Addressing Nocturnal Sleep/Wake Effects on Risk of Suicide in Older Adults (ANSWERS-OA)

Addressing Nocturnal Sleep/Wake Effects on Risk of Suicide in Older Adults (ANSWERS-OA): A Pilot, Open-Label, Randomized Controlled Trial of Digital Cognitive Behavioral Therapy for Insomnia

Suicide is a leading cause of death in the US, and insomnia is a risk factor for suicidal thoughts and behaviors. In older adults, suicide is associated with impaired cognitive functioning, and insomnia, which is more prevalent in older adults, is also linked to disrupted cognition. However, there is limited evidence on whether treatment of insomnia can improve suicidal ideation (with or without improving cognition), and no evidence specifically in older adults. Additionally, no studies have investigated digital cognitive behavioral therapy for insomnia (dCBT-I) in this populations. Consequently, this study will help inform future study designs and provide preliminary data on whether dCBT-I is effective for suicidal thinking in older adults.

The primary goal of this pilot trial is to establish the feasibility and preliminary safety of implementing dCBT-I in older adults with insomnia and suicidal ideation. Secondary goals include estimating the potential efficacy and durability of dCBT-I for insomnia and suicidal ideation in this population, as well as evaluating neurocognitive functioning as a mediator/moderator of treatment response. To accomplish this, individuals 65 and older with insomnia and recent suicidal ideation will be recruited to either 12 weeks of treatment (dCBT-I) or waitlist control (WLC). After completion of dCBT-I, individuals in WLC will crossover to dCBT-I (WLC + dCBT-I). All participants will be re-evaluated at 6- and 12-months post-treatment. The primary aims for this project are as follows: Aim 1: Evaluate whether dCBT-I is a feasible intervention for older adults with insomnia and suicidal ideation. This will be assessed by subject participation and adherence to dCBT-I, evaluation of technological or cognitive barriers to accessing treatment, and by recruitment and dropout outcomes. Aim 2: Investigate whether dCBT-I is safe for older adults with suicidal ideation. This will be measured by comparing post-treatment insomnia, depression, anxiety, and cognitive outcomes and spontaneous adverse event reports between dCBT-I and WLC, as well as post-treatment responses to the Side Effect Rating Scale - Patient Self Report (SERS-Pat) form. The secondary aims for this project are as follows: Aim 3: Explore whether dCBT-I can reduce suicidal ideation in older adults. While the investigators anticipate that dCBT-I will reduce suicidal ideation in older adults with insomnia, gathering preliminary data for effect size estimates will allow us to appropriately power future studies. Suicidal ideation will be measured pre-/post-treatment using the Columbia Suicide Severity Rating Scale (CSSRS) as well as weekly throughout treatment using self-report ratings of suicidal ideation severity. Comparisons will be dCBT-I vs. WLC (between groups) and WLC vs. WLC + dCBT-I (within group) using linear mixed-effects or generalized estimating equations models. Aim 4: Assess the durability of dCBT-I treatment on suicidal ideation in older adults. Based on follow-up assessments at 6- and 12-months, the investigators will assess the potential duration of sustained improvement in suicidal ideation following dCBT-I in older adults, and how this is related to concurrent sleep continuity and quality. Aim 5: Investigate whether changes in sleep and suicidal ideation during dCBT-I are associated with changes in neurocognition. Neurocognitive functioning will be formally assessed pre- and post-treatment using the NeuroCognitive Performance Test, a web-based neuropsychological assessment. Additionally, weekly assessment of response inhibition will occur using the Color Match task implemented as part of the same system.

Randomized Clinical Trial, digital Cognitive Behavioral Therapy for Insomnia, Older Adults, Suicidal Ideation, Insomnia

A randomized parallel clinical trial of digital cognitive behavioral therapy for insomnia versus waitlist control with subsequent crossover to digital cognitive behavioral therapy for insomnia.

Following baseline evaluation, participants in this group will receive 8 weeks of digital Cognitive Behavioral Therapy for Insomnia delivered using Sleep Healthy Using the Internet (SHUTi). After the interim assessment, participants will then crossover to 8 weeks of active monitoring.

Following baseline evaluation, participants in this group will undergo weekly monitoring of insomnia and suicidal ideation for 8 weeks. Participants will continue whatever treatments they are currently receiving, but will receive no specific instructions or behavioral interventions for insomnia. After the interim assessment, participants will then crossover to receive digital Cognitive Behavioral Therapy for Insomnia.

