Sleep and Human Health Institute

Dr Krakow recently published a book, Life Saving Sleep: New Horizons in Mental Health Treatment. He owns and operates the website www.barrykrakowmd.com, which offers sleep coaching services, training resources for sleep professionals, and books and videos for the treatment of sleep disorders.

Complex insomnia (co-occurring chronic insomnia disorder and sleep apnea) is more prevalent than previously recognized, yet no RCTs have investigated different PAP modes in this cohort. Standard CPAP often produces adverse effects (expiratory pressure intolerance; iatrogenic central apneas) in complex insomnia patients. We hypothesized ASV would alleviate side-effects and yield greater improvements in insomnia severity compared to CPAP. A prospective, single-blind (patients), RCT studied 40 chronic insomniacs, who had never seen a sleep specialist or received a sleep apnea diagnosis; and none believed they suffered a sleep breathing disorder or that it caused their chronic insomnia. Despite their insomnia chief complaint, all patients were diagnosed with OSA on PSG. Patients completed an intensive 15-week protocol, comprising 5 follow-up appointments (two-week intervals) interspersed with 3 in-lab retitrations (six-week intervals) to encourage regular PAP use [ASV (n=19), CPAP (n=21); ResMed AirCurveTM]. The sample suffered moderately severe insomnia (mean ISI=19.30) for an average of 9.81years with no baseline differences between groups. All patients reported failing multiple treatments for chronic insomnia, including sleep hygiene, OTC drugs, prescription sedatives, psychotropic medications and psychotherapy. At final follow-up, main effect showed a significant, large decrease in ISI (mean change -11.43, p=.0001); group x time interaction was statistically significant (p=.04), demonstrating ASV superiority (mean change -13.22, g=3.82) over CPAP (mean change -9.29, g=2.07). Clinically, ASV superiority manifested in 68.4% of patients no longer meeting criteria for a clinical insomnia disorder (ISI<8) compared to 23.8% of CPAP users (p=.006). Among classic chronic insomnia disorder patients who perceived their sleep condition as psychological and whose providers focused on conventional therapies, complex insomnia was ultimately diagnosed and successfully treated with PAP therapy. Compared to CPAP, ASV proved superior by nearly twice the effect size in decreasing insomnia severity and by three times the number of cured cases. ASV provided greater comfort, adaptability, and efficacy. In sum, for many patients, insomnia was caused exclusively by a patho-physiological medical disorder. Thus, failure to utilize PSG in chronic insomnia delays accurate diagnosis and precludes appropriate treatment. ResMed.

Nightmares are a universal and timeless phenomenon. They occur in most healthy adults as well as a significant portion of clinical populations, especially those exposed to trauma. Considerable advances in the pharmacological and psychological treatment of post-traumatic nightmares have occurred over the last decade with continuing advances in psychological interventions over the last few years. Pharmacologically, the medication prazosin is showing robust clinical effects with minimal side effects. Psychologically, imagery rehearsal therapy commands the greater portion of the nightmare literature due to its established efficacy. These issues are reviewed in the following paper along with recommendations for future studies.

Few studies have examined the co-morbidity between insomnia and sleep-disordered breathing in the clinical setting. This study evaluated treatment-seeking insomnia patients and their self-report of sleep breathing complaints. A retrospective chart review was conducted on 1,035 consecutive treatment-seeking, chronic insomnia patients who reported insomnia as their primary problem upon seeking care at a private, community-based sleep medical center. Measurements included the insomnia severity index, standard subjective sleep measures as well as rankings, attributions, and self-reports about sleep breathing disorders, problems, and symptoms. A total of 1,035 adult, treatment-seeking insomnia patients indicated insomnia interfered with daytime functioning, and their average insomnia severity was in the range of a clinically relevant problem: total sleep time (5.50 h, SD = 1.60), sleep efficiency (71.05 %, SD = 18.26), wake time after sleep onset (120.70 min, SD = 92.56), and an insomnia severity index (18.81, SD = 5.09). Of these 1,035 insomnia patients, 42 % also ranked a sleep breathing disorder among their list of reasons for seeking treatment, another 13 % revealed a concern about a sleep breathing problem, and another 26 % reported awareness of sleep breathing symptoms. Only 19 % of this clinical insomnia sample reported no awareness or concerns about sleep breathing disorders, problems, or symptoms. A greater proportion of men than women reported significantly more sleep breathing disorders, problems, or symptoms. Sleep breathing complaints were extremely common among a large sample of treatment-seeking, self-identified, adult chronic insomnia patients. Prospective prevalence research is needed to corroborate or revise these findings, and polysomnography should be considered in appropriate cohorts to determine the clinical relevance of treatment-seeking chronic insomnia patients' sleep breathing complaints.

Some chronic insomnia patients who take nightly prescription medication achieve less than optimal results. The US Food and Drug Administration (FDA) and the American Academy of Sleep Medicine (AASM) recommend reevaluation of this type of patient to assess for potential psychiatric or medical causes to explain this "failure for insomnia to remit." A retrospective chart review examined a consecutive series of chronic insomnia patients with persistent insomnia complaints despite current nightly use of prescription medication from May 2005 to February 2008. To assess the role of psychiatric influences on insomnia symptoms, our sample (N = 218) was divided into 2 subgroups: a group with a history of psychiatric complaints (psychiatric insomnia, n = 189) and a control group of no psychiatric complaints (insomnia, n = 29). The average patient reported insomnia for a decade and took prescription medication for sleep for a mean of 4.5 years. Although 100% of the sample used nightly sleep drugs, only 20% believed medication was the best solution for their condition. As evaluated by self-report and polysomnography, these patients exhibited moderately severe insomnia across most measures. Only a few differences were noted between groups. Subjective perception of insomnia severity was worse in the psychiatric insomnia group, which also reported significantly more insomnia-related interference in daily functioning, symptoms of sleep maintenance insomnia, and a trend toward greater daytime fatigue. The mean Apnea-Hypopnea Index score was 19.5 events/hour, yielding an obstructive sleep apnea diagnosis in 75% of patients per conservative AASM nosology (79% in the insomnia group and 74% in the psychiatric insomnia group, P = .22). In this treatment-seeking sample of patients regularly taking sleep medications, residual insomnia was widespread, and patients with psychiatric insomnia may have perceived their condition as more problematic than a control group of insomnia patients without mental health complaints. Both groups exhibited high rates of objectively diagnosed obstructive sleep apnea, a medical condition associated with pervasive sleep fragmentation. These findings support FDA and AASM guidelines to reassess chronic insomnia patients who manifest residual symptoms despite nightly use of prescription medication for sleep.

Current screening for obstructive sleep apnea (OSA) emphasizes self-reported snoring and other breathing symptoms. Nocturia, a symptom with a precise pathophysiological link to sleep apnea, has not been assessed as a screening tool for this common disorder of sleep respiration. In a large sample of adults presenting to area sleep centers, we aimed to determine the predictive power of nocturia for OSA and compare findings with other markers of OSA commonly used to screen for this disease. This was a retrospective chart review. A consecutive sample of 1,007 adult patients seeking treatment at two sleep centers in New Mexico completed detailed medical and sleep history questionnaires and completed diagnostic polysomnography testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of nocturia, snoring, high body mass index, sex, and age for OSA were determined. Hierarchical linear regression determined unique variance contribution to the apnea-hypopnea index, the objective measure of sleep apnea severity. The results are as follows: sensitivities--snoring, 82.6% and nocturia, 84.8%; specificities--snoring, 43.0% and nocturia, 22.4%; PPVs--snoring, 84.7% and nocturia, 80.6%; and NPVs--snoring, 39.6% and nocturia, 27.9%. With hierarchical linear regression, patient-reported nocturia frequency predicted apnea-hypopnea index (OSA severity) above and beyond body mass index, sex, age, and self-reported snoring (P<0.0001). Nocturia appears comparable to snoring as a screening tool for OSA in patients presenting to a sleep medical center. Research in urology and primary care clinics is needed to definitively clarify the use of nocturia as a screening instrument for obstructive sleep apnea.

Using American Academy of Sleep Medicine research criteria, sleep-disordered breathing (SDB) was assessed in a pilot study of 187 sexual assault survivors with posttraumatic stress symptoms. Nightmares, sleep quality, distress, and quality of life were also assessed along with historical accounts of prior treatments for sleep complaints. Presumptive SDB diagnoses were established for 168 patients. Twenty-one of 168 underwent sleep testing, and all met objective SDB diagnostic criteria. There were no clinically meaningful differences in age, body-mass index, sleep quality, distress, or quality of life measures between 21 confirmed SDB cases and 147 suspected cases not tested. Compared with 19 women without SDB, 168 women with diagnosed or suspected SDB reported significantly worse nightmares, sleep quality, anxiety, depression, posttraumatic stress, and impaired quality of life. Despite suffering from sleep problems for an average of 20 years, which had not responded to repeated use of psychotropic medications or psychotherapy, few of these women had been referred to sleep specialists. SDB appears widespread among sexual assault survivors seeking help for nightmares. Research is needed to clarify the associations among SDB, distress, and physical and mental health impairment in trauma patients.