A 10-year trend of insomnia prevalence in the adult Norwegian population

Sleep and Mental Health Issues in Current and Former Athletes: A Mini Review

Sleep and mental health are important aspects of human health that work concurrently. However, sleep and mental health disorders are often overlooked and undiagnosed in sport due to the negative stigma associated with them. Evidence suggests that athletes are disproportionately affected by mental health issues and sleep problems. Internal and external pressures contribute to psychological distress. Variable competition times, travel and stress are detrimental to sleep quality. Retirement from sport can deteriorate sleep and psychological wellbeing, particularly for those who retired involuntarily and identify strongly with their athletic role. When untreated, these issues can manifest into a range of clinical disorders. This is concerning, not only for compromised athletic performance, but for general health and wellbeing beyond sport. Previous research has focussed on sleep and health independently among currently competing, or former, athletes. To date, no research has comprehensively assessed and compared sleep complaints and mental health issues between these two cohorts. Moreover, research has failed to obtain data across a variety of different competition levels, sports, and genders, leaving the current scope of the literature narrow. Comorbid conditions (e.g., concussion history, obesity), ex-college athletes, and mental health has been the focus of existing literature post-retirement. Future research would benefit from employing both quantitative and qualitative methodologies to comprehensively assess the prevalence and severity of sleep and mental health disorders across current and retired athletes. Research outcomes would inform education strategies, safeguarding athletes from these issues by reducing negative stigmas associated with help-seeking in sport and ultimately increase self-guided treatment.

U-shaped association between sleep duration and subjective cognitive complaints in Chinese elderly: a cross-sectional study

BACKGROUND

Subjective cognitive decline (SCD) may be the early screening signal to distinguish susceptible population with Alzheimer's disease (AD) and mild cognitive impairment (MCI). Subjective cognitive complaints (SCCs) have been proved strongly associated with SCD. This study aimed to explore the association between sleep duration and SCCs in the Chinese elderly.

METHODS

We conducted a cross-sectional study involving 688 participants aged 60 years and older in Guangdong Province, China. SCCs were assessed by the Subjective Cognitive Decline questionnaire 9 (SCD-Q9), which contained 9 items with two dimensions, including the overall memory function and time comparison (OMTC) and daily activity ability (DAA). Restricted cubic splines and generalized additive model (GAM) were used to fit the association between sleep duration and SCD-Q9 score.

RESULTS

There were significant U-shaped associations between sleep duration and overall score of SCD-Q9 (EDF = 3.842, P < 0.001), as well as the OMTC dimension (EDF = 4.471, P < 0.001) in the age- and gender-adjusted GAM. The lowest points on the overall score of SCD-Q9 and OMTC score were observed in those sleeping 8 h per night. After further adjusting for other demographic characteristics, lifestyle behaviors, hypertension and diabetes, the U-shaped associations between sleep duration and the overall score of SCD-Q9 (EDF = 3.575, P = 0.004), sleep duration and the OMTC score (EDF = 4.478, P = 0.010) were still found. The daily activity ability (DAA) score was also non-linear associated with sleep duration both in the age- and gender-adjusted GAM (EDF = 2.314, P < 0.001) and further adjusted GAM (EDF = 2.080, P = 0.010).

CONCLUSIONS

Both longer sleep duration (> 8 h) and shorter duration (< 8 h) were linked to worse SCCs. Future studies should explore the protective effect of managing sleep duration on SCD and its progression to dementia.

A randomized controlled trial on the effects of blue-blocking glasses compared to partial blue-blockers on sleep outcomes in the third trimester of pregnancy

OBJECTIVE

Sleep disturbances are common in pregnancy. Blocking blue light has been shown to improve sleep and may be a suitable intervention for sleep problems during pregnancy. The present study investigated the effects of blue light blocking in the evening and during nocturnal awakenings among pregnant women on primary sleep outcomes in terms of total sleep time, sleep efficiency and mid-point of sleep.

METHODS

In a double-blind randomized controlled trial, 60 healthy nulliparous pregnant women in the beginning of the third trimester were included. They were randomized, using a random number generator, either to a blue-blocking glass intervention (n = 30) or to a control glass condition constituting partial blue-blocking effect (n = 30). Baseline data were recorded for one week and outcomes were recorded in the last of two intervention/control weeks. Sleep was measured by actigraphy, sleep diaries, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale.

RESULTS

The results on the primary outcomes showed no significant mean difference between the groups at posttreatment, neither when assessed with sleep diary; total sleep time (difference = .78[min], 95%CI = -19.7, 21.3), midpoint of sleep (difference = -8.9[min], 95%CI = -23.7, 5.9), sleep efficiency (difference = -.06[%], 95%CI = -1.9, 1.8) and daytime functioning (difference = -.05[score points], 95%CI = -.33, .22), nor by actigraphy; total sleep time (difference = 13.0[min], 95%CI = -9.5, 35.5), midpoint of sleep (difference = 2.1[min], 95%CI = -11.6, 15.8) and sleep efficiency (difference = 1.7[%], 95%CI = -.4, 3.7). On the secondary outcomes, the Bergen Insomnia Scale, the Karolinska Sleepiness Scale and the Pre-Sleep Arousal Scale the blue-blocking glasses no statistically significant difference between the groups were found. Transient side-effects were reported in both groups (n = 3).

CONCLUSIONS

The use of blue-blocking glasses compared to partially blue-blocking glasses in a group of healthy pregnant participants did not show statistically significant effects on sleep outcomes. Research on the effects of blue-blocking glasses for pregnant women with sleep-problems or circadian disturbances is warranted.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov (NCT03114072).

Psychometric Validation of the Athens Insomnia Scale Among Nurses: A Robust Approach Using Both Classical Theory and Rating Scale Model Parameters

PURPOSE

Few studies have investigated the validity of the Athens insomnia scale (AIS) using a robust approach of both classical theory and the rating scale model. Therefore, in this study, we investigated psychometric validation of the AIS using both of these approaches in nurses.

METHODS

Nurses (n= 563, age= 33.2±7.1 years) working in health facilities in Saudi Arabia participated in a cross-sectional study. Participants completed the AIS, socio-demographics tool, and sleep health-related questions.

RESULTS

Confirmatory factor analysis (CFA) favored a 2-factor structure with both comparative fit index (CFI), and incremental fit index (IFI) having values above 0.95. The 2-factor model had the lowest values of Akaike information criterion (AIC), root mean square error of approximation (RMSEA), χ ², and χ ²/df. This 2-factor structure showed configural invariance (CFI more than 0.95, RMSEA less than 0.08, and Χ²/df less than 3), and metric, scalar, and strict invariance (based on Δ CFI ≤-0.01, and Δ RMSEA ≥ 0.015 criteria). No ceiling/floor effects were seen for the AIS total scores. Infit and outfit mean square values for all the items were within the acceptable range (<1.4, >0.6). The threshold estimates for each item were ordered as expected. Cronbach's α for the AIS tool, factor-1 score, factor-2 score was 0.86, 0.82, and 0.72, respectively. AIS factor scores-1/2 were significantly associated with a habitual feeling of tiredness after usual night sleep (p<0.001), Impairment of daytime socio-occupational functioning (p<0.05), and with a feeling of daytime fatigue, irritability, and restlessness (p<0.05).

CONCLUSION

The findings favor the validity of a 2-factor structure of the AIS with adequate item properties, convergent validity, and reliability in nurses.

Sleep and Actigraphy Research Trends: A Bibliometric and Keyword Network Analysis From 2004 to 2020

Background and Objective As sleep is a predictor of quality of life, studying sleep health and measurement is important. Actigraphy as a physiologic measure based on monitoring an individual’s movement has also been increasing in use as it has several advantages over traditional self-reports. This study aimed to report the research trends of sleep and actigraphy using a bibliometric and keyword analysis.Methods Using topic search queries, this study collected data from 3955 publications published between 2004 and 2020 and listed in the Web of Science Core Collection. A text-mining unstructured data analysis was performed using author keywords and a bibliographic analysis.Results Studies on sleep and actigraphy have been actively conducted in the fields of neurosciences and neurology but not in other fields. A gradual increase in publication and the steep increase in citations related to this topic occurring during the period considered. By clustering the author keywords, the analysis revealed five clusters: 1) monitoring physical activity and blood pressure, 2) measuring sleep quality, 3) insomnia and cognitive behavioral therapy for adolescents and children, 4) disorders and circadian rhythms, and 5) shift work. The leading research cluster has changed over the time.Conclusions With the increase in the number of studies and citations on sