Insomnia is a common health complaint that often becomes a persistent problem. The theoretical frameworks for understanding and treating insomnia have mostly been behavioural, yet the importance of cognitive processes has received greater attention over the years. The overall aim of this dissertation was to expand the knowledge on the processes from the Cognitive Model of Insomnia by investigating them in novel contexts. Study I examined the outcomes from cognitive therapy for insomnia on adolescents. Study II explored the relationship between cognitive processes and the association with remission and persistence of insomnia in the general population. Lastly, Study III investigated if cognitive processes mediated between cognitive behavioural therapy for insomnia (CBT-I) and outcomes of insomnia and depressive severity in a sample of people with insomnia comorbid with depressive problems. The findings show that cognitive therapy for insomnia affected sleep for adolescents, thus this is a promising treatment option for this age group. Further, it was found that cognitive processes distinguished between adults with normal sleep and persistent insomnia. For people with insomnia, elevated sleep-related worry at baseline increased the risk of reporting persistent insomnia later on, whereas a lowering of selective attention and monitoring, and safety behaviours over time increased the likelihood of remission from insomnia. This has clinical implications for insomnia assessment and treatment, as well as theoretical implications, and warrants further research. CBT-I was associated with greater reductions in dysfunctional beliefs and sleep-related safety behaviours compared to control treatment. Dysfunctional beliefs mediated between CBT-I and insomnia severity and depressive severity respectively. This supports the importance of negative thought content in both insomnia and depression.

This thesis consists of three essays on the economics of sleep time and work stress. The first essay, “the impact of economic factors on sleep: the role of insomnia”, discusses the role played by insomnia on the link between economic variables and sleep time. Insomnia is a common phenomenon experienced by many Canadians. This paper uses the Canadian General Social Survey (GSS) 2005 to investigate the effect of economic factors on the sleep time of the labour force. It replicates previous work by Biddle and Hamermesh (1990) and then extends this work to look at the role played by insomnia on the link between economic variables and sleep time. The paper concludes that the presence of sleep problems can significantly change the impact of economic determinants such as wage and education on sleep time. This paper finds that a 10 percent increase in the wage rate decreases sleep time by almost 20 minutes per week for non-insomniacs while an increase in the wage rate does not have any impact on sleep time for insomniacs. In fact, the link between wage and sleep time appears to be broken for insomniacs as they do not want to, or cannot, sacrifice their sleep time in order to have more money in their pockets. The second essay, “sleep time and wages: the role of chronic diseases and work environment”, examines the role played by chronic diseases and work environment on the link between economic variables and sleep time. This paper, which expands on the work of the first essay, uses the Canadian Community Health Survey (CCHS) 2001 to investigate the roles of insomnia, chronic diseases and stressful work environments on the link between the wage rate and sleep time. Whereas Biddle and Hamermesh (1990) report that individuals sleep 14 minutes less per week as a result of a 10% increase in the wage rate, I find that this number increases to 30 minutes for individuals without sleep problems while it is zero for insomniacs. Moreover, the impact of wages on sleep time is even more pronounced – more than 60 minutes per week - once account is taken of health conditions and of the work environment. Interestingly, these health and environmental effects are in addition to their impact on insomnia: in other words, individuals with chronic health problems who are not insomniacs do not respond to an increase in the wage rate by reducing their sleep time. This means that the actual impact of wages on sleep time for those who do not suffer from these conditions is much more important than originally reported by Biddle and Hamermesh (1990). The third essay, “are Québecers more stressed out at work than others? An investigation into the differences between Québec and the Rest of Canada in the level of work stress” discusses the level of stress experienced by workers in Canada. Work stress has a large socio-economic impact: it affects worker absenteeism, productivity, and family life. Psychological health problems including stress at workplace are an important issue in Canada. Using nine cycles spanning twelve years of the Canadian Community Health Survey (CCHS), I find that the level of work stress in Québec is much higher than in any other province. In Québec, 40% of the population report having quite a bit or extremely stressful jobs. In the other provinces, this number is much smaller, in the order of 30% in Ontario, Alberta, Manitoba and British Columbia, and even lower in the Atlantic Provinces. I find that Québec still has a higher level of reported work stress even after controlling for the main determinants of work stress: income, education, health, age, gender, marital status, children and work environment. Unionization rate and unemployment rate in the province do not seem to matter. However, I find that immigrants in Québec have less work stress than native-born Francophones. Also, Francophones in Québec and elsewhere have higher levels of work stress than Anglophones and Allophones. A body of literature has examined the subject of work stress, and while it has been noted by a few authors (Bordeleau and Traoré, 2007 and Lesage et al., 2010) that Québec is different; a thorough analysis of the causes of this phenomenon needs to be done. This paper estimates regression models that include a large number of factors such as age, gender, marital status, census metropolitan area (CMA), urban, immigrants, having young children, household type, living arrangement, mother tongue, language of conversation, race, education, income, working hours, part time job, health, physical activity, type of smoker, type of drinker, sense of belonging to community, provincial unionization rate and provincial unemployment rate to examine why there may be a consistent and persistent different between those who reside in Québec relative to the rest of Canada. I find that, even after controlling for those factors, work stress is still higher in Québec. This study suggests that differences in the legal systems and in cultures may be some of the reasons of the differences between Québec and the rest of Canada.

Bakgrund: Datorspel kan ge en ökad dagtrötthet och försämrad sömnkvalitet hos individer som spelar mer än 2h/dag. Fysisk aktivitet har en akut positiv inverkan på många delar i sömnen såsom sömnkvalitet och dagtrötthet. Syftet med studien var att kartlägga den fysiska aktivitetsnivån och sömnsvårigheter hos datorspelande vuxna, samt undersöka ett eventuellt samband mellan fysisk aktivitet och sömnsvårigheter.  Metod: Författarna genomförde en icke experimentell kvantitativ tvärsnittsstudie med vuxna individer som spelade datorspel minst 2h/dag. 116 svar inkluderades till frågeställning 1 (internt bortfall till frågeställning 2 & 3 n = 20). En webbenkät publicerades i tre svenska Facebook-grupper inriktade mot datorspel för att kartlägga deltagarnas sömn samt fysisk aktivitet. Sömnen mättes med Insomnia Severity Index (ISI) och den fysiska aktiviteten mättes med International Activity Questionnaire Short Form (IPAQ-SF). Resultat: 70% av studiens respondenter hade “Inga kliniska sömnsvårigheter” enligt ISI och 59% bedömdes ha en hög aktivitetsgrad enligt IPAQ-SF. Det förekom inget signifikant samband mellan respondenternas sömnbesvär och fysiska aktivitet.  Diskussion: Förekomsten av sömnbesvär och antal deltagare som uppfyllde kriterierna för insomni var jämförbar med den svenska populationen. Vidare var respondenternas aktivitetsgrad högre än vad som tidigare setts i den svenska befolkningen. För att kunna se ett tydligare samband mellan dessa faktorer är bedömningen att det skulle krävas ett större urval med respondenter. / Background: Computer games can negatively impact sleep in individuals who play more than 2 hours/day. Physical activity can improve many parts of sleep such as sleep quality and less daytime fatigue. The purpose of the study was to map the level of physical activity and sleep difficulties in computer-gaming adults, and to investigate whether there is a correlation between physical activity and sleep difficulties. Method: The authors conducted a non-experimental quantitative cross-sectional study with computer-gaming adults who played at least 2 hours/day. 116 answers were included to question 1 (internal dropout to question 2 & 3 n = 20). A web-survey was published in three Swedish computer game-oriented Facebook groups to map the participants' sleep and physical activity. Sleep was measured with the Insomnia Severity Index (ISI) and physical activity was measured with the International Activity Questionnaire Short Form (IPAQ-SF) Results: 70% of the study respondents had “No clinical sleep difficulties” according to ISI and 59% were classified to have a high activity level according to IPAQ-SF. There was no significant association between the respondents' sleep difficulties and physical activity. Discussion: The occurrence of sleep difficulties and the number of participants who met the criteria for insomnia was comparable to the Swedish population. Furthermore, the respondents' degree of physical activity was higher than previously seen in the Swedish population. In order to be able to see a clearer connection between these factors, the assessment is that a larger selection of respondents would be required.

