- Behavioral Sleep Medicine
- Athlete well-being
Clinical Associate Professor, Psychiatry and Behavioral Sciences
Director, Clinical Psychology Fellowship (APA approved), Department of Psychiatry (2021 - Present)
Director, Clinical Fellowship (SBSM, APA approved), Sleep Health & Insomnia Program (2017 - Present)
Associate Director, Sleep Health & Insomnia Program (2015 - Present)
Board Certification: American Board of Sleep Medicine, Sleep Medicine (2013)
Internship: Warren Alpert Medical School Brown University (2009) RI
PhD Training: University of Pennsylvania (2009) PA
Fellowship: Stanford University Medical Center (2013) CA
T32 Fellowship, Beth Israel Deaconess Medical Center/Harvard Medical School (2011)
Graduate and Fellowship Programs
RCT of the effectiveness of stepped-care sleep therapy in general practice: The RESTING study protocol.
Contemporary clinical trials
Cognitive behavioral therapy for insomnia (CBT-I) is an effective, non-pharmacological intervention, designated by the American College of Physicians as the first-line treatment of insomnia disorder. The current randomized controlled study uses a Hybrid-Type-1 design to compare the effectiveness and implementation potential of two approaches to delivering CBT-I in primary care. One approach offers therapy to all patients through an automated, digital CBT-I program (ONLINE-ONLY). The other is a triaged STEPPED-CARE approach that uses a simple Decision Checklist to start patients in either digital or therapist-led treatment; patients making insufficient progress with digital treatment at 2 months are switched to therapist-led treatment. We will randomize 240 individuals (age 50 or older) with insomnia disorder to ONLINE-ONLY or STEPPED-CARE arms. The primary outcomes are insomnia severity and hypnotic medication use, assessed at baseline and at months 2, 4, 6, 9, and 12 after randomization. We hypothesize that STEPPED-CARE will be superior to ONLINE-ONLY in reducing insomnia severity and hypnotic use. We also aim to validate the Decision Checklist and explore moderators of outcome. Additionally, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will use mixed methods to obtain data on the potential for future dissemination and implementation of each approach. This triaged stepped-care approach has the potential to improve sleep, reduce use of hypnotic medications, promote safety, offer convenient access to treatment, and support dissemination of CBT-I to a large number of patients currently facing barriers to accessing treatment. Clinical trial registration:NCT03532282.
View details for DOI 10.1016/j.cct.2022.106749
View details for PubMedID 35367385
CHARACTERISTICS ASSOCIATED WITH NAPPING AMONG PREGNANT WOMEN WITH INSOMNIA
OXFORD UNIV PRESS INC. 2021: A132
View details for Web of Science ID 000698984300329
MEASURING DAYTIME SLEEPINESS IN INSOMNIA DISORDER
OXFORD UNIV PRESS INC. 2021: A151-A152
View details for Web of Science ID 000698984300381
HISTORICAL USE OF SUBSTANCES FOR INSOMNIA IMPACTS CURRENT BELIEFS ABOUT HYPNOTIC MEDICATIONS
OXFORD UNIV PRESS INC. 2021: A148
View details for Web of Science ID 000698984300372
AGE IS ONLY A NUMBER: TREATMENT MODALITY PREFERENCES IN A RANDOMIZED CONTROLLED TRIAL OF CBTI IN OLDER ADULTS
OXFORD UNIV PRESS INC. 2021: A264
View details for Web of Science ID 000698984300674
EXAMINING USE AND BELIEFS ABOUT SLEEP MEDICATIONS IN A SAMPLE OF OLDER ADULTS: THE ROLE OF HYPNOTIC DEPENDENCY
OXFORD UNIV PRESS INC. 2021: A142
View details for Web of Science ID 000698984300355
EVENING CHRONOTYPE PREDICTS SUBJECTIVE SLEEP SYMPTOM SEVERITY IN PREGNANT WOMEN WITH INSOMNIA DISORDER
OXFORD UNIV PRESS INC. 2021: A151
View details for Web of Science ID 000698984300380
- Extending the reach of cognitive behavioral therapy for insomnia via telemedicine. Sleep 2021; 44 (1)
- Treating Insomnia during the COVID-19 Pandemic: Observations and Perspectives from a Behavioral Sleep Medicine Clinic. Behavioral sleep medicine 2020: 1–3
- Insomnia and obstetric outcomes MOSBY-ELSEVIER. 2020: S110–S111
Mothers' postpartum sleep disturbance is associated with the ability to sustain sensitivity toward infants.
