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1.  Barriers and Facilitators to Being Physically Active on a Rural U.S. Northern Plains American Indian Reservation 
The objective of the present study was to identify barriers to and facilitators of physical activity among American Indian adults living on a rural, U.S. Northern Plains reservation using the nominal group technique (NGT). NGT is a method of data generation and interpretation that combines aspects of qualitative (free generation of responses) and quantitative (systematic ranking of responses) methodologies. Adults participated in one of two NGT sessions asking about either barriers to (n = 6), or facilitators of (n = 5), being physically active. Participants nominated and ranked 21 barriers and 18 facilitators. Barriers indicated lack of knowledge of how to fit physical activity into a daily schedule, work, caring for family members, and prioritizing sedentary pursuits. Other responses included environmental barriers such as lack of access and transportation to a gym, unsafe walking conditions, and inclement weather. Facilitators to following recommendations included knowledge of health benefits of physical activity and the perception of physical activity as enjoyable, including feeling good when working out. Environmental facilitators included being outdoors walking and biking as well as parks and exercise facilities. Responses provided direction for locally designed community-based programs to promote facilitators and decrease barriers to individual’s engagement in physical activity.
PMCID: PMC4245660  PMID: 25421064
American Indians; physical activity; rural; reservation; barriers; facilitators
2.  A Randomized Controlled Trial of an Internet Intervention for Adults with Insomnia: Effects on Comorbid Psychological and Fatigue Symptoms 
Journal of clinical psychology  2013;69(10):1078-1093.
Insomnia is frequently comorbid with other medical and psychological disorders. This secondary data analysis investigated whether an Internet-delivered cognitive behavioral therapy for insomnia (CBT-I) intervention could also reduce comorbid psychological and fatigue symptoms.
Data from a pilot randomized controlled trial (RCT) testing the efficacy of Internet-delivered CBT-I relative to a waitlist control was used to examine changes in symptoms of depression, anxiety, mental health quality of life (QOL), and fatigue.
Group by time interactions from repeated measures analyses revealed significant post intervention improvements in Internet participants (n = 22) relative to control participants (n = 22) on all psychological symptoms, mental health QOL, and fatigue. A small post hoc subsample of Internet participants with mild or moderate depression also showed large effect size changes in these constructs (depression, anxiety, mental health QOL, and fatigue).
Internet-delivered CBT-I appears to not only improve sleep but also reduce comorbid psychological and fatigue symptoms.
PMCID: PMC4078738  PMID: 24014057
insomnia; eHealth; depression; anxiety; fatigue; Internet; online; CBT; CBT-I; cognitive behavioral therapy; web
3.  ‘Folk theories’ about the causes of insomnia 
Cognitive therapy and research  2013;37(5):10.1007/s10608-013-9543-2.
The present study investigates ‘folk theories’ about the causes of insomnia. Participants with insomnia (n = 69) completed a qualitative and quantitative assessment of their folk theories. The qualitative assessment was to speak aloud for 1 minute in response to: ‘What do you think causes your insomnia?’. The quantitative assessment involved completing the ‘Causal Attributions of My Insomnia Questionnaire’ (CAM-I), developed for this study. The three most common folk theories for both the causes of one’s own insomnia as well as insomnia in others were ‘emotions’, ‘thinking patterns’ and ‘sleep-related emotions’. Interventions targeting these factors were also perceived as most likely to be viable treatments. Seventy-five percent of the folk theories of insomnia investigated with the CAM-I were rated as more likely to be alleviated by a psychological versus a biological treatment. The results are consistent with research highlighting that folk theories are generally coherent and inform a range of judgments. Future research should focus on congruence of ‘folk theories’ between treatment providers and patients, as well as the role of folk theories in treatment choice, engagement, compliance and outcome.
PMCID: PMC3811969  PMID: 24187398
insomnia; folk theories; causal attributions
4.  Efficacy of an Internet-Based Behavioral Intervention for Adults with Insomnia 
Archives of general psychiatry  2009;66(7):692-698.
Insomnia is a major health problem with significant psychological, health, and economic consequences. However, availability to one of the most effective insomnia treatments, Cognitive Behavioral Therapy (CBT), is significantly limited. The Internet may be a key conduit for delivering this intervention.
To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia.
Design, Setting, and Participants:
45 adults were randomly assigned to an Internet intervention (n=22) or wait-list control group (n=23). 44 eligible participants were included in the analyses (mean age, 44.86±11.03 years; 34 women), who had, on average, a history of sleep difficulties greater than 10 years (10.59±8.89).
The Internet intervention is based on well-established face-to-face CBT, incorporating the primary components of sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and relapse prevention.
Main Outcome Measure(s):
The Insomnia Severity Index (ISI) and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset (WASO) and sleep efficiency (SE).
Intent-to-treat analyses showed that scores on the ISI significantly improved from 15.73 (95% CI, 14.07-17.39) to 6.59 (95% CI, 4.73-8.45) for the Internet group, but did not change for the control group, 16.27 (95% CI, 14.61-17.94) to 15.50 (95% CI, 13.64-17.36), F (1, 42) = 29.64, p<.001. The Internet group maintained their gains at six month follow-up. Internet participants also achieved significant decreases in WASO (55%; 95% CI, 34%-76%) and increases in SE (16%; 95% CI, 9%-22%) compared to the non-significant control group changes of WASO (8%; 95% CI, −17%-33%) and SE (3%; 95% CI, −4%-9%).
Participants who received the Internet intervention for insomnia significantly improved their sleep, whereas the control group did not change. The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia.
PMCID: PMC3723339  PMID: 19581560
Sleep medicine  2011;13(1):52-57.
To explore how insomnia symptoms are hierarchically organized in individuals reporting daytime consequences of their sleep disturbances.
This is a cross-sectional study conducted in the general population of the states of California, New York and Texas. The sample included 8,937 individuals aged 18 years or older representative of the general population. Telephone interviews on sleep habits and disorders were managed with the Sleep-EVAL expert system and using DSM-IV and ICSD classifications. Insomnia symptoms and Global Sleep Dissatisfaction (GSD) had to occur at least three times per week for at least three months.
A total of 26.2% of the sample had a GSD. Individuals with GSD reported at least one insomnia symptom in 73.1% of the cases. The presence of GSD in addition to insomnia symptoms considerably increased the proportion of individuals with daytime consequences related to insomnia. In the classification trees performed, GSD arrived as the first predictor for daytime consequences related to insomnia. The second predictor was nonrestorative sleep followed by difficulty resuming sleep and difficulty initiating sleep.
Classification trees are a useful way to hierarchically organize symptoms and to help diagnostic classifications. In this study, GSD was found to be the foremost symptom in identifying individuals with daytime consequences related to insomnia.
PMCID: PMC3249005  PMID: 22036602
6.  A founder mutation in the PEX6 gene is responsible for increased incidence of Zellweger syndrome in a French Canadian population 
BMC Medical Genetics  2012;13:72.
Zellweger syndrome (ZS) is a peroxisome biogenesis disorder due to mutations in any one of 13 PEX genes. Increased incidence of ZS has been suspected in French-Canadians of the Saguenay-Lac-St-Jean region (SLSJ) of Quebec, but this remains unsolved.
We identified 5 ZS patients from SLSJ diagnosed by peroxisome dysfunction between 1990–2010 and sequenced all coding exons of known PEX genes in one patient using Next Generation Sequencing (NGS) for diagnostic confirmation.
A homozygous mutation (c.802_815del, p.[Val207_Gln294del, Val76_Gln294del]) in PEX6 was identified and then shown in 4 other patients. Parental heterozygosity was confirmed in all. Incidence of ZS was estimated to 1 in 12,191 live births, with a carrier frequency of 1 in 55. In addition, we present data suggesting that this mutation abolishes a SF2/ASF splice enhancer binding site, resulting in the use of two alternative cryptic donor splice sites and predicted to encode an internally deleted in-frame protein.
We report increased incidence of ZS in French-Canadians of SLSJ caused by a PEX6 founder mutation. To our knowledge, this is the highest reported incidence of ZS worldwide. These findings have implications for carrier screening and support the utility of NGS for molecular confirmation of peroxisomal disorders.
PMCID: PMC3483250  PMID: 22894767
Zellweger syndrome; Founder effect; Peroxisome biogenesis disorders; Next generation sequencing
7.  Relations between sleep, fatigue and health-related quality of life in individuals with insomnia 
Journal of psychosomatic research  2010;69(5):475-483.
This study explored the relations between sleep, fatigue and health-related quality of life in a sample of individuals with chronic insomnia.
A total of 160 adults meeting diagnostic criteria for chronic insomnia underwent three nights of polysomnography (PSG) and completed sleep diaries and questionnaires assessing daytime functioning including fatigue and health-related quality of life.
A cluster analysis was conducted based on PSG-defined sleep disturbances and fatigue severity. A four-cluster solution (R2 = 0.68) was found, classifying individuals as having either (a) both severe sleep disturbance and severe fatigue (n = 15); (b) severe sleep disturbance but milder fatigue (n = 15); (c) milder sleep disturbance but severe fatigue (n = 68) or (d) both milder sleep disturbance and milder fatigue (n = 61). Health-related quality of life was lower in both clusters with severe fatigue compared to those with milder fatigue, and was further decreased when severe sleep disturbances were present. Relations between several indicators of fatigue and health-related quality of life were then examined using factor analysis in order to identify different domains of impairment. A three-factor structure was selected, suggesting that daytime symptoms can be classified as relating to fatigue, physical health, or mental health. These different subtypes of daytime impairment were predicted by distinct sets of variables.
More severe fatigue is not necessarily related to poorer PSG-defined sleep but appears associated with greater impairment in health-related quality of life. Fatigue and health-related quality of life appear to be distinct but interrelated constructs.
PMCID: PMC2958173  PMID: 20955867
insomnia; sleep disturbances; fatigue; health-related quality of life; daytime impairment
8.  Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia: Acute and Maintenance Therapeutic Effects 
Cognitive-behavior therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome.
To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome.
Design, Setting, and Patients
Prospective, randomized, clinical trial involving two-stage therapy with 160 adults with persistent insomnia treated at a university hospital sleep center between January 2002 and April 2005.
Participants received CBT alone or CBT plus zolpidem for an initial six-week therapy, followed by extended 6-month therapy. Patients treated with CBT initially attended monthly maintenance CBT or no additional treatment and those treated with combined therapy initially continued with CBT plus intermittent medication or CBT without medication (tapering).
Main Outcome Measures
Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary) and response and remission rates derived from the Insomnia Severity Index (secondary).
CBT used singly or in combination with medication produced significant improvements of sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (Ps < 0.001); a larger increase of sleep time was obtained with the combined approach (P = 0.04). Both CBT and combined therapies produced similar rates of treatment responders (60% [45/75] vs. 61% [45/74], P = 0.84) and remissions (39% [29/75] vs. 44% [33/74], P = 0.52) with acute treatment, but combined therapy produced a higher remission rate relative to CBT alone over the extended therapy and follow up period (56% [43/74, 32/59] vs. 43% [34/75, 28/68], P = 0.05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up relative to patients who remained on medication during extended therapy (67% [20/30] vs. 41% [12/29], P = 0.04)
In patients with persistent insomnia, the addition of medication to CBT produces added benefits during acute therapy, but long-term outcome is optimized when medication is discontinued during maintenance CBT.
PMCID: PMC3050624  PMID: 19454639
Insomnia; treatment; CBT; medication
9.  Examining maladaptive beliefs about sleep across insomnia patient groups 
Unhelpful beliefs about sleep have been linked to insomnia, and increasing one's cognitive flexibility about sleep has been linked to post-treatment sleep improvement. This study evaluated if levels of such beliefs differ across insomnia groups, and whether there are particular beliefs that differ for specific insomnia subtypes.
Participants (N = 1384) were people with insomnia and good sleepers ranging from 18 to 89 years old (M = 42.6, SD = 19.4). Data from previous studies at five insomnia clinical sites were pooled to examine responses on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16) across differing insomnia groups.
Group analyses revealed that those from community-based insomnia clinics and those who are hypnotic-dependent generally had the highest levels of unhelpful sleep-related beliefs. With the exception of beliefs about sleep needs (wherein only community sleep clinic patients had high scores relative to good sleepers), all insomnia groups had higher scores on the DBAS-16 than good sleepers. A validity analysis suggested that a DBAS-16 index score > 3.8 was the level of unhelpful beliefs associated with clinically significant insomnia, although a slightly lower cutoff may be useful to identify an unhelpful degree of sleep-related beliefs in highly screened PI and medical patient groups.
This study offers descriptive data for the use of the DBAS-16 across insomnia subgroups, which will help the user understand what degree of maladaptive sleep beliefs are most strongly associated with clinically significant levels of insomnia. Results also may have implications for cognitive targeting during treatment for particular insomnia groups.
PMCID: PMC2796256  PMID: 20004301
Beliefs about sleep; cognitive behavior therapy; insomnia; sensitivity and specificity
10.  Management of Hypnotic Discontinuation in Chronic Insomnia 
Sleep medicine clinics  2009;4(4):583-592.
The management of hypnotic discontinuation following regular and prolonged use may be a challenging task for patients and clinicians alike. Current evidence suggests that a stepped-care approach may be a cost-effective approach to assist patients in tapering hypnotics. This approach may involve simple information about the need to discontinue medication, implementation of a supervised and systematic tapering schedule, with or without professional guidance, and cognitive-behavioral therapy. Research evidence shows that this approach appears promising; further research is however necessary to identify treatment and individual characteristics associated with better outcome.
PMCID: PMC2896266  PMID: 20607118
Insomnia; Benzodiazepines; Hypnotic Medications; Discontinuation; Stepped-care approach; Sleep Disorder
11.  Development and Perceived Utility and Impact of an Internet Intervention for Insomnia 
Insomnia is a major health problem, with significant psychological, health, and economic consequences. Studies have demonstrated that cognitive-behavioural therapy can effectively treat insomnia; however, treatment availability is limited by many factors, including a lack of trained clinicians. One potential way to overcome these barriers is to use the Internet to deliver treatment. Toward this aim, we developed a self-guided, interactive, tailored Internet intervention for adults with insomnia (SHUTi: Sleep Healthy Using The Internet). The current paper provides a detailed description of SHUTi and examines users’ perceptions of the intervention’s usefulness and effectiveness. The study was part of a larger randomised controlled trial (RCT) to test the efficacy of SHUTi, but findings in this paper are based only on the 21 participants who completed the post-assessment after using SHUTi. The overwhelming majority rated SHUTi as convenient, understandable, and useful. Nearly all (95%) indicated that the program had at least somewhat improved their sleep, sleep efficiency, and overall quality of life. Ninety percent perceived the intervention as effective and predicted it would be effective in producing a long-term cure. Although these results were based on a small sample, they provide encouraging evidence of the potential for Internet interventions to be accepted by patients.
PMCID: PMC2954428  PMID: 20953264
Internet; Web-based; Insomnia; Patient Acceptance; Behaviour Treatment; Intervention
13.  Generalized anxiety disorder and health care use 
Canadian Family Physician  2005;51(10):1363.
To examine self-reported health care use and health care–seeking behaviour of patients meeting DSM-IV’s diagnostic criteria for generalized anxiety disorder (GAD).
Survey of outpatients recruited at three different times of the day using questionnaires on worry and anxiety (a six-item screening questionnaire based on DSM-IV criteria for GAD), on perceived health problems, and on health care use and health care–seeking behaviour. The assessment package also included well validated assessment instruments for insomnia and depression symptoms. All patients seeking health care were invited to participate. Participants completed the survey as they waited in the reception area.
Four randomly selected community-based medical clinics of Quebec city’s metropolitan area.
A final sample of 1110 patients among 1878 outpatients invited to participate included 219 (19.7%) who tested positive for GAD.
Self-reported worry and anxiety (based on DSM-IV criteria for GAD), self-perceived health problems, health care use and health care–seeking behaviour, insomnia, and symptoms of depression.
Participants who tested positive on a screening test for GAD reported more annual medical visits (5.3 versus 3.4) than other patients. Those who reported at least five annual medical visits were nearly four times more likely to have positive results for GAD. Women were 1.6 times more likely to have positive results than men were. Patients who tested positive reported insomnia-type sleep disturbances, depressive symptoms, fatigue, and gastric problems significantly more often than others. Forty-two percent had consulted a family physician in the past year with a complaint of anxiety. Eighty percent of patients who tested positive reported they believed they had an anxiety problem, and this belief predicted positive test results (odds ratio = 20.3). Yet most reported not having sought other types of medical or psychological care specifically for anxiety in the past year.
Some patients in this sample with symptoms of GAD mainly seek primary care for their symptoms. Questions about excessive worrying and anxiety, as part of routine examination, can increase recognition of GAD.
PMCID: PMC1479795  PMID: 16926971
14.  Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial 
Long-term use of hypnotics is not recommended because of risks of dependency and adverse effects on health. The usual clinical management of benzodiazepine dependency is gradual tapering, but when used alone this method is not highly effective in achieving long-term discontinuation. We compared the efficacy of tapering plus cognitive-behavioural therapy for insomnia with tapering alone in reducing the use of hypnotics by older adults with insomnia.
People with chronic insomnia who had been taking a benzodiazepine every night for more than 3 months were recruited through media advertisements or were referred by their family doctors. They were randomly assigned to undergo either cognitive-behavioural therapy plus gradual tapering of the drug (combined treatment) or gradual tapering only. The cognitive-behavioural therapy was provided by a psychologist in 8 weekly small-group sessions. The tapering was supervised by a physician, who met weekly with each participant over an 8-week period. The main outcome measure was benzodiazepine discontinuation, confirmed by blood screening performed at each of 3 measurement points (immediately after completion of treatment and at 3- and 12-month follow-ups).
Of the 344 potential participants, 65 (mean age 67.4 years) met the inclusion criteria and entered the study. The 2 study groups (35 subjects in the combined treatment group and 30 in the tapering group) were similar in terms of demographic characteristics, duration of insomnia and hypnotic dosage. Immediately after completion of treatment, a greater proportion of patients in the combined treatment group had withdrawn from benzodiazepine use completely (77% [26/34] v. 38% [11/29]; odds ratio [OR] 5.3, 95% confidence interval [CI] 1.8–16.2; OR after adjustment for initial benzodiazepine daily dose 7.9, 95% CI 2.4–30.9). At the 12-month follow-up, the favourable outcome persisted (70% [23/33] v. 24% [7/29]; OR 7.2, 95% CI 2.4–23.7; adjusted OR 7.6, 95% CI 2.5–26.6); similar results were obtained at 3 months.
A combination of cognitive-behavioural therapy and benzodiazepine tapering was superior to tapering alone in the management of patients with insomnia and chronic benzodiazepine use. The beneficial effects were sustained for up to 1 year. Applying this multidisciplinary approach in the community could help reduce benzodiazepine use by older people.
PMCID: PMC236226  PMID: 14609970

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