Sleep disturbances are prevalent in primary care patients and can be exacerbated by interpersonal dysfunction and depression. As well, thwarted interpersonal needs (TIN), including thwarted belongingness and perceived burdensomeness, contribute to depression. However, the presence of gratitude, a cognitive-emotional protective factor, may improve symptoms. We longitudinally examined the mediating role of depressive symptoms on the relation between TIN and sleep disturbances, and the moderating role of gratitude on the TIN-sleep disturbances and depression-sleep disturbances linkages. Our primary care patient sample (N = 223) completed self-report surveys at baseline (T1) and at a one-year follow-up (T2; n = 97). Patients with greater TIN reported more depressive symptoms (T1) and, in turn, increased sleep disturbances (T2). Gratitude did not moderate the belongingness model but, in the burdensomeness model, buffered the linkage between burdensomeness and sleep disturbances and strengthened the relation between depressive symptoms and sleep disturbances. Clinical implications and future research directions are discussed.

Syftet med studien var att beskriva och syntetisera erfarenheter och effekten av olika interventioner för vuxna personer med sömnsvårigheter. Metoden som användes var en litteraturöversikt, genom en mixad metod av kvalitativ innehållsanalys och narrativ sammanställning av kvantitativ data. Litteratursökning genomfördes i fyra databaser, varav 12 studier identifierades motsvara studiens syfte för inkludering. Åtta RCT-studier och fyra studier med kvalitativ metod. Sju interventioner framkom för förbättrad sömnsvårighet vid insomni. Sex av interventionerna har visat ge signifikanta positiva effekter för förbättring vid sömnsvårigheter; Digital eller internetbaserad kognitiv beteendeterapi, Sömnrestriktion, Individanpassad Homeopathy, Sömnhygien, Dreampillow och IRest meditation. Positiva erfarenheter från deltagare med sömnsvårigheter och behandlare kunde kopplas till intervention Sömnrestriktion. Intervention Digital eller Internetbaserad Kognitiv Beteendeterapi var den intervention som föredrogs av vuxna med sömnsvårigheter. Utöver de sömninterventioner som arbetsterapeuter utför kan arbetsterapeuters kompetens gällande att öka aktivitetsbalans bidra till att stötta patienter att fullfölja sömninterventioner. Utifrån resultatet dras följande slutsats att multiprofessionella team bör utformas inom vården för att ta tillvara på professioners olika kompetenser kring sömninterventioner för att genom ett personcentrerat arbetssätt kunna erbjuda bästa möjliga behandling för personer med sömnsvårigheter. Denna litteraturöversikt bidrar till inspiration för vidare förbättringsarbeten för sjukvården för att främja hälsa i samhället genom att behandla sömnsvårigheter. / The purpose of the study was to describe and synthesize experiences and the effect of different interventions for adults with sleep difficulties. The method used was a literature review, through a mixed method of qualitative content analysis and narrative summery of quantitative data. Literature search was performed in four databases, of which 12 articles were identified corresponding to the study's purpose for inclusion. Eight RCT-studies and four studies with a qualitative method. Seven interventions emerged for improved sleep difficulties with insomnia. Six of the interventions have been shown to have significant positive effects for improving sleep difficulties; Digital or internet-based cognitive behavioral therapy, Sleep restriction, Individualized Homeopathy, Sleep hygiene, Dreampillow and IRest meditation. Positive experiences from participants with sleep difficulties and therapists could be linked to intervention Sleep restriction. Intervention Digital or Internet-based Cognitive Behavioral Therapy was the intervention preferred by adults with sleep disorders. In addition to the sleep interventions performed by occupational therapists, occupational therapists' competence in increasing the activity balance can contribute to supporting patients to complete sleep interventions. Based on the results, the following conclusion is drawn that Multiprofessional teams should be designed in healthcare to take advantage of professionals' different competencies regarding sleep interventions in order to be able to offer the best possible treatment for people with sleep difficulties through a person-centered approach. This literature review contributes to inspiration for further improvement work for healthcare to promote health in society by treating sleep difficulties.

Bakgrund: Sedan 2002 har inte bara rubrikerna om sömnstörningar och sömnsvårigheter ökat i de stora medierna. Antalet unga med sömnstörningar ökar varje år, där unga kvinnor är den grupp som ökat mest. Enligt folkhälsomyndighetens rapport 2019 upplever mer än var tredje svensk, 39 %, sömnbesvär i någon grad. Distriktssköterskan arbetar redan med att främja god kost, motion, sunda alkoholvanor, minskad rökning, stress och våld; faktorer som påverkar hälsan i allra högsta grad. Syfte: Att undersöka vilken effekt KBT har på symptomen av sömnproblem, och om metoden applicerbar att utföras av distriktssköterskor. Metod: Systematisk litteraturöversikt där 14 studier valdes ur databaserna Cinahl, Psycinfo och Pubmed. Artiklarna bearbetades gemensamt och de kategorier som framkom återfinns nedan, under respektive rubrik. Resultat: KBT-I både i grupp och i digital form visade på signifikanta förbättringar av sömnen och dess effekt på det dagliga livet. / Background: Since 2002 not only have the headliners about sleep difficulties and sleep disturbances multiplied in the big media. The number of young people with insomnia increases each year, and young women are the group that increases the most. Last year more than every third swede, 39 percent suffered from various grades of insomnia. District nurses already play a big part in preventing disease and promoting health by giving support and knowledge to patients about healthy foods, exercising, drinking habits, smoking, violence at home and stress; all of those very much the key to individual’s health. Aim: of the study to explore how CBT-I might affect the symptoms of insomnia and if this treatment can be performed by nurses. Method: Systematic review by synthesizing 14 studies from the databases Chinal, Psycinfo and Pubmed. The studies were processed individually and thereby mutually to find emerging themes which are to be presented under each heading. Result: CBT-I both in group and in digital form showed significant improvements in sleep and its effect on daily life. / <p>Godkännandedatum: 2020-11-04</p>

Disruption of sleep causes adverse health outcomes and poor quality of life. People with sleep disruption have higher levels than people without disrupted sleep of depression and anxiety and increased rates of cardiovascular diseases. Women have a higher incidence than men of insomnia and depression related to poor sleep. The types of complaints differ significantly between the sexes. Women are more likely than men to complain of insomnia, headache, irritability, and fatigue than the "typical" symptoms of loud snoring and breathing cessation during sleep. Hormones play an important role in sleep in women. Reproductive hormones were found to have a protective effect on sleep apnea in women of premenopausal age. Pregnancy is another period when the prevalence of sleep apnea and restless leg syndrome increases from hormonal effect. Cardiovascular mortality is high in women with obstructive sleep apnea. Continuous positive airway pressure therapy improves outcomes in most cases of obstructive sleep apnea. The epidemiology, risk factors, diagnostic criteria, and therapies for the three most common sleep disorders (insomnia, obstructive sleep apnea, and restless leg syndrome), along with effects of menopause, pregnancy, and social factors on sleep in women, are key considerations for clinicians caring for female patients across the adult life span.

Disruption of sleep causes adverse health outcomes and poor quality of life. People with sleep disruption have higher levels than people without disrupted sleep of depression and anxiety and increased rates of cardiovascular diseases. Women have a higher incidence than men of insomnia and depression related to poor sleep. The types of complaints differ significantly between the sexes. Women are more likely than men to complain of insomnia, headache, irritability, and fatigue than the "typical" symptoms of loud snoring and breathing cessation during sleep. Hormones play an important role in sleep in women. Reproductive hormones were found to have a protective effect on sleep apnea in women of premenopausal age. Pregnancy is another period when the prevalence of sleep apnea and restless leg syndrome increases from hormonal effect. Cardiovascular mortality is high in women with obstructive sleep apnea. Continuous positive airway pressure therapy improves outcomes in most cases of obstructive sleep apnea. The epidemiology, risk factors, diagnostic criteria, and therapies for the three most common sleep disorders (insomnia, obstructive sleep apnea, and restless leg syndrome), along with effects of menopause, pregnancy, and social factors on sleep in women, are key considerations for clinicians caring for female patients across the adult life span.