Digital cognitive behavioral therapy for insomnia is an automated, internet-based delivery system for the core components of cognitive behavioral therapy for insomnia (CBT-I). For this trial, dCBT-I will be delivered using Sleep Healthy Using the Internet (SHUTi), which delivers the core content of CBT-I in 6 interactive lessons called Cores: Getting Ready; Sleep Scheduling; Sleep Practices; Thinking Differently; Sleep Hygiene; and Moving On. The primary therapeutic approaches deployed through these cores are stimulus control and sleep restriction. The minimum acceptable dose for this study is completion of 4 out of 6 cores; completion of fewer than 4 cores will be considered a dropout.

Aim 1a: Evaluate whether dCBT-I is a feasible intervention for older adults with insomnia and suicidal ideation.

Subaim 1a: Determine participant engagement with 10 weeks of dCBT-I. Metric: Percent of subjects enrolled who complete the 10 week treatment period

Aim 1b: Evaluate whether dCBT-I is a feasible intervention for older adults with insomnia and suicidal ideation.

Subaim 1b: Measure participant adherence to dCBT-I treatment. Metric: Percent of subjects who complete 4 out of 6 treatment modules.

Metric: The frequency of self-reported side effects as measured by the Side Effect Rating Scale - Patient Self-Report (SERS-Pat) form. The SERS-Pat assesses 11 common side effects (with options for the patient to list others) by asking about their frequency ("Not at all", "A little more than usual", "More than usual", "Much more than usual") and their perceived relationship to treatment ("Not at all related", "Possibly related", "Probably related").

Measurement of changes in Columbia Suicide Severity Rating Scale (CSSRS) scores from baseline. The CSSRS measures the presence and severity of suicidal thoughts and behaviors over an individual's lifetime, prior 3 months, and since last visit/interview. Questions are either yes/no or roughly range from 0-5, with higher scores reflecting more severe symptoms.

Inclusion Criteria: Individuals 65 and older English speaking Male or female Current insomnia (Insomnia Severity Index score ≥ 8 during the baseline period). Recent suicidal ideation (endorsement of Items 1 or 2 of the Columbia Suicide Severity Rating Scale - Suicidal Ideation subscale within the past month). All participants must consent to a release of information between the research team and their treatment provider (either their prescribing psychiatrist, their masters-level non-trainee therapist, or their doctoral-level psychologist). Exclusion Criteria: Diagnosis of bipolar disorder, any psychotic disorder, or other serious mental illness deemed a contraindication for dCBT-I. If a subject is taking psychotropic medication(s) (e.g., antidepressants, hypnotics), they should not have changed the dose within the past 6 weeks and should agree to not change the dose during the trial. If a subject is not taking psychotropic medication(s), they should be medication free for at least 6 weeks and should agree to not start a new medication for the duration of the trial. Suspicion or evidence of untreated sleep apnea, restless legs syndrome, or other untreated sleep disorder requiring treatment by a physician. Uncontrolled or unstable chronic medical conditions Life expectancy of less than 1 year as determined by record review and intake interview. Cognitive impairment sufficient to impair delivery or retention of dCBT-I as indicated by the Short Blessed Test. Are currently or are planning to work evening/overnight shifts. Lack of access to internet or technology necessary to engage in digital therapy. Participants who have been hospitalized for a suicide attempt or severe suicidal ideation, or who endorse any intent to commit suicide in the last 3 months must receive assent/approval from their treatment provider to participate, in addition to providing a release of information for the research team to communicate with the treatment team.

Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012 Sep;73(9):e1160-7. doi: 10.4088/JCP.11r07586.

Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep. 2015 Mar;17(3):554. doi: 10.1007/s11920-015-0554-4.

Harris LM, Huang X, Linthicum KP, Bryen CP, Ribeiro JD. Sleep disturbances as risk factors for suicidal thoughts and behaviours: a meta-analysis of longitudinal studies. Sci Rep. 2020 Aug 17;10(1):13888. doi: 10.1038/s41598-020-70866-6.

Liu RT, Steele SJ, Hamilton JL, Do QBP, Furbish K, Burke TA, Martinez AP, Gerlus N. Sleep and suicide: A systematic review and meta-analysis of longitudinal studies. Clin Psychol Rev. 2020 Nov;81:101895. doi: 10.1016/j.cpr.2020.101895. Epub 2020 Aug 8.

Zuromski KL, Cero I, Witte TK. Insomnia symptoms drive changes in suicide ideation: A latent difference score model of community adults over a brief interval. J Abnorm Psychol. 2017 Aug;126(6):739-749. doi: 10.1037/abn0000282. Epub 2017 May 29.

Hedstrom AK, Hossjer O, Bellocco R, Ye W, Trolle LY, Akerstedt T. Insomnia in the context of short sleep increases suicide risk. Sleep. 2021 Apr 9;44(4):zsaa245. doi: 10.1093/sleep/zsaa245.

Wang HE, Campbell-Sills L, Kessler RC, Sun X, Heeringa SG, Nock MK, Ursano RJ, Jain S, Stein MB. Pre-deployment insomnia is associated with post-deployment post-traumatic stress disorder and suicidal ideation in US Army soldiers. Sleep. 2019 Feb 1;42(2):zsy229. doi: 10.1093/sleep/zsy229.

Rossler W, Angst J, Ajdacic-Gross V, Haker H, Berrouiguet S, Ujeyl M, Glozier N, Hengartner MP. Sleep Disturbances and Suicidality-A Longitudinal Analysis From a Representative Community Study Over 30 Years. Front Psychiatry. 2018 Jul 16;9:320. doi: 10.3389/fpsyt.2018.00320. eCollection 2018.

Ferentinos P, Porichi E, Christodoulou C, Dikeos D, Papageorgiou C, Douzenis A. Sleep disturbance as a proximal predictor of suicidal intent in recently hospitalized attempters. Sleep Med. 2016 Mar;19:1-7. doi: 10.1016/j.sleep.2015.10.021. Epub 2015 Nov 24.

Li SX, Lam SP, Yu MW, Zhang J, Wing YK. Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective study. J Clin Psychiatry. 2010 Nov;71(11):1440-6. doi: 10.4088/JCP.09m05661gry.

Lin HT, Lai CH, Perng HJ, Chung CH, Wang CC, Chen WL, Chien WC. Insomnia as an independent predictor of suicide attempts: a nationwide population-based retrospective cohort study. BMC Psychiatry. 2018 May 2;18(1):117. doi: 10.1186/s12888-018-1702-2.

Fujino Y, Mizoue T, Tokui N, Yoshimura T. Prospective cohort study of stress, life satisfaction, self-rated health, insomnia, and suicide death in Japan. Suicide Life Threat Behav. 2005 Apr;35(2):227-37. doi: 10.1521/suli.35.2.227.62876.

Perlis ML, Grandner MA, Chakravorty S, Bernert RA, Brown GK, Thase ME. Suicide and sleep: Is it a bad thing to be awake when reason sleeps? Sleep Med Rev. 2016 Oct;29:101-7. doi: 10.1016/j.smrv.2015.10.003. Epub 2015 Oct 19.

Perlis ML, Grandner MA, Brown GK, Basner M, Chakravorty S, Morales KH, Gehrman PR, Chaudhary NS, Thase ME, Dinges DF. Nocturnal Wakefulness as a Previously Unrecognized Risk Factor for Suicide. J Clin Psychiatry. 2016 Jun;77(6):e726-33. doi: 10.4088/JCP.15m10131.

Tubbs AS, Perlis ML, Basner M, Chakravorty S, Khader W, Fernandez F, Grandner MA. Relationship of Nocturnal Wakefulness to Suicide Risk Across Months and Methods of Suicide. J Clin Psychiatry. 2020 Feb 25;81(2):19m12964. doi: 10.4088/JCP.19m12964.

Tubbs AS, Fernandez FX, Perlis ML, Hale L, Branas CC, Barrett M, Chakravorty S, Khader W, Grandner MA. Suicidal ideation is associated with nighttime wakefulness in a community sample. Sleep. 2021 Jan 21;44(1):zsaa128. doi: 10.1093/sleep/zsaa128.

Tubbs AS, Harrison-Monroe P, Fernandez FX, Perlis ML, Grandner MA. When reason sleeps: attempted suicide during the circadian night. J Clin Sleep Med. 2020 Oct 15;16(10):1809-1810. doi: 10.5664/jcsm.8662.

Munch M, Knoblauch V, Blatter K, Wirz-Justice A, Cajochen C. Is homeostatic sleep regulation under low sleep pressure modified by age? Sleep. 2007 Jun;30(6):781-92. doi: 10.1093/sleep/30.6.781.

Cajochen C, Brunner DP, Krauchi K, Graw P, Wirz-Justice A. Power density in theta/alpha frequencies of the waking EEG progressively increases during sustained wakefulness. Sleep. 1995 Dec;18(10):890-4. doi: 10.1093/sleep/18.10.890.

Verweij IM, Romeijn N, Smit DJ, Piantoni G, Van Someren EJ, van der Werf YD. Sleep deprivation leads to a loss of functional connectivity in frontal brain regions. BMC Neurosci. 2014 Jul 19;15:88. doi: 10.1186/1471-2202-15-88.

Valdez P, Ramirez C, Garcia A, Talamantes J, Cortez J. Circadian and homeostatic variation in sustained attention. Chronobiol Int. 2010 Jan;27(2):393-416. doi: 10.3109/07420521003765861.

Drummond SP, Paulus MP, Tapert SF. Effects of two nights sleep deprivation and two nights recovery sleep on response inhibition. J Sleep Res. 2006 Sep;15(3):261-5. doi: 10.1111/j.1365-2869.2006.00535.x.

Frey S, Birchler-Pedross A, Hofstetter M, Brunner P, Gotz T, Munch M, Blatter K, Knoblauch V, Wirz-Justice A, Cajochen C. Young women with major depression live on higher homeostatic sleep pressure than healthy controls. Chronobiol Int. 2012 Apr;29(3):278-94. doi: 10.3109/07420528.2012.656163.

Birchler-Pedross A, Frey S, Chellappa SL, Gotz T, Brunner P, Knoblauch V, Wirz-Justice A, Cajochen C. Higher frontal EEG synchronization in young women with major depression: a marker for increased homeostatic sleep pressure? Sleep. 2011 Dec 1;34(12):1699-706. doi: 10.5665/sleep.1440.

Niggemyer KA, Begley A, Monk T, Buysse DJ. Circadian and homeostatic modulation of sleep in older adults during a 90-minute day study. Sleep. 2004 Dec 15;27(8):1535-41. doi: 10.1093/sleep/27.8.1535.

Schmidt C, Collette F, Cajochen C, Peigneux P. A time to think: circadian rhythms in human cognition. Cogn Neuropsychol. 2007 Oct;24(7):755-89. doi: 10.1080/02643290701754158.

Wyatt JK, Ritz-De Cecco A, Czeisler CA, Dijk DJ. Circadian temperature and melatonin rhythms, sleep, and neurobehavioral function in humans living on a 20-h day. Am J Physiol. 1999 Oct;277(4 Pt 2):R1152-63. doi: 10.1152/ajpregu.1999.277.4.r1152.

May CP. Synchrony effects in cognition: the costs and a benefit. Psychon Bull Rev. 1999 Mar;6(1):142-7. doi: 10.3758/bf03210822.

Wright KP, Lowry CA, Lebourgeois MK. Circadian and wakefulness-sleep modulation of cognition in humans. Front Mol Neurosci. 2012 Apr 18;5:50. doi: 10.3389/fnmol.2012.00050. eCollection 2012.

May CP, Hasher L. Synchrony effects in inhibitory control over thought and action. J Exp Psychol Hum Percept Perform. 1998 Apr;24(2):363-79. doi: 10.1037//0096-1523.24.2.363.

Monk TH, Buysse DJ, Reynolds CF 3rd, Berga SL, Jarrett DB, Begley AE, Kupfer DJ. Circadian rhythms in human performance and mood under constant conditions. J Sleep Res. 1997 Mar;6(1):9-18. doi: 10.1046/j.1365-2869.1997.00023.x.

Boivin DB, Czeisler CA, Dijk DJ, Duffy JF, Folkard S, Minors DS, Totterdell P, Waterhouse JM. Complex interaction of the sleep-wake cycle and circadian phase modulates mood in healthy subjects. Arch Gen Psychiatry. 1997 Feb;54(2):145-52. doi: 10.1001/archpsyc.1997.01830140055010.

Murray G, Allen NB, Trinder J. Mood and the circadian system: investigation of a circadian component in positive affect. Chronobiol Int. 2002 Nov;19(6):1151-69. doi: 10.1081/cbi-120015956.

Monk TH, Buysse DJ, Reynolds CF 3rd, Jarrett DB, Kupfer DJ. Rhythmic vs homeostatic influences on mood, activation, and performance in young and old men. J Gerontol. 1992 Jul;47(4):P221-7. doi: 10.1093/geronj/47.4.p221.

Brewster GS, Riegel B, Gehrman PR. Insomnia in the Older Adult. Sleep Med Clin. 2018 Mar;13(1):13-19. doi: 10.1016/j.jsmc.2017.09.002. Epub 2017 Nov 22.

Patel D, Steinberg J, Patel P. Insomnia in the Elderly: A Review. J Clin Sleep Med. 2018 Jun 15;14(6):1017-1024. doi: 10.5664/jcsm.7172.

Kay DB, Dombrovski AY, Buysse DJ, Reynolds CF, Begley A, Szanto K. Insomnia is associated with suicide attempt in middle-aged and older adults with depression. Int Psychogeriatr. 2016 Apr;28(4):613-9. doi: 10.1017/S104161021500174X. Epub 2015 Nov 10.

Richard-Devantoy S, Szanto K, Butters MA, Kalkus J, Dombrovski AY. Cognitive inhibition in older high-lethality suicide attempters. Int J Geriatr Psychiatry. 2015 Mar;30(3):274-83. doi: 10.1002/gps.4138. Epub 2014 May 12.

McGirr A, Dombrovski AY, Butters MA, Clark L, Szanto K. Deterministic learning and attempted suicide among older depressed individuals: cognitive assessment using the Wisconsin Card Sorting Task. J Psychiatr Res. 2012 Feb;46(2):226-32. doi: 10.1016/j.jpsychires.2011.10.001. Epub 2011 Oct 22.

Clark L, Dombrovski AY, Siegle GJ, Butters MA, Shollenberger CL, Sahakian BJ, Szanto K. Impairment in risk-sensitive decision-making in older suicide attempters with depression. Psychol Aging. 2011 Jun;26(2):321-330. doi: 10.1037/a0021646.

Dombrovski AY, Clark L, Siegle GJ, Butters MA, Ichikawa N, Sahakian BJ, Szanto K. Reward/Punishment reversal learning in older suicide attempters. Am J Psychiatry. 2010 Jun;167(6):699-707. doi: 10.1176/appi.ajp.2009.09030407. Epub 2010 Mar 15.

Gibbs LM, Dombrovski AY, Morse J, Siegle GJ, Houck PR, Szanto K. When the solution is part of the problem: problem solving in elderly suicide attempters. Int J Geriatr Psychiatry. 2009 Dec;24(12):1396-404. doi: 10.1002/gps.2276.

Dombrovski AY, Butters MA, Reynolds CF 3rd, Houck PR, Clark L, Mazumdar S, Szanto K. Cognitive performance in suicidal depressed elderly: preliminary report. Am J Geriatr Psychiatry. 2008 Feb;16(2):109-15. doi: 10.1097/JGP.0b013e3180f6338d.

McCall WV, Benca RM, Rosenquist PB, Youssef NA, McCloud L, Newman JC, Case D, Rumble ME, Szabo ST, Phillips M, Krystal AD. Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): A Randomized Clinical Trial. Am J Psychiatry. 2019 Nov 1;176(11):957-965. doi: 10.1176/appi.ajp.2019.19030267. Epub 2019 Sep 20.

Margolis SA, Kelly DA, Daiello LA, Davis J, Tremont G, Pillemer S, Denby C, Ott BR. Anticholinergic/Sedative Drug Burden and Subjective Cognitive Decline in Older Adults at Risk of Alzheimer's Disease. J Gerontol A Biol Sci Med Sci. 2021 May 22;76(6):1037-1043. doi: 10.1093/gerona/glaa222.

Puustinen J, Lahteenmaki R, Polo-Kantola P, Salo P, Vahlberg T, Lyles A, Neuvonen PJ, Partinen M, Raiha I, Kivela SL. Effect of withdrawal from long-term use of temazepam, zopiclone or zolpidem as hypnotic agents on cognition in older adults. Eur J Clin Pharmacol. 2014 Mar;70(3):319-29. doi: 10.1007/s00228-013-1613-6. Epub 2013 Dec 12.

Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, Coleman J, Kapur V, Lee-Chiong T, Owens J, Pancer J, Swick T; American Academy of Sleep Medicine. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006 Nov;29(11):1415-9.

Trockel M, Karlin BE, Taylor CB, Brown GK, Manber R. Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep. 2015 Feb 1;38(2):259-65. doi: 10.5665/sleep.4410.

Pigeon WR, Funderburk JS, Cross W, Bishop TM, Crean HF. Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial. Transl Behav Med. 2019 Nov 25;9(6):1169-1177. doi: 10.1093/tbm/ibz108.

Hedegaard H, Curtin SC, Warner M. Suicide Mortality in the United States, 1999-2017. NCHS Data Brief. 2018 Nov;(330):1-8.

Manber R, Simpson NS, Bootzin RR. A step towards stepped care: delivery of CBT-I with reduced clinician time. Sleep Med Rev. 2015 Feb;19:3-5. doi: 10.1016/j.smrv.2014.09.003. Epub 2014 Oct 8. No abstract available.

Christensen H, Batterham PJ, Gosling JA, Ritterband LM, Griffiths KM, Thorndike FP, Glozier N, O'Dea B, Hickie IB, Mackinnon AJ. Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. Lancet Psychiatry. 2016 Apr;3(4):333-41. doi: 10.1016/S2215-0366(15)00536-2. Epub 2016 Jan 28. Erratum In: Lancet Psychiatry. 2016 Apr;3(4):320.

Zachariae R, Lyby MS, Ritterband LM, O'Toole MS. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev. 2016 Dec;30:1-10. doi: 10.1016/j.smrv.2015.10.004. Epub 2015 Oct 24.

Cheng P, Luik AI, Fellman-Couture C, Peterson E, Joseph CLM, Tallent G, Tran KM, Ahmedani BK, Roehrs T, Roth T, Drake CL. Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial. Psychol Med. 2019 Feb;49(3):491-500. doi: 10.1017/S0033291718001113. Epub 2018 May 24.

Klingman KJ, Jungquist CR, Perlis ML. Questionnaires that screen for multiple sleep disorders. Sleep Med Rev. 2017 Apr;32:37-44. doi: 10.1016/j.smrv.2016.02.004. Epub 2016 Feb 27.

Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001 Jul;2(4):297-307. doi: 10.1016/s1389-9457(00)00065-4.

Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77. doi: 10.1176/appi.ajp.2011.10111704.

Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging. 1997 Jun;12(2):277-87. doi: 10.1037//0882-7974.12.2.277.

Radloff LS. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc. 1991 Apr;20(2):149-66. doi: 10.1007/BF01537606.

Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. doi: 10.1001/archinte.166.10.1092.

Grandner MA, Olivier K, Gallagher R, Hale L, Barrett M, Branas C, Killgore WDS, Parthasarathy S, Gehrels JA, Alfonso-Miller P. Quantifying impact of real-world barriers to sleep: The Brief Index of Sleep Control (BRISC). Sleep Health. 2020 Oct;6(5):587-593. doi: 10.1016/j.sleh.2020.01.013. Epub 2020 May 29.

Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL, Morin CM. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep. 2012 Feb 1;35(2):287-302. doi: 10.5665/sleep.1642.

Kleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. J Abnorm Psychol. 2017 Aug;126(6):726-738. doi: 10.1037/abn0000273. Epub 2017 May 8.

Morris JC, Heyman A, Mohs RC, Hughes JP, van Belle G, Fillenbaum G, Mellits ED, Clark C. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology. 1989 Sep;39(9):1159-65. doi: 10.1212/wnl.39.9.1159.

Morrison GE, Simone CM, Ng NF, Hardy JL. Reliability and validity of the NeuroCognitive Performance Test, a web-based neuropsychological assessment. Front Psychol. 2015 Nov 3;6:1652. doi: 10.3389/fpsyg.2015.01652. eCollection 2015.

WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002 Sep;97(9):1183-94. doi: 10.1046/j.1360-0443.2002.00185.x.

Dawson DA, Grant BF, Stinson FS. The AUDIT-C: screening for alcohol use disorders and risk drinking in the presence of other psychiatric disorders. Compr Psychiatry. 2005 Nov-Dec;46(6):405-16. doi: 10.1016/j.comppsych.2005.01.006.