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Insomnia is underrecognized and inadequately managed, with close to 60% of cancer survivors experiencing insomnia at some point in the treatment trajectory. The objective of this study was to further understand predisposing, precipitating, and perpetuating factors in the development and maintenance of insomnia in cancer survivors.
A heterogeneous sample of 63 patients who had completed active treatment was recruited. Participants were required to have a score >7 on the Insomnia Severity Index and meet the diagnostic criteria for insomnia disorder. Open-ended, semistructured interviews were conducted to elicit participants’ experiences with sleep problems. An a priori set of codes and a set of codes that emerged from the data were used to analyze the data.
The mean age of the sample was 60.5 years, with 30% identifying as non-white and 59% reporting their sex as female. The cancer types represented were heterogeneous with the two most common being breast (30%) and prostate (21%). Participants described an inherited risk for insomnia, anxious temperament, and insufficient ability to relax as predisposing factors. Respondents were split as to whether they classified their cancer diagnosis as the precipitating factor for their insomnia. Participants reported several behaviors that are known to perpetuate problems with sleep including napping, using back-lit electronics before bed, and poor sleep hygiene. One of the most prominent themes identified was the use of sleeping medications. Participants reported that they were reluctant to take medication but felt that it was the only option to treat their insomnia and that it was encouraged by their doctors.
Significance of results
Insomnia is a prevalent, but highly treatable, disorder in cancer survivors. Patients and provider education is needed to change individual and organizational behaviors that contribute to the development and maintenance of insomnia and increase access to evidence-based nonpharmacological interventions.
This study examined insomnia in the context of breast cancer, both as an independent symptom and as a component of a symptom cluster that includes depression, anxiety, fatigue, and pain.
Women with a history of breast cancer currently taking an aromatase inhibitor and who had completed cancer treatment at least one month prior to enrollment were included (n = 413). Participants completed validated measures of insomnia, fatigue, pain, depression, and anxiety. Factor analysis was utilized to examine the extent to which these symptoms could be represented by common latent factors. Insomnia severity was then separated into a symptom cluster component (I–SC) and an insomnia-unique (I–U) component. The associations between each insomnia component and demographic and clinical factors were examined in multivariate models.
A single-factor solution provided the best fit to the symptom measures. Some 53.3% of the variance in insomnia severity was captured by this symptom cluster (I–SC), with the remaining 43.7% being unique to insomnia (I–U). Unique patterns of demographic factors (e.g., age and body–mass index), but not clinical factors, were associated with each insomnia measure.
Significance of results:
Approximately 50% of insomnia severity was related to the symptom cluster, with the rest being unique to insomnia. Different sociodemographic risk factors were related to the different insomnia measures. Stronger underlying foundations for the mechanisms of each component could lead to refined diagnoses and targeted interventions for addressing the overall insomnia burden in cancer patients.
Disturbed sleep is a central feature of depression. Sleep may be construed in terms of sleep continuity ϵ, sleep architecture, and sleep micro-architecture, as well as various subtypes of these patterns. Investigation of the role of circadian rhythms in depression has generally supported a phase advance of the circadian rhythm. An alternate approach to studying brain activity during sleep is through the use of neuro-imaging, which has produced data that help to clarify the earlier rapid eye movement (REM) and non-rapid eye movement (NREM) findings. A number of investigators have examined the clinical correlates of sleep disturbance in depression. Clearly, sleep disturbance and depression are intricately intertwined, although the direction of causation and potential interactions are less certain. There is a long history of research investigating the relationship between sleep disturbance and depression. Sleep abnormalities include disturbances in sleep continuity, sleep architecture, quantitative EEG, circadian rhythms, and CNS arousal.
There are a number of meta-analyses that summarize the literatures for both benzodiazepines (BZs) and benzodiazepine receptor agonists and for cognitive behavioral therapy for insomnia (CBT-I). The DSM-IV differentiates between primary insomnia, in which the sleep disorder occurs as an isolated condition, and secondary insomnia, in which it occurs in the context of another disorder. In general there are three main types of therapy that can be employed, from a behavioral standpoint, to deal with chronic insomnia: stimulus control, sleep restriction, and sleep hygiene therapies. CBT techniques for insomnia can be challenging for both the client and the practitioner. Insomnia represents one of the more ubiquitous forms of sleep disturbance in psychiatric and medical disorders, and in its primary form. Unfortunately, despite its prevalence and associated negative sequelae, only a small fraction of patients seek out treatment or have access to behavioral sleep medicine specialists.
Obstructive sleep apnea (OSA), a frequent form of sleep disordered breathing (SDB), is associated with commonly occurring cardiovascular disorders, including hypertension, coronary artery disease, congestive heart failure. Central sleep apnea (CSA) is frequently associated with congestive heart failure (CHF). Cheyne Stokes respiration (CSR), a form of periodic breathing, commonly accompanies CSA patients with heart failure and portends increased mortality. This chapter explores these and other associations between sleep disorders and cardiovascular disease. SDB is highly prevalent in the elderly and the odds of having significant SDB are estimated at 1.79 per 10-year increase in age. The relation between insomnia and cardiovascular disorders has been less well examined than that between SDB and cardiovascular disorders, especially in the elderly. Large prospective studies will be needed to understand the association between insomnia complaints and coronary artery disease (CAD), and determine the direction of causality, if any.