Bridging the Gap Between Science and Practice

Disturbed and insufficient sleep are well-documented public health concerns, with significant negative impacts on health, performance, and overall well-being. Further, poor sleep results in massive societal costs – direct treatment costs, increased health care utilization, decreased workplace productivity, and increased accident risk. There is an overwhelming need for cost-effective screening, assessment, and intervention that can be easily adopted in medical and organizational settings.

My research interests focus on biobehavioral sleep processes including sleep as therapy for the body and brain, the most common sleep disorders, sleep in special populations, and dissemination of best practices. The manner in which knowledge is disseminated and technologies are  adopted or commercialized is both vital and under-appreciated.

Peer-reviewed journal articles

• Maximizing CPAP Adherence
• Insomnia and Obstructive Sleep Apnea
• Sleep and the Military Population
• Pre-Sleep Routine and Treatment Development
• Sleep and Chronic Pain
• Home Sleep Testing
• Sleep Education
• Book Chapters

Maximizing CPAP Adherence

Wickwire, E.M., Lettieri, C.J., Cairns, A., & Collop, N.A. (2013). Maximizing PAP adherence in adults: A common-sense approach. Chest, 144, 680-693 .

Positive airway pressure (PAP) therapy is considered the most efficacious treatment of obstructive sleep apnea (OSA), especially moderate to severe OSA, and remains the most commonly prescribed. Yet suboptimal adherence presents a challenge to sleep-medicine clinicians. The purpose of the current review is to highlight the efficacy of published interventions to improve PAP adherence and to suggest a patient-centered clinical approach to enhancing PAP usage.

Dombrowsky, J., Williams, S., Wickwire, E.M., & Lettieri, C.J. (2012). Strategies to enhance PAP adherence for OSA. Clinical Pulmonary Medicine, 20, 21-28.

Recent technological advances in diagnostics and therapeutics have allowed for widespread recognition and treatment of obstructive sleep apnea (OSA). However, practice standards are highly variable and adherence remains poor in many patients. Untreated OSA has numerous well-documented health consequences, including cardiovascular disease and metabolic sequelae. It is therefore crucial to optimize treatment of OSA by enhancing adherence to proven therapies. Utilizing technological advancements, identifying barriers to continuous positive airway pressure use, ensuring proper education regarding the need for and proper use of continuous positive airway pressure, and implementing robust follow-up programs can result in an improved therapeutic response as well as a higher rate of adherence. We review the current literature and provide personal anecdotes, emphasizing the importance of patient education as well as common troubleshooting strategies, particularly during the initial phase of therapy.

Wickwire, E.M. (2009). Behavioral management of sleep-disordered breathing. Primary Psychiatry, 16, 34-41.

Sleep-disordered breathing (SDB) is a common medical condition with significant health consequences. Primary care and mental health practitioners are frequently unaware of the often subtle presentation of SDB, which can mask as conditions including depression, anxiety attention deficit, and other cognitive complaints. SDB is a progressive disease, increasing from mild snoring to complete blockage of the upper airway. For patients whose disease has not progressed beyond the mild stage, numerous simple behavioral interventions can be considered as minimally invasive or adjunctive treatments. Nonetheless, most SDB patients are treated with continuous positive airway pressure (CPAP) therapy. However, adaptation and poor adherence are significant problems associated with this treatment approach. This article reviews the most common behavioral treatments for SDB and provides a theoretical framework for factors influencing CPAP use.
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Insomnia and Obstructive Sleep Apnea

Wickwire, E.M., Smith, M.T., Birnbaum, S. & Collop, N. (2010). Insomnia complaints predict poor CPAP adherence: A clinical case series. Sleep Medicine, 11, 772-776.

Background: Although CPAP is a highly efficacious treatment for obstructive sleep apnea (OSA), low adherence presents a significant challenge for sleep medicine clinicians. The present study aimed to evaluate the relationship between insomnia symptoms and CPAP use. We hypothesized that pre-treatment insomnia complaints would be associated with poorer CPAP adherence at clinical follow-up.