2019; 65: 74–83
BACKGROUND/OBJECTIVE: Infancy is a period of rapid development when the quality of caregiving behavior may be particularly consequential for children's long-term functioning. During this critical period for caregiving behavior, parents experience changes in their sleep that may affect their ability to provide sensitive care. The current study investigated the association of mothers' sleep disturbance with both levels and trajectories of maternal sensitivity during interactions with their infants.METHODS: At 18 weeks postpartum, mothers and their infants were observed during a home-based 10-minute "free play" interaction. Mothers' nighttime sleep was objectively measured using actigraphy and subjectively measured using sleep diaries. Maternal sensitivity was coded in two-minute intervals in order to characterize changes in sensitivity across the free play interaction. We used exploratory factor analysis to reduce the dimensionality of the objective and subjective measures of mothers' sleep, identifying a subjective sleep disturbance and an objective sleep continuity factor.RESULTS: Using multi-level modeling, we found that mothers with poorer objective sleep continuity evidenced decreasing sensitivity toward their infants across the interaction. Mothers' self-reports of sleep disturbance were not associated with maternal sensitivity.CONCLUSIONS: Although future research is necessary to identify the mechanisms that may explain the observed association between poor sleep continuity and the inability to sustain sensitivity toward infants, mothers' postpartum sleep continuity may be one factor to consider when designing interventions to improve the quality of caregiving.CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT01846585.
View details for DOI 10.1016/j.sleep.2019.07.017
View details for PubMedID 31734620
Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications.
Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology
Pain can be both a cause and a consequence of sleep deficiency. This bidirectional relationship between sleep and pain has important implications for clinical management of patients, but also for chronic pain prevention and public health more broadly. The review that follows will provide an overview of the neurobiological evidence of mechanisms thought to be involved in the modulation of pain by sleep deficiency, including the opioid, monoaminergic, orexinergic, immune, melatonin, and endocannabinoid systems; the hypothalamus-pituitary-adrenal axis; and adenosine and nitric oxide signaling. In addition, it will provide a broad overview of pharmacological and non-pharmacological approaches for the management of chronic pain comorbid with sleep disturbances and for the management of postoperative pain, as well as discuss the effects of sleep-disturbing medications on pain amplification.
View details for DOI 10.1038/s41386-019-0439-z
View details for PubMedID 31207606
- Cognitive Behavioral Therapy for Prenatal Insomnia A Randomized Controlled Trial LIPPINCOTT WILLIAMS & WILKINS. 2019: 911–19
Cognitive Behavioral Therapy for Prenatal Insomnia: A Randomized Controlled Trial.
