1001/jamapsychiatry.2019.4491. View

Bei B, Pinnington D, Quin N, Shen L, Blumfield M, Wiley J . Improving perinatal sleep via a scalable cognitive behavioural intervention: findings from a randomised controlled trial from pregnancy to 2 years postpartum. Psychol Med. 2021; 53(2):513-523. PMC: 8738775. DOI: 10.1017/S0033291721001860. View

Felder J, Epel E, Neuhaus J, Krystal A, Prather A . Randomized controlled trial of digital cognitive behavior therapy for prenatal insomnia symptoms: effects on postpartum insomnia and mental health. Sleep. 2021; 45(2). PMC: 8842335. DOI: 10.1093/sleep/zsab280. View

Kalmbach D, Cheng P, Reffi A, Ong J, Swanson L, Fresco D . Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy. Sleep Med. 2023; 108:79-89. PMC: 10402889. DOI: 10.1016/j.sleep.2023.05.026. View

Morin C, Belleville G, Belanger L, Ivers H . The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011; 34(5):601-8. PMC: 3079939. DOI: 10.1093/sleep/34.5.601. View

Schwartz D, Carney C . Mediators of cognitive-behavioral therapy for insomnia: a review of randomized controlled trials and secondary analysis studies. Clin Psychol Rev. 2012; 32(7):664-75. DOI: 10.1016/j.cpr.2012.06.006. View

Cox J, Holden J, Sagovsky R . Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987; 150:782-6. DOI: 10.1192/bjp.150.6.782. View

Harris K, Spiegelhalder K, Espie C, MacMahon K, Cleland Woods H, Kyle S . Sleep-related attentional bias in insomnia: A state-of-the-science review. Clin Psychol Rev. 2015; 42:16-27. DOI: 10.1016/j.cpr.2015.08.001. View

10.

Tomfohr-Madsen L, Clayborne Z, Rouleau C, Campbell T . Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy. Behav Sleep Med. 2016; 15(5):377-393. DOI: 10.1080/15402002.2016.1141769. View

11.

Bernstein A, Hadash Y, Lichtash Y, Tanay G, Shepherd K, Fresco D . Decentering and Related Constructs: A Critical Review and Metacognitive Processes Model. Perspect Psychol Sci. 2015; 10(5):599-617. PMC: 5103165. DOI: 10.1177/1745691615594577. View

12.

Dietch J, Manber R . Insomnia and cognitive arousal are important potential targets to reduce perinatal depression risk. Sleep. 2021; 44(6). PMC: 8193559. DOI: 10.1093/sleep/zsab091. View

13.

Manber R, Bei B, Simpson N, Asarnow L, Rangel E, Sit A . Cognitive Behavioral Therapy for Prenatal Insomnia: A Randomized Controlled Trial. Obstet Gynecol. 2019; 133(5):911-919. PMC: 6485299. DOI: 10.1097/AOG.0000000000003216. View

14.

Gu J, Strauss C, Bond R, Cavanagh K . How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clin Psychol Rev. 2015; 37:1-12. DOI: 10.1016/j.cpr.2015.01.006. View

15.

Broomfield N, Espie C . Towards a valid, reliable measure of sleep effort. J Sleep Res. 2005; 14(4):401-7. DOI: 10.1111/j.1365-2869.2005.00481.x. View

16.

Renna M, Quintero J, Fresco D, Mennin D . Emotion Regulation Therapy: A Mechanism-Targeted Treatment for Disorders of Distress. Front Psychol. 2017; 8:98. PMC: 5292405. DOI: 10.3389/fpsyg.2017.00098. View

17.

Kyle S, Morgan K, Spiegelhalder K, Espie C . No pain, no gain: an exploratory within-subjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT) for insomnia. Sleep Med. 2011; 12(8):735-47. DOI: 10.1016/j.sleep.2011.03.016. View

18.

Deyo M, Wilson K, Ong J, Koopman C . Mindfulness and rumination: does mindfulness training lead to reductions in the ruminative thinking associated with depression?. Explore (NY). 2009; 5(5):265-71. DOI: 10.1016/j.explore.2009.06.005. View

19.

Swanson L, Kalmbach D, Raglan G, OBrien L . Perinatal Insomnia and Mental Health: a Review of Recent Literature. Curr Psychiatry Rep. 2020; 22(12):73. PMC: 9109228. DOI: 10.1007/s11920-020-01198-5. View

20.

Ong J, Ulmer C, Manber R . Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. Behav Res Ther. 2012; 50(11):651-60. PMC: 3466342. DOI: 10.1016/j.brat.2012.08.001. View