Sleep Initiation and Maintenance Disorders: Nowakowski S

Perlis ML, Smith MT, Orff H, Enright T, Nowakowski S, Jungquist C, Plotkin K. · Sleep Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, NY, USA. · Sleep. · Pubmed #15283007 No free full text.

Abstract: BACKGROUND: Daytime fatigue, if not frank sleepiness, is a common symptom among patients with insomnia, one that is exacerbated during acute treatment with cognitive behavior therapy (CBT). The present study was undertaken to assess whether modafinil could be used to reduce daytime fatigue, sleepiness, or both in patients with primary insomnia and whether the pharmacologic augmentation of wakefulness might produce improved sleep by itself or in combination with CBT. METHODS: 30 subjects with primary insomnia were enrolled in this study and were randomly assigned to 1 of 3 treatment conditions: (1) placebo plus CBT, (2) 100 mg modafinil plus CBT, or (3) 100 mg modafinil plus a contact control (monitor-only condition). Subjects were continuously monitored with sleep diaries from study intake until study end (10 weeks) and were evaluated on a weekly basis for changes in sleepiness. RESULTS: The mean age of the group was 41.3 years (SD, 13.4), and 70.4% of subjects were women. All 3 groups exhibited mean sleep latency and wake after sleep-onset times that were more than 30 minutes in duration. The mean pretreatment sleep profiles did not significantly differ. Modafinil, when administered alone, did not significantly affect the patients' sleep profiles. A trend, however, was evident for improved sleep latency. Modafinil, as an adjunct to CBT, tended to (1) reduce daytime sleepiness as measured by the Epworth Sleepiness Scale and (2) enhance compliance with CBT. With respect to the latter, subjects in the modafinil plus CBT group more reliably adhered to the prescribed phase delay in bedtime than did the placebo plus CBT group. DISCUSSION: These data suggest that modafinil may be used to diminish the negative side effects of CBT (increased daytime sleepiness) and may increase subject compliance with therapy. Whether enhanced daytime function mediates the change in adherence and whether reduced sleepiness and enhanced compliance translate to less patient attrition in the clinical setting remain to be evaluated.

Orff HJ, Drummond SP, Nowakowski S, Perils ML. · Joint Doctoral Program in Clinical Psychology, San Diego State University and University of California, San Diego, CA, USA. · Sleep. · Pubmed #17910392 links to  free full text

Abstract: STUDY OBJECTIVES: While daytime impairment is a defining feature of primary insomnia (PI), prior research using objective measures has not yielded clear and reliable evidence of global or specific deficits. In this investigation subjective and neuropsychological measures of daytime impairment were concurrently evaluated in subjects with primary insomnia (PIs) and in healthy good sleeper subjects (GSs). The goals for the study were to assess (1) whether PIs differ from GSs on subjective and/or objective measures and (2) the extent to which subjective and objective measures provide discordant information. DESIGN: Subjects were evaluated on multiple self-report measures of sleep and daytime performance and were administered a comprehensive set of neuropsychological tests. SETTING: The University of Rochester Sleep and Neurophysiology Research Laboratory (Rochester, NY). PATIENTS OR PARTICIPANTS: Forty-nine subjects (32 PIs and 17 GSs). Seventy-one percent of the sample was female; average age 39 +/- 11 yrs. RESULTS: Overall, PIs reported worse sleep, diminished activity levels, and a greater number and severity of daytime complaints. However, PIs did not show deficits on neuropsychological tests. Additionally, neuropsychological measures were not associated with severity of daytime complaints. Objectively measured sleep was found to be associated with performance (motor speed), while prospective and objective sleep measures were associated with level of daytime complaint. CONCLUSIONS: The discrepancy between subjective daytime complaints and objective performance in individuals with insomnia is common, but poorly understood. This discordance may suggest that daytime impairment corresponds less to "output" and more to attentional bias or to the realistic appraisal that "effort" is required to maintain normal performance.

Perlis ML, Smith MT, Cacialli DO, Nowakowski S, Orff H. · Sleep Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, University of Rochester, Rochester, NY 14642, USA. · J Psychosom Res. · Pubmed #12505555 No free full text.

Abstract: OBJECTIVES: Recently, we undertook an empirical review using meta-analytic techniques to assess the extent to which these therapeutic strategies produce comparable outcomes. No differences between the two therapeutic strategies were found, except for sleep latency (SL). Behavior therapy demonstrated a greater reduction in latency to sleep onset as compared to pharmacotherapy. In the present paper, we provide a brief summary of our meta-analysis and then (1) critically review the outcomes and (2) place the findings into a larger context that takes into account what factors represent barriers to treatment and how can we insure that in the future patients will have increased access to behavioral sleep medicine services.