Methods: This was a retrospective chart review of 232 patients (56.5% men, mean age=53.6+/-12.4years) newly diagnosed with OSA (mean AHI=41.8+/-27.7) and prescribed CPAP in the Johns Hopkins Sleep Disorder Center. Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were measured via three self-report items. CPAP use was measured via objective electronic monitoring cards.

Results: Thirty-seven percent of the sample reported at least one frequent insomnia complaint, with 23.7% reporting difficulty maintaining sleep, 20.6% reporting early morning awakening and 16.6% reporting difficulty initiating sleep. After controlling for age and gender, sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p<.05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p<.02).

Conclusions: To our knowledge, these are the first empirical data to document that insomnia can be a risk factor for poorer CPAP adherence. Identifying and reducing insomnia complaints among patients prescribed CPAP may be a straightforward and cost-effective way to increase CPAP adherence.

Wickwire, E.M. & Collop, N. (2010). Insomnia and sleep-related breathing disorders. Chest, 137, 1449-1463.

Insomnia disorder and obstructive sleep apnea are the two most common sleep disorders among adults. Historically, these conditions have been conceptualized as orthogonal, or insomnia has been considered a symptom of sleep apnea. Insomnia researchers have sought to exclude participants at risk for sleep-related breathing disorders (SRBD), and vice versa. In recent years, however, there has been a growing recognition of co-occurring insomnia disorder and SRBD and interest in the prevalence, consequences, and treatment of the two conditions when they co-occur. Although plagued by inconsistent diagnostic criteria and operational definitions, evidence from clinical and research samples consistently suggests high rates of comorbidity between the two disorders. More important, insomnia disorder and SRBD have additive negative effects. To date, only a few studies have explored the combined or sequential treatment of the conditions. Results support the importance of an integrated, interdisciplinary approach to sleep medicine. This article reviews the empirical literature to date and provides clinical recommendations as well as suggestions for future research.

Wickwire, E.M., Schumacher, J.A., Richert, A.C., Baran, A.S., & Roffwarg, H.P. (2008). Combined insomnia and poor CPAP compliance: Case study and discussion. Clinical Case Studies, 7, 267-286.

This report describes the case of Samuel, a Caucasian man in his early sixties who self-referred to a behavioral insomnia clinic at a university medical center. Samuel had recently been diagnosed with obstructive sleep apnea and had been prescribed continuous positive air pressure (CPAP) therapy for this condition. At the time he presented for treatment, he was non-compliant with his CPAP prescription and maintained that the physician who diagnosed obstructive sleep apnea was mistaken. His presenting complaint to the insomnia clinic was a 25-year history of difficulty initiating sleep, which he believed was the sole cause of his problem with daytime sleepiness. In addition to his obstructive sleep apnea, Samuel was diagnosed with obstructive sleep apnea and psychophysiological insomnia. The treatments selected were a motivational enhancement treatment for CPAP compliance and a cognitive-behavioral intervention for insomnia. Treatments were presented in a combined, sequential fashion. At treatment follow-up, Samuel reported increased CPAP compliance, decreased daytime sleepiness, and decreased insomnia severity.
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Sleep and The Military Population

Williams, S.G., Collen, J., Wickwire, E.M., Mysliwiec, V., & Lim, I. (2015). Management of co-morbid sleep disorders and PTSD. Federal Practitioner.

Sleep in the military has traditionally been thought of as a luxury and is sometimes considered at odds with optimal productivity. Every minute that a servicemember is asleep he is not performing his primary duty, and getting a minimal amount of sleep is often seen as a badge of honor and strength. More recently, though, research has been conducted which is underscoring the importance of sleep management as an operational variable which must be accounted for in order to achieve optimal performance and to promote resiliency. Both the quality and the duration of sleep must be considered, particularly given the increasingly complicated tasks that every servicemember must perform in war as well as during peacetime. It has been well established that higher order mental tasks are the most vulnerable to sleep loss, as are those with little mental or physical stimulation such as guard duty. Since we expect our servicemembers not only to aggressively and lethally destroy the enemy but also to behave and operate ethically in spite of the fog of war, we must consider the importance of adequate sleep. Table 1, adapted from a recent review that we have published, lists some common challenges encountered by servicemembers when attempting to obtain adequate sleep. This review will highlight the recent diagnostic and treatment advances with respect to the overlap of sleep disorders and post-traumatic stress disorder (PTSD).

Williams, S.G., Collen, J., Wickwire, E.M., Lettieri, C.J., & Mysliwiec, V. (2014). The impact of sleep on soldier performance. Current Psychiatry Reports, 16, 459.

The military population is particularly vulnerable to a multitude of sleep-related disorders owing to the type of work performed by active duty servicemembers (ADSMs). Inadequate sleep, due to insufficient quantity or quality, is increasingly recognized as a public health concern. Traditionally, ADSMs have been encouraged that they can adapt to insufficient sleep just as the body adapts to physical training, but there is a substantial body of scientific literature which argues that this is not possible. Additionally, the military work environment creates unique challenges with respect to treatment options for common sleep disorders like obstructive sleep apnea, restless legs syndrome, and parasomnias. This review highlights sleep disorders which are prevalent in the modern military force and discusses the impact of poor sleep on overall performance. Medical treatments and recommendations for unit leaders are also discussed.
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Pre-Sleep Routine and Treatment Development

Wickwire, E.M., Schumacher, J.A., & Clarke, E. (2009). Patient-reported benefits from the pre-sleep routine approach to treating Insomnia: Findings from a treatment development trial. Sleep and Biological Rhythms, 7, 71-77.

This uncontrolled trial evaluated the feasibility, acceptability, and initial changes in sleep associated with a novel cognitive-behavioral treatment for insomnia, the pre-sleep routine. Patients were encouraged to develop a “sacred” bedroom space only for sleep or sex, and a ritual for entering it. Nine chronic insomniacs (seven women, mean age, 57.9 ± 12.9 years) who met International Classification of Sleep Disorders Diagnostic and Coding Manual, second edition (ICSD-2) criteria for primary insomnia completed daily sleep diaries throughout four weekly sessions and a 15-min booster session. Post-treatment and 1-month follow-up data indicated that the pre-sleep routine was well liked and associated with numerous self-reported improvements in sleep and daytime functioning. These findings need to be interpreted cautiously in light of the small sample and uncontrolled design.

Ong, J., Wickwire, E.M., Southam-Gerow, M., Schumacher, J.A., & Orsillo, S. (2008). Developing cognitive-behavioral treatments: A primer for students and early career psychologists. The Behavior Therapist, 31, 73-77.

It is important to ensure that the best available treatments reach those who are in need of services. Despite the empirical support for many cognitive-behavioral therapies (CBT), continued work is needed to develop novel treatments as new findings about a particular disorder are unveiled or technological advances allow for innovative approaches. However, guidance is scarce regarding the process of translating a new treatment idea into a program of research designed to evaluate this treatment—especially in contrast to the extensive literature guiding the later stages of efficacy testing. As a result, procedures within the earliest stages of treatment development are often unfamiliar to young investigators, including students and early career psychologists (ECP). This is unfortunate given that these young investigators are prime candidates for conducting treatment development work. ECPs are often seeking to establish a research niche but have little or no funding to support an independent program of research. However, they can bring a fresh perspective, are usually eager to collect data, and many would welcome the opportunity to direct a small scale project that could lead to a program of research.

We believe that treatment development is a vital, exciting, and largely underappreciated area within clinical research. The purpose of this paper is to bring attention to the process of conducting treatment development research, with particular emphasis on those issues relevant to graduate students and ECPs. First, we describe the characteristics of treatment development research and review the most common approaches to conducting these studies. Next, we offer ideas and strategies for helping students and ECPs to conduct treatment development research with an eye toward career development, early career funding, and dissemination of results. It is hoped that this paper will encourage ECPs to adopt a programmatic approach to clinical research with specific considerations for treatment development.
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Home Sleep Testing

Cairns, A, Wickwire, EM, Schaefer E, Nyanjom D. A pilot validation study for the NOX T3 ^TM portable monitor for the detection of OSA. Sleep Breathing. 2014 Jan 19. [Epub ahead of print].

Purpose: The aim of the current pilot study is to compare the diagnostic accuracy of the NOX T3 ^TM (T3) portable sleep monitor (PM) to that of simultaneously recorded in-lab polysomnogram (PSG).

Methods: A total of 40 participants were recruited following face-to-face evaluation at a sleep disorders clinic. Each participant wore both PSG and PM equipment simultaneously during their in-lab PSG. PSG records were manually scored using the American Academy of Sleep Medicine (AASM) criteria, and PM records were double-scored using the device’s autoscore algorithm as well as manual scoring.

Results: The final sample consisted of 32 participants (56 % male, 50 % black) with a mean ESS, BMI, and apnea–hypopnea index (AHI) of 10.4, 32.8, and 16.3, respectively. Three participants (7.5 %) were excluded for poor PM signal quality. Mean AHI derived from the T3’s autoscore algorithm was similar to that from manual scoring (19.6 ± 18.9 vs. 18.6 ± 19.1, respectively). Autoscore-derived T3 AHI and PSG-derived AHI were strongly related (r = .93). The T3 (autoscored AHI) demonstrated a high degree of sensitivity for the presence of obstructive sleep apnea syndrome (OSA; 100 %) and acceptable specificity for the exclusion of OSA using an AHI cutoff of ≥5 events/h (70 %). The unit (autoscored) had a high degree of both sensitivity (92 %) and specificity (85 %) when the presence of OSA was defined more conservatively (AHI > 15 events/h). For OSA defined as an AHI of ≥5, the T3 (autoscored) correctly identified 88 % of positive cases and 100 % of negative cases.

Conclusions: In this small, clinic-based sample, the T3 demonstrated very good measurement agreement compared to PSG and a high degree of sensitivity for detecting even mild OSA. False positives appeared to be due to respiratory effort-related arousals (RERAs) being autoscored as obstructive apneas and may be due to inherent discrepancy in flow measurement sensitivity between PSG and portable monitors.
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Sleep and Chronic Pain

Quartana, P., Wickwire, E.M., Klick, B., Grace, E., & Smith, M.T. (2010). Naturalistic changes in insomnia and pain in Temporomandibular Joint Disorder: A cross lagged panel analysis. Pain, 149<, 325-331

An increasing number of prospective studies suggest a bi-directional association between the pain and sleep quality. Few of these investigations have controlled for synchronous correlations, an important source of extraneous variance in lagged associations, which may have confounded conclusions of prior investigations. Despite high rates of insomnia in temporomandibular joint disorders (TMD), no studies have examined temporal associations between naturalistic fluctuations in insomnia and pain in TMD. We conducted cross-lagged panel analysis to examine reciprocal temporal associations between 1-month changes in insomnia symptom severity and self-reported pain over 3 months among 53 TMD patients. This rigorous analytic strategy represents a comprehensive method to explore possible reciprocal temporal associations between insomnia and pain that controls for both auto- and synchronous correlations. Analyses revealed that initial-month increases in insomnia were associated with next-month increases in average daily pain, but not vice versa. The direction of the effect was such that initial-month increases in insomnia symptom severity were associated with next-month increases in average daily pain. These data suggest that naturally occurring fluctuations in insomnia symptom severity are prospectively associated with fluctuations in daily pain experience for persons with TMD. Potential mechanisms by which insomnia might influence pain in TMD and therapeutic implications of these findings are discussed.

Smith, M.T., Wickwire, E.M., Grace, E. Edwards, R.R., Buenaver, L., Peterson, S.C., Klick, B., & Haythornthwaite, J. (2009). Sleep disorders and their association with laboratory pain sensitivity in Temporomandibular Joint Disorder. Sleep, 32, 779-790.

Study Objectives: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity.

Design: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold.

Setting: Orofacial pain clinic and inpatient sleep research facility.

Participants: Fifty-three patients meeting research diagnostic criteria for myofascial TMD.

Interventions: N/A.

Measurements and Results: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05).

Conclusions: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.
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Sleep Medicine Education

Ioachimescu, O.C., Wickwire, E.M., Harrington, J., Kristo, D, Arnedt, J.T., Ramar, K., Won, C., Billings, M.E., Delrosso, L., Williams, S., Paruthi, S., Morgenthaler, T.I. (2014). A Dozen Years of American Academy of Sleep Medicine (AASM) International Mini-Fellowship: Program Evaluation and Future Directions. Journal of Clinical Sleep Medicine, 10, 331-4.

Sleep medicine remains an underrepresented medical specialty worldwide, with significant geographic disparities with regard to training, number of available sleep specialists, sleep laboratory or clinic infrastructures, and evidence-based clinical practices. The American Academy of Sleep Medicine (AASM) is committed to facilitating the education of sleep medicine professionals to ensure high-quality, evidence-based clinical care and improve access to sleep centers around the world, particularly in developing countries. In 2002, the AASM launched an annual 4-week training program called Mini-Fellowship for International Scholars, designed to support the establishment of sleep medicine in developing countries. The participating fellows were generally chosen from areas that lacked a clinical infrastructure in this specialty and provided with training in AASM Accredited sleep centers. This manuscript presents an overview of the program, summarizes the outcomes, successes, and lessons learned during the first 12 years, and describes a set of programmatic changes for the near-future, as assembled and proposed by the AASM Education Committee and recently approved by the AASM Board of Directors.

Problem Gambling

Prior to stumbling into sleep medicine in 2004, my graduate school research involved perceptions of parent and peer attitudes and behavior, social cognitive influences, and outcome expectations and their relation to problem and pathological gambling among adolescents and young adults. This novel line of research has been continued by my graduate school mentors, Drs. Jim Whelan and Andy Meyers, and their fine team at The Institute for Gambling Education and Research at The University of Memphis (TIGER).

Wickwire, E.M., Whelan, J.P., & Meyers, A. (2010). Outcome expectancies and gambling behavior among urban adolescents. Psychology of Addictive Behaviors, 24, 75-88.

Wickwire, E.M., Burke, R.S., Brown, S.A., Parker, J.D., & May, R. (2008). Psychometric evaluation of the National Opinion Research Center DSM-IV screen for gambling problems (NODS). The American Journal on Addictions, 17, 392-395.

Wickwire, E.M., Whelan, J.P., Meyers, A., McCausland, C., Luellen, J., & Studaway, A. (2008). Environmental correlates of gambling behavior among college students: A partial application of Problem Behavior Theory. Journal of College Student Development, 49, 459-475.

Wickwire, E.M., Whelan, J.P., West, R., Meyers, A., McCausland, C., & Luellen, J. (2007). Perceived availability, risks, and benefits of gambling among college students. J Gambling Studies, 23, 397-408.

Wickwire, E.M., Whelan, J.P., Meyers, A., & Murray, D.M. (2007). Environmental correlates of gambling behavior in urban adolescents. The Journal of Abnormal Child Psychology, 35, 179-190 .
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Book Chapters

Wickwire, E.M. & Williams, S.G. (2013). Medical consequences of Obstructive Sleep Apnea. In D. Kirsch (Ed.), Sleep in Neurology (pp. 79-89). New York: Oxford University Press.

Wickwire, E.M., Smith, M.T., & Collop, N. (2010). Insomnia and sleep-disordered breathing. In M. Sateia & D. Buysse (Eds.), Insomnia: Diagnosis and treatment (pp. 210-223). New York: Informa Healthcare.

Wickwire, E.M. & Smith, M.T. (2010). Insomnia in chronic pain conditions. In M. Sateia & D. Buysse (Eds.), Insomnia: Diagnosis and treatment (pp. 139-152). New York: Informa Healthcare.

Wickwire, E.M., Roland, M.M.S., Elkin, T.D., & Schumacher, J.A. (2007). Sleep disorders in children and adolescents. In M. Hersen & D. Reitman (Eds.), Handbook of assessment, conceptualization, and treatment volume II: Children and adolescents (pp. 622-652). New York: John Wiley.
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