Indiana University-Purdue University Indianapolis (IUPUI) / Study 1: Background: Insomnia may be a risk factor for cardiovascular disease in HIV (HIV-CVD); however, mechanisms have yet to be elucidated. Methods: We examined cross-sectional associations of insomnia symptoms with biological mechanisms of HIV-CVD (immune activation, systemic inflammation, and coagulation) among 1,542 people living with HIV from the Veterans Aging Cohort Study (VACS) Biomarker Cohort. Past-month insomnia symptoms were assessed by the item, “Difficulty falling or staying asleep?,” with the following response options: “I do not have this symptom” or “I have this symptom and…” “it doesn’t bother me,” “it bothers me a little,” “it bothers me,” “it bothers me a lot.” Circulating levels of the monocyte activation marker soluble CD14 (sCD14), inflammatory marker interleukin-6 (IL-6), and coagulation marker D-dimer were determined from blood specimens. Demographic- and fully-adjusted (CVD risk factors, potential confounders, HIV-related factors) regression models were constructed, with log-transformed biomarker variables as the outcomes. We present the exponentiated regression coefficient (exp[b]) and its 95% confidence interval (CI). Results: For sCD14 and D-dimer, we observed no significant associations. For IL-6, veterans in the “bothers a lot” group had 15% higher IL-6 than veterans in the “I do not have this symptom” group in the demographic-adjusted model (exp[b]=1.15, 95%CI=1.02-1.29, p=.03). This association was nonsignificant in the fully-adjusted model (exp[b]=1.07, 95%CI=0.95-1.19, p=.25). Conclusion: We observed little evidence of relationships between insomnia symptoms and markers of biological mechanisms of HIV-CVD. Other mechanisms may be responsible for the insomnia-CVD relationship in HIV; however, future studies with comprehensive assessments of insomnia symptoms are warranted. Study 2: Background: While insomnia has been identified as a potential risk factor for cardiovascular disease in HIV (HIV-CVD), research on the underlying pathophysiological mechanisms is scarce. Methods: We examined associations between 0-to-12-week changes in sleep disturbance and the concurrent 0-to-12-week changes and the subsequent 12-to-24-week changes in markers of systemic inflammation, coagulation, and endothelial dysfunction among people living with HIV (n = 33-38) enrolled in a depression clinical trial. Sleep disturbance was measured using the Pittsburgh Sleep Quality Index. Inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP) and coagulation marker D-dimer were determined from blood specimens; endothelial dysfunction marker brachial flow-mediated dilation (FMD) was determined by ultrasound. 0-to-12-week variables were calculated as 12-week visit minus baseline, and 12-to-24-week variables were calculated as 24-week minus 12-week. We constructed multivariate linear regression models for each outcome adjusting for age, sex, race/ethnicity, Framingham risk score, and baseline depressive symptoms. Results: We did not observe statistically significant associations between 0-to-12-week changes in sleep disturbance and 0-to-12-week or 12-to-24-week changes in IL-6, CRP, D-dimer, or FMD. However, we did observe potentially meaningful associations, likely undetected due to low power. For 0-to-12-weeks, every 1-standard deviation (SD) increase, or worsening, in the sleep disturbance change score was associated with a 0.41 pg/mL and 80 ng/mL decease in IL-6 and D-dimer, respectively. For 12-to-24-weeks, every 1-SD increase in sleep disturbance change score was associated with a 0.63 mg/L, 111 ng/mL, and 0.82% increase in CRP, D-dimer, and FMD, respectively. Conclusion: We observed potentially meaningful, though not statistically significant, associations between changes in sleep disturbance and changes in biological mechanisms underlying HIV-CVD over time. Some associations were in the expected direction, but others were not. Additional studies are needed that utilize larger samples and validated, comprehensive assessments of insomnia.

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