The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls

doi:10.1016/j.jad.2013.04.041

Journal of Affective Disorders

Volume 150, Issue 2, 5 September 2013, Pages 466-473

https://doi.org/10.1016/j.jad.2013.04.041 Get rights and content

Abstract

Background

Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression.

Methods

Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder.

Results

Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment.

Limitations

Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based.

Conclusions

Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.

Introduction

Unhelpful beliefs and attitudes about sleep include rigidly-held beliefs and unrealistic expectations about sleep (Carney et al., 2010). Such beliefs and attitudes are associated with disturbed sleep and insomnia (Morin et al., 1993, Carney and Edinger, 2006). Fortunately, cognitive behavioral therapy for insomnia (CBT-I) modifies the rigidity of sleep-related beliefs, while increasing sleep efficiency and reducing insomnia symptoms (Carney and Edinger, 2006). Individuals with mood disorders may have even higher rates of sleep-related beliefs than those with primary insomnia (i.e., not due to an underlying medical or psychiatric disorder; Carney et al., 2007), but it is not known whether individuals with seasonal affective disorder (SAD) endorse these beliefs as well. If individuals with SAD endorse unhelpful beliefs about sleep, this may have significant treatment implications. SAD involves a seasonally recurring pattern of major depressive episodes, usually in the fall or winter, followed by remission or change to mania or hypomania in spring or summer (Rosenthal et al., 1984a, Rosenthal et al., 1984b). SAD is characterized by sleep disturbances, particularly a relatively high frequency of self-reported hypersomnia (Kaplan and Harvey, 2009, Harvey, 2011). It is unknown whether the sleep-related beliefs endorsed in nonseasonal depression, characterized by insomnia, and primary insomnia are also present in SAD.

The cognitive model of insomnia posits that certain beliefs about sleep cause increased arousal and cognitive attention to “sleep-related threats,” leading to or exacerbating sleep disruption (Harvey, 2002). If individuals with SAD reporting hypersomnia are spending more time asleep, then they may be less likely to share beliefs about sleep with individuals experiencing insomnia. However, reviews suggest that individuals reporting hypersomnia spend more time in bed, but not necessarily more time asleep (Kaplan and Harvey, 2009, Harvey, 2011). Also, others suggest that individuals with mood disorders may report hypersomnia as a reflection of fatigue, rather than actual increased total sleep time (Nofzinger et al., 1991). Hypersomnia may be a function of this same cognitive mechanism. Both those reporting insomnia and those reporting hypersomnia may wish for more sleep, may be vigilant for factors that could interfere with sleep, and may worry about the consequences of not getting enough sleep—all of which reflect unhelpful beliefs and attitudes about sleep. This study will examine the extent to which individuals with SAD endorse unhelpful beliefs and attitudes about sleep, and whether or not the endorsement of these beliefs is associated with insomnia or hypersomnia.

Sleep-related beliefs could be considered a vulnerability factor that persists after treatment for depression and could therefore increase risk for relapse in mood disorders (Carney et al., 2011). One study of individuals with co-occurring insomnia and depression found that levels of depression did not account for the high levels of unhelpful beliefs about sleep (Carney and Edinger, 2006). A follow-up study treating those with depression and insomnia found that a solely depression-focused cognitive-behavioral treatment did not change endorsement of maladaptive sleep-related beliefs (Carney et al., 2011). Therefore, unhelpful beliefs about sleep are thought to be unique, and not simply a subset of more general negative beliefs (Carney et al., 2011). If such beliefs are found in SAD, adjunctive treatment with CBT-I may be useful. However, given that individuals with SAD report both hypersomnia and insomnia, it must first be determined if unhelpful beliefs about sleep are unique to those reporting insomnia, or if they are also observed with hypersomnia.