Obstetrics and gynecology
OBJECTIVE: To evaluate the effectiveness of cognitive behavioral therapy for insomnia during pregnancy.METHODS: Randomized, unmasked, 3-site controlled trial. Participants were randomly allocated to cognitive behavioral therapy for insomnia (a first-line, empirically supported psychosocial intervention that addresses sleep-related behaviors and cognitions) or a control intervention consisting of imagery exercises that paired patient-identified distressing nighttime experiences with patient-identified neutral images. Participants were eligible if they met diagnostic criteria for insomnia disorder and were between 18 and 32 weeks of gestation. Patients were ineligible if they met diagnostic criteria for major psychiatric disorders, including depression, or were receiving nonstudy treatments that could affect sleep (or both). The primary outcome was the Insomnia Severity Index score, a validated brief questionnaire, with scores between 14 and 21 representing clinically meaningful insomnia of moderate severity, scores higher than 21 representing severe insomnia, and scores less than 8 representing no insomnia. Secondary outcomes included remission of insomnia (Insomnia Severity Index score less than 8), objectively measured and self-reported time awake (ie, total wake time), and the Edinburgh Postnatal Depression Scale score. All outcomes were measured weekly. Analysis included 48 participants who did not complete treatment. We estimated that 184 women would be required to have 80% power, with a two-tailed test, to detect a moderate Cohen's d effect size (.5) with alpha=.05.RESULTS: Between May 2013 and April 2017, 194 pregnant women were randomized and 149 completed treatment; 179 with available baseline data (92%) were ultimately analyzed, 89 in the cognitive therapy group and 90 in the control group. Women assigned to cognitive behavioral therapy for insomnia experienced significantly greater reductions in insomnia severity (scores decreased from 15.4±4.3 to 8.0±5.2 in the cognitive behavioral therapy group vs from 15.9±4.4 to 11.2±4.9 in the control therapy group [P<.001, d=0.5]). Remission of insomnia (to an Insomnia Severity Index score less than 8) disorder was attained by 64% of women in the cognitive behavioral therapy for insomnia group vs 52% in the control group. Women receiving cognitive behavioral therapy for insomnia experienced faster remission of insomnia disorder, with a median of 31 days vs 48 days in the control therapy (P<.001). Cognitive behavioral therapy for insomnia led to significantly greater reduction in self-reported but not objective total wake time and a small but significantly greater decline in Edinburgh Postnatal Depression Scale scores vs the control group.CONCLUSION: Cognitive behavioral therapy for insomnia is an effective nonpharmacologic treatment for insomnia during pregnancy.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT01846585.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
View details for PubMedID 30969203
ACTIGRAPHY MEASURES OF MATERNAL SLEEP DISRUPTION ARE ASSOCIATED WITH THE INABILITY TO SUSTAIN SENSITIVE CAREGIVING IN THE POSTPARTUM PERIOD
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001161
CBT FOR PERINATAL INSOMNIA - POSTPARTUM OUTCOME
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001162
SUBJECTIVE SLEEP QUALITY IN POSTPARTUM WOMEN ENROLLED IN A STUDY OF CBT FOR INSOMNIA
OXFORD UNIV PRESS INC. 2019
View details for Web of Science ID 000471071001136
DEVELOPMENT OF A SLEEP EDUCATIONAL RESOURCE FOR STUDENT ATHLETES
OXFORD UNIV PRESS INC. 2019: A394
View details for Web of Science ID 000471071004001
- Heart rate variability rebound following exposure to persistent and repetitive sleep restriction SLEEP 2019; 42 (2)
- Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization PAIN 2018; 159 (1): 33–40
Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization.
2018; 159 (1): 33-40
Chronic pain conditions are highly comorbid with insufficient sleep. While the mechanistic relationships between the 2 are not understood, chronic insufficient sleep may be 1 pathway through which central pain-modulatory circuits deteriorate, thereby contributing to chronic pain vulnerability over time. To test this hypothesis, an in-laboratory model of 3 weeks of restricted sleep with limited recovery (5 nights of 4-hour sleep per night followed by 2 nights of 8-hour sleep per night) was compared with 3 weeks of 8-hour sleep per night (control protocol). Seventeen healthy adults participated, with 14 completing both 3-week protocols. Measures of spontaneous pain, heat-pain thresholds, cold-pain tolerance (measuring habituation to cold over several weeks), and temporal summation of pain (examining the slope of pain ratings during cold water immersion) were assessed at multiple points during each protocol. Compared with the control protocol, participants in the sleep-restriction protocol experienced mild increases in spontaneous pain (P < 0.05). Heat-pain thresholds decreased after the first week of sleep restriction (P < 0.05) but normalized with longer exposure to sleep restriction. By contrast, chronic exposure to restricted sleep was associated with decreased habituation to, and increased temporal summation in response to cold pain (both P < 0.05), although only in the past 2 weeks of the sleep-restriction protocol. These changes may reflect abnormalities in central pain-modulatory processes. Limited recovery sleep did not completely resolve these alterations in pain-modulatory processes, indicating that more extensive recovery sleep is required. Results suggest that exposure to chronic insufficient sleep may increase vulnerability to chronic pain by altering processes of pain habituation and sensitization.
View details for DOI 10.1097/j.pain.0000000000001053
View details for PubMedID 28891869
View details for PubMedCentralID PMC5832516
Optimizing sleep to maximize performance: implications and recommendations for elite athletes
SCANDINAVIAN JOURNAL OF MEDICINE & SCIENCE IN SPORTS
2017; 27 (3): 266-274
Despite a growing body of literature demonstrating a positive relationship between sleep and optimal performance, athletes often have low sleep quality and quantity. Insufficient sleep among athletes may be due to scheduling constraints and the low priority of sleep relative to other training demands, as well as a lack of awareness of the role of sleep in optimizing athletic performance. Domains of athletic performance (e.g., speed and endurance), neurocognitive function (e.g., attention and memory), and physical health (e.g., illness and injury risk, and weight maintenance) have all been shown to be negatively affected by insufficient sleep or experimentally modeled sleep restriction. However, healthy adults are notoriously poor at self-assessing the magnitude of the impact of sleep loss, underscoring the need for increased awareness of the importance of sleep among both elite athletes and practitioners managing their care. Strategies to optimize sleep quality and quantity in athletes include approaches for expanding total sleep duration, improving sleep environment, and identifying potential sleep disorders.
View details for DOI 10.1111/sms.12703
View details for Web of Science ID 000394615800001
View details for PubMedID 27367265
Repeating patterns of sleep restriction and recovery: Do we get used to it?
BRAIN BEHAVIOR AND IMMUNITY
2016; 58: 142-151
Despite its prevalence in modern society, little is known about the long-term impact of restricting sleep during the week and 'catching up' on weekends. This common sleep pattern was experimentally modeled with three weeks of 5 nights of sleep restricted to 4h followed by two nights of 8-h recovery sleep. In an intra-individual design, 14 healthy adults completed both the sleep restriction and an 8-h control condition, and the subjective impact and the effects on physiological markers of stress (cortisol, the inflammatory marker IL-6, glucocorticoid receptor sensitivity) were assessed. Sleep restriction was not perceived to be subjectively stressful and some degree of resilience or resistance to the effects of sleep restriction was observed in subjective domains. In contrast, physiological stress response systems remain activated with repeated exposures to sleep restriction and limited recovery opportunity. Morning IL-6 expression in monocytes was significantly increased during week 2 and 3 of sleep restriction, and remained increased after recovery sleep in week 2 (p<0.05) and week 3 (p<0.09). Serum cortisol showed a significantly dysregulated 24h-rhythm during weeks 1, 2, and 3 of sleep restriction, with elevated morning cortisol, and decreased cortisol in the second half of the night. Glucocorticoid sensitivity of monocytes was increased, rather than decreased, during the sleep restriction and sleep recovery portion of each week. These results suggest a disrupted interplay between the hypothalamic-pituitary-adrenal and inflammatory systems in the context of repeated exposure to sleep restriction and recovery. The observed dissociation between subjective and physiological responses may help explain why many individuals continue with the behavior pattern of restricting and recovering sleep over long time periods, despite a cumulative deleterious physiological effect.
