Sleep therapy becoming increasingly important in depression treatment

Insomnia-Electronic-Cigarettes

An insomnia therapy that scientists just reported could double the effectiveness of depression treatment is not widely available nor particularly well understood by psychiatrists or the public. The American Board of Sleep Medicine has certified just 400 practitioners in the United States to administer it, and they are sparse, even in big cities.

That may change soon, however. Four rigorous studies of the treatment are nearing completion and due to be reported in coming months. In the past year, the American Psychological Association recognized sleep psychology as a specialty, and the Department of Veterans Affairs began a program to train about 600 sleep specialists. So-called insomnia disorder is defined as at least three months of poor sleep that causes problems at work, at home or in relationships.

The need is great: Depression is the most common mood disorder, affecting some 18 million Americans in any given year, and most have insomnia.

“I think it’s increasingly likely that this kind of sleep therapy will be used as a possible complement to standard care,” said Dr. John M. Oldham, chief of staff at the Menninger Clinic in Houston. “We are the court of last resort for the most difficult-to-treat patients, and I think sleep problems have been extremely underrecognized as a critical factor.”

The treatment, known as cognitive behavioral therapy for insomnia, or CBT-I, is not widely available. Most insurers cover it, and the rates for private practitioners are roughly the same as for any psychotherapy, ranging from $100 to $250 an hour, depending on the therapist.

“There aren’t many of us doing this therapy,” said Shelby Harris, the director of the behavioral sleep medicine program at Montefiore Medical Center in the Bronx, who also has a private practice in Tarrytown, N.Y. “I feel like we all know each other.”

According to preliminary results, one of the four studies has found that when CBT-I cures insomnia — it does so 40 percent to 50 percent of the time, previous work suggests — it powerfully complements the effect of antidepressant drugs.

“There’s been a huge recognition that insomnia cuts across a wide variety of medical disorders, and there’s a need to address it,” said Michael T. Smith, a professor at the Johns Hopkins School of Medicine and president of the Society of Behavioral Sleep Medicine.

The therapy is easy to teach, said Colleen Carney, director of the sleep and depression lab at Ryerson University in Toronto, whose presentation at a conference of the Association for Behavioral and Cognitive Therapies in Nashville on Saturday raised hopes for depression treatment. “In the study we did, I trained students to administer the therapy,” she said in an interview, “and the patients in the study got just four sessions.”

CBT-I is not a single technique but a collection of complementary ideas. Some date to the 1970s, others are more recent. One is called stimulus control, which involves breaking the association between being in bed and activities like watching television or eating. Another is sleep restriction: setting a regular “sleep window” and working to stick to it. The therapist typically has patients track their efforts on a standardized form called a sleep diary. Patients record bedtimes and when they wake up each day, as well as their perceptions about quality of sleep and number of awakenings. To this the therapist might add common-sense advice like reducing caffeine and alcohol intake, and making sure the bedroom is dark and quiet.

Those three elements — stimulus control, restriction and common sense — can do the trick for many patients. For those who need more, the therapist applies cognitive therapy — a means of challenging self-defeating assumptions. Patients fill out a standard questionnaire that asks how strongly they agree with statements like: “Without an adequate night’s sleep, I can hardly function the next day”; “I believe insomnia is the result of a chemical imbalance”; and “Medication is probably the only solution to sleeplessness.” In sessions, people learn to challenge those beliefs, using evidence from their own experiences.

“If someone has the belief that if they don’t sleep, they’ll somehow fail the next day, I’ll ask, ‘What does failure mean? You’ll be slower at work, not get everything done, not make dinner?’ ” Dr. Harris said. “Then we’ll look at the 300 nights they didn’t sleep well over the past few years and find out they managed; it might not have been as pleasant as they liked, but they did not fail. That’s how we challenge those kinds of thoughts.”

Dr. Aaron T. Beck, an emeritus professor of psychiatry at the University of Pennsylvania who is recognized as the father of cognitive therapy for mental disorders, said the techniques were just as applicable to sleep problems. “In fact, I have used it myself when I occasionally have insomnia,” he said by email.

In short-term studies of a month or two, CBT-I has been about as effective as prescription sleeping pills. But it appears to have more staying power. “There’s no data to show that if you take a sleeping pill — and then stop taking it — that you’ll still be good six months later,” said Jack Edinger, a professor at National Jewish Health in Denver and an author, with Dr. Carney, of “Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach.”

“It might happen, but those certainly aren’t the people who come through my door,” he said.

Dr. Edinger and others say that those who respond well to CBT-I usually do so quickly — in an average of four sessions, and rarely more than eight. “You’re not going to break the bank doing this stuff; it’s not a marriage,” he said. “You do it for a fixed amount of time, and then you’re done. Once you’ve got the skills, they don’t go away.”

Documentary on Sleep Paralysis this May

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Stephanie Pappas, LiveScience Senior Writer

When filmmaker Carla MacKinnon started waking up several times a week unable to move, with the sense that a disturbing presence was in the room with her, she didn’t call up her local ghost hunter. She got researching. Now, that research is becoming a short film and multiplatform art project exploring the strange and spooky phenomenon of sleep paralysis. The film, supported by the Wellcome Trust and set to screen at the Royal College of Arts in London, will debut in May.

Sleep paralysis happens when people become conscious while their muscles remain in the ultra-relaxed state that prevents them from acting out their dreams. The experience can be quite terrifying, with many people hallucinating a malevolent presence nearby, or even an attacker suffocating them. Surveys put the number of sleep paralysis sufferers between about 5 percent and 60 percent of the population. “I was getting quite a lot of sleep paralysis over the summer, quite frequently, and I became quite interested in what was happening, what medically or scientifically, it was all about,” MacKinnon said.

Her questions led her to talk with psychologists and scientists, as well as to people who experience the phenomenon. Myths and legends about sleep paralysis persist all over the globe, from the incubus and succubus (male and female demons, respectively) of European tales to a pink dolphin-turned-nighttime seducer in Brazil. Some of the stories MacKinnon uncovered reveal why these myths are so chilling.

One man told her about his frequent sleep paralysis episodes, during which he’d experience extremely realistic hallucinations of a young child, skipping around the bed and singing nursery rhymes. Sometimes, the child would sit on his pillow and talk to him. One night, the tot asked the man a personal question. When he refused to answer, the child transformed into a “horrendous demon,” MacKinnon said.

For another man, who had the sleep disorder narcolepsy (which can make sleep paralysis more common), his dream world clashed with the real world in a horrifying way. His sleep paralysis episodes typically included hallucinations that someone else was in his house or his room — he’d hear voices or banging around. One night, he awoke in a paralyzed state and saw a figure in his room as usual. “He suddenly realizes something is different,” MacKinnon said. “He suddenly realizes that he is in sleep paralysis, and his eyes are open, but the person who is in the room is in his room in real life.” The figure was no dream demon, but an actual burglar.

Sleep paralysis experiences are almost certainly behind the myths of the incubus and succubus, demons thought to have sex with unsuspecting humans in their sleep. In many cases, MacKinnon said, the science of sleep paralysis explains these myths. The feeling of suffocating or someone pushing down on the chest that often occurs during sleep paralysis may be a result of the automatic breathing pattern people fall into during sleep. When they become conscious while still in this breathing pattern, people may try to bring their breathing under voluntary control, leading to the feeling of suffocating. Add to that the hallucinations that seem to seep in from the dream world, and it’s no surprise that interpretations lend themselves to demons, ghosts or even alien abduction, MacKinnon said.

What’s more, MacKinnon said, sleep paralysis is more likely when your sleep is disrupted in some way — perhaps because you’ve been traveling, you’re too hot or too cold, or you’re sleeping in an unfamiliar or spooky place. Those tendencies may make it more likely that a person will experience sleep paralysis when already vulnerable to thoughts of ghosts and ghouls. “It’s interesting seeing how these scientific narratives and the more psychoanalytical or psychological narratives can support each other rather than conflict,” MacKinnon said.

Since working on the project, MacKinnon has been able to bring her own sleep paralysis episodes under control — or at least learned to calm herself during them. The trick, she said, is to use episodes like a form of research, by paying attention to details like how her hands feel and what position she’s in. This sort of mindfulness tends to make scary hallucinations blink away, she said. “Rationalizing it is incredibly counterintuitive,” she said. “It took me a really long time to stop believing that it was real, because it feels so incredibly real.”

http://www.livescience.com/28325-spooky-film-explores-sleep-paralysis.html

Research on letting babies ‘cry it out’

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Cry-it-out is a sleep training method that advocates letting your baby cry (or the more innocuous-sounding “self-soothe”) for varying periods of time before offering comfort. The goal is to get your baby to learn how to fall asleep on her own, so you, too, can rest.

Central to it all is stress and sanity: the baby’s, yours and that of everyone with earshot.

The method is the subject of intense debate, passionate opinions and conflicting research findings.

A few weeks ago, the journal Developmental Psychology published a study supporting the notion that a majority of infants over the age of 6 months may best be left to self-soothe and fall back to sleep on their own.

Noting that sleep deprivation can exacerbate maternal depression, Temple University researcher and professor Marsha Weinraub concluded: “Because the mothers in our study described infants with many awakenings per week as creating problems for themselves and other family members, parents might be encouraged to establish more nuanced and carefully targeted routines to help babies with self-soothing and to seek occasional respite.”

There is broad agreement that parents’ well-being is critical to infants’ health and development. Weintraub suggested that the link between infant awakenings and maternal depression would benefit from further research.

Adequate sleep is, of course, key to parents’ stress levels. Loss of sleep has been associated with a dramatically higher risk of depression in mothers and marital problems.

It is how well (or not) the baby fares in the cry-it-out scenario that muddies the waters.

On the pro sleep-training side, an Australian study published in September followed 326 children with parent-reported sleep problems at 7 months. Half the babies were placed in a sleep-training group and the other half in a control group that did not use sleep training.

Five years later, researchers followed up with the now-6-year-old participants and their parents.

The children in the two groups showed very little to no significant differences in terms of emotional health, behavior or sleep problems. Mothers’ stress or depression levels were roughly the same, as were the parent-child bonds in both groups.

The researchers found no harm in permitting children to cry for limited periods of time while they learned to sleep on their own.

Directly contradicting this study is research conducted at the University of North Texas that was published in the Early Human Development journal last year. Observing 25 infants aged 4 to 10 months in a five-day inpatient sleep training program, researchers monitored levels of the stress hormone cortisol in the babies, who were left to cry themselves to sleep without being soothed.

The scientists measured how long the infants cried each night before they fell asleep. The mothers sat in the next room and listened to their children cry but were not permitted to go in and soothe their babies.

By the third night, the babies were crying for a shorter period of time and falling asleep faster. However, the cortisol levels measured in their saliva remained high, indicating that the infants were just as “stressed” as if they had remained crying. So while the infants’ internal physiological distress levels had not changed, their outward displays of that stress were extinguished by sleep training.

In the mothers, on the other hand, the stress hormone levels fell as the babies appeared — at least outwardly — to settle down and sleep.

The study did not clarify whether the babies’ stress levels lowered as their sleep patterns settle over time. The researchers are now studying this issue, among others, in a longer follow-up.

As with most things in life, when it comes to babies and the science of sleep, the only certainty is that there is no certainty. Those of us on the roller coaster of modern parenting are the first to attest to the fact that perfection simply does not exist, especially when you’re bleary-eyed and sleep-deprived at 4:15 a.m., with a full workday looming.

Some researchers suggest that parents may gain clarity by working backward from a longer-term goal.

Darcia Narvaez, professor of psychology at the University of Notre Dame, studies moral cognition and development. Her research examines how early life experience may influence brain development, moral functioning and character in children and adults.

Narvaez advocates a more responsive style of parenting that mirrors nurturing ancestral practices, including breastfeeding, frequent touch, soothing babies in distress, outdoor play and a wider community of caregivers.

According to Narvaez, research shows that responsive parenting can help develop infants’ self-regulation and may influence conscience, impulse control, empathy, resilience and other character-related attributes.

Narvaez’s list is strikingly similar to a set of character traits discussed by journalist Paul Tough in his book, “How Children Succeed: Grit, Curiosity, and the Hidden Power of Character.”

In the book, Tough examines the skills and traits that lead to success and ultimately advances the hypothesis that character attributes may be more crucial than cognitive skills like IQ and intelligence.

“(I)n the past decade, and especially in the past few years,” writes Tough, “a disparate congregation of economists, educators, psychologists, and neuroscientists have begun to produce evidence that … (w)hat matters most in a child’s development … is not how much information we can stuff into her brain in the first few years.

“What matters, instead, is whether we are able to help her develop a very different set of qualities, a list that includes persistence, self-control, curiosity, conscientiousness, grit and self-confidence.”

Can responsive parenting in a child’s first year lay the groundwork for better regulation of social and behavioral responses and perhaps even greater life success? Seems like a heavy burden. And no one knows for sure — not even the dueling Upper West Side mothers.

http://www.cnn.com/2013/01/24/health/child-sleep-debate-enayati/index.html?hpt=he_c1

Fragmented Sleep May Disrupt Your Memory

But when sleep is interrupted frequently–as it is in a wide range of disorders, including sleep apnea, alcoholism and Alzheimer’s disease–the ability to learn new things can be dramatically impaired, says a new studyconducted on mice and published this week in the Proceedings of the National Academy of Sciences. 

http://www.pnas.org/content/early/2011/07/20/1015633108.abstract?sid=400915e1-7405-4539-be26-06f6ac13ac4b

The researchers used a novel method to isolate the effects of sleep fragmentation from overall sleep quality. Studies to date have shown that when sleep is frequently interrupted, memory suffers. But no one really knew whether the memory problems they observed were the result of shorter cumulative sleep times, poor overall sleep quality, the degradation of some distinct part of the sleep cycle, or the sheer annoyance of being prodded awake repeatedly while sleeping. This study suggests that even when frequent waking doesn’t affect sleep quality and doesn’t cut into overall sleep time, memory takes a hit.

Read a summary of the study here:  http://articles.latimes.com/2011/jul/26/news/la-heb-sleep-memory-learning-20110726

Lasting affect of parental fighting on sleeping patterns of their kids

Infants’ sleep patterns can be disrupted if their parents are constantly arguing, a new study finds.

Infants who heard regular blow-ups between parents when they were 9 months old continued to have troubled sleep patterns — marked by problems getting to sleep and staying asleep — even when they were 18-month-old toddlers.

More than 300 U.S. children and parents were stuydies, and all of the children were adopted at birth in order to control for any influence of genetics.

http://health.usnews.com/health-news/family-health/sleep/articles/2011/05/11/parents-fighting-can-even-affect-infants-study