We administered the 16-item Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16; Morin et al., 2007), which consists of items from the original 30-item scale that have moderate means, sufficient variance to avoid a floor effect, good internal consistency, low missing-data rates, and are non-redundant (Morin et al., 2007). The DBAS-16 has been associated with clinically significant insomnia in multiple insomnia groups, and can distinguish these groups from good sleepers (Carney et al., 2010). Although some beliefs about sleep are specific to insomnia (i.e., “I am concerned that chronic insomnia may have serious consequences on my physical health.”), many items are compatible with hypersomnia (i.e., “Without an adequate night's sleep, I can hardly function the next day.”).

Our first prediction is that individuals with SAD will have elevated DBAS-16 scores compared to controls, and similar levels compared to individuals with nonseasonal unipolar depression (MDD). Second, we predict that individuals reporting both insomnia and hypersomnia will have increased rates of unhelpful beliefs about sleep compared to those reporting neither hypersomnia nor insomnia. Third, we predict that self-reported hypersomnia will be associated with fatigue, as reports of hypersomnia may reflect a desire or wish for more sleep due to fatigue.

Section snippets

Participants

Participants were adults of age 18–65 recruited through local media in Pittsburgh, Pennsylvania, for a study on SAD. Individuals were encouraged to volunteer if they had a history of depression, either with or without a seasonal pattern, or in the case of controls, no history of depression. Participants completed their assessments during the fall or winter months. All study procedures were explained to participants prior to obtaining informed consent, and they were given an opportunity to ask

Results

The total frequency of self-reported hypersomnia in our SAD group was 64.7% (including both individuals reporting hypersomnia only and those reporting both hypersomnia and insomnia) (Table 1). A total of 147 individuals completed the DBAS-16, and groups did not differ by age (F(3146)=2.35, p=0.08) or gender (X²=4.04, p=0.26) (Table 2). Groups did differ significantly by average DBAS-16 score (F(2146)=31.87, p<.001, partial eta squared (η²)=0.31). Specific contrasts show that DBAS-16 scores in

Discussion

Regarding our first hypothesis, we found that individuals with SAD are likely to report elevated rates of unhelpful beliefs about sleep compared to those with no history of depression. This indicates that individuals with SAD may benefit from interventions focused on altering such beliefs about sleep. In addition, individuals with insomnia, hypersomnia, and both insomnia and hypersomnia all have elevated unhelpful beliefs and attitudes about sleep compared to never-depressed controls,

Conclusions and future directions

An index score of 3.8 on the DBAS-16 scale has been identified as a cut-off for clinically significant level of endorsement of unhelpful beliefs and attitudes about sleep (Carney et al., 2010). Because our SAD group had an average index score of 4.6 (SD=2.0), treatments designed to target dysfunctional beliefs and attitudes about sleep may be beneficial as adjunctive treatment for those diagnosed with SAD. A 4-session CBT designed to address sleep disruptive beliefs and habits protocol versus a

Role of funding source

The project described was supported by the National Institutes of Health through Grant nos. UL1RR024153 and UL1TR000005.

Conflict of interest

All other authors declare that they have no conflicts of interest.

Acknowledgments

We are grateful to Daniel J. Buysse, M.D., for help with the manuscript.