View details for DOI 10.1016/j.bbi.2016.06.001
View details for Web of Science ID 000385905600018
View details for PubMedID 27263430
View details for PubMedCentralID PMC5067189
Sleep characteristics as predictor variables of stress systems markers in insomnia disorder
JOURNAL OF SLEEP RESEARCH
2015; 24 (3): 296-304
This study investigates the extent to which sleep characteristics serve as predictor variables for inflammatory, hypothalamic-pituitary-adrenal and autonomic systems markers. Twenty-nine participants with a diagnosis of insomnia disorder based on the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (age 25.3 ± 1.6 years, insomnia duration 6.6 ± 0.8 years) and 19 healthy control sleepers (age 25.4 ± 1.4 years) underwent a 2-week at-home evaluation keeping a sleep diary and wearing an actigraph, followed by a visit to the Research Center to measure blood pressure, and collect blood and urine samples. The actigraphy- and diary-based variables of sleep duration, sleep-onset latency, wake after sleep onset and sleep fragmentation/number of night-time awakenings were averaged and entered as dependent variables in regression analyses. Composite scores were calculated for the autonomic (blood pressure, norepinephrine), inflammatory (monocyte counts, interleukin-6, C-reactive protein) and hypothalamic-pituitary-adrenal systems (cortisol), and used as predictor variables in regression models. Compared with controls, individuals with insomnia had a shorter sleep duration (P < 0.05), and a higher hypothalamic-pituitary-adrenal and inflammatory composite score (P < 0.05). The higher inflammatory score was mainly due to higher circulating monocytes (P < 0.05), rather than differences in interleukin-6 or C-reactive protein. In persistent insomnia disorder, cortisol is upregulated and associated with actigraphy- and diary-based wake after sleep onset, suggesting that wake after sleep onset may serve as a marker to identify individuals at increased risks for disorders associated with a hyperactive hypothalamic-pituitary-adrenal system. The absence of autonomic and pro-inflammatory changes (interleukin-6, C-reactive protein), despite a substantial decrease in actigraphic sleep duration, may relate to a higher resilience to the adverse biological consequences of insomnia in this young age group.
View details for DOI 10.1111/jsr.12259
View details for Web of Science ID 000354805600008
View details for PubMedID 25524529
A step towards stepped care: Delivery of CBT-I with reduced clinician time
SLEEP MEDICINE REVIEWS
2015; 19: 3–5
View details for PubMedID 25454675
Intervention Format and Delivery Preferences Among Young Adult Cancer Survivors
INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE
2013; 20 (2): 304-310
Young adult cancer survivors face a number of increased medical and psychosocial risks, including an increased risk of cardiovascular disease and emotional distress. Although behavioral strategies, such as exercise, may diminish some of these risks, few behavioral interventions have been developed for this population.As a first step toward developing interventions specifically for young survivors, we conducted a qualitative study of their intervention-related preferences. A key objective was to identify the preferred format for delivering interventions (e.g., face-to-face, online).In-depth, semi-structured individual interviews were conducted with 20 young adult cancer survivors between the ages of 18 and 39. This research was conducted in Rhode Island, USA.Participants identified advantages and disadvantages to a variety of intervention formats including: telephone-based, print-based, computer-based, and several types of face-to-face interventions. The dominant theme that emerged was that interventions developed for young adult cancer survivors should take into account their multiple competing needs and obligations (e.g., work, family). Two closely related subthemes were: (1) the importance of developing interventions that are convenient and (2) the need for interventions that provide social support. Interventions for this population may be most successful if they take into account these themes.Data indicate that young adult cancer survivors have some unique needs (e.g., multiple competing demands of young adulthood) and preferences (e.g., comfort with remotely delivered interventions) that differentiate them from older cancer survivors. Thus, young survivors would be best served by interventions designed to specifically target this population.
View details for DOI 10.1007/s12529-012-9227-4
View details for Web of Science ID 000318505900018
View details for PubMedID 22328444