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Sleep disturbances beyond hypersomnia are often overlooked in seasonal depression. The ‘Disrupted sleep’ cluster evidenced fragmented and irregular sleep, supporting prior sleep fragmentation symptoms reported in seasonal samples (Borisenkov et al., 2015; Roecklein et al., 2013; Winkler et al., 2005). The presence of an ‘Disrupted sleep’ cluster with total sleep times similar to controls could have obscured the existence of longer total sleep times in seasonal depression in prior studies (Anderson et al., 1994; Shapiro et al., 1994; Winkler et al., 2005; Wescott et al., 2021).
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Sleep and circadian disruptions in seasonal depression are not uniformly characterized by hypersomnia and circadian phase delay. Presence of distinct sleep and circadian subgroups in seasonal depression may predict successful treatment response. Prospective assessment and tailoring of individual sleep and circadian disruptions may reduce treatment failures.
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Poor sleep quality is common in depression, but complaints of poor sleep quality are not necessarily tied to objective sleep, and the construct of sleep quality remains poorly understood. Previous work suggests that beliefs about sleep may influence sleep quality appraisals, as might sleep variability from night to night.
We tested whether beliefs about sleep predict daily sleep quality ratings above and beyond nightly variability of actigraphy and diary-assessed sleep over the course of multiple nights.
Eighty-eight participants aged 18–65 years across a depressive continuum completed sleep diaries and reported their sleep quality and mood each morning; actigraphy was also completed for 67 of those participants. Multilevel models were used to test previous night's total sleep time and sleep efficiency as predictors of self-reported sleep quality (VAS-SQ) and mood (VAS-M), and whether unhelpful beliefs about sleep predicted VAS-SQ and VAS-M above and beyond the sleep variables.
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Although childhood maltreatment has been studied in multiple psychopathologies, its role in Seasonal Affective Disorder (SAD) is unknown. The current study examined possible mediators of the relationship between retrospectively-reported childhood maltreatment and adult SAD symptom severity during a major depressive episode in winter.
Participants (N = 113), ages 18 to 65, completed measures of childhood maltreatment, SAD severity, sleep disturbances, ruminative brooding, and maladaptive cognitions. Mediation analyses testing the relationship between childhood maltreatment and SAD symptom severity via sleep and cognitive factors were conducted using PROCESS (Hayes, 2012).
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Including time in bed variables [29] and incorporating home actigraphy or polysomnography would determine if hypersomnolence reports stem from increased time in bed, or other behavioral or emotional factors. Self-reports of combined insomnia and hypersomnolence in a seasonal depression sample suggests alternating patterns of insomnia and hypersomnolence, which may be obscured when averaging sleep duration across multiple nights [30•]. After a night of difficulty initiating sleep, individuals might compensate by taking daytime naps, getting into bed early, or sleeping in the next morning [39].
Sleep in seasonal affective disorder (SAD) has been primarily characterized by delayed sleep timing and self-reports of hypersomnolence. It is unclear whether delayed sleep timing is due to circadian or behavioral misalignment and if effective treatments operate independently of the circadian system. Discrepancies between self-report and actigraphic/polysomnographic sleep duration in SAD hinder clarification of hypersomnolence as a cardinal symptom. Previous studies have largely neglected the summer remission period in SAD, which could yield valuable insight to the role sleep disturbances play in the onset and recurrence of winter depressive episodes. Future studies should incorporate multi-method, multi-season assessment of sleep and circadian rhythms to best characterize relevant sleep-circadian phenotypes. Empirically determining sleep phenotypes present in SAD will pave the way for targeted sleep interventions.
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Trait ruminators exhibit significantly higher levels of sleep disturbance than those without this cognitive vulnerability. However, support for the sleep disruptive effects of state rumination, especially in the pre-sleep period, is rare, and hindered by methodological drawbacks such as self-report and single night assays of sleep. Finally, despite the pervasiveness of the ruminative response style among individuals with depression, the association between rumination and sleep disturbance has not been explored in this population. The present study employed a week-long daily sampling approach to examine the effects of naturally occurring pre-sleep rumination on self-reported and actigraphy-based sleep among individuals with high depressive symptomatology.
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Research reportThe role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls

Abstract

Background

Methods

Results

Limitations

Conclusions

Introduction

Section snippets

Participants

Results

Discussion

Conclusions and future directions

Role of funding source

Conflict of interest

Acknowledgments

J. Psychosom. Res.

Psychiatr. Res.

J. Psychosom. Res.

J. Psychosom. Res.

J. Psychosom. Res.

Behav. Res. Ther.

Sleep Med. Rev.

J. Psychiatr. Res.

Behav. Ther.

J. Affect. Disord.

The etiology and management of insomnia

Va. Med. Q

Identifying critical beliefs about sleep in primary insomnia

Sleep

Residual sleep beliefs and sleep disturbance following Cognitive Behavioral Therapy for major depression

Depress. Anxiety

Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial

Sleep

Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/PSY SCREEN)

Research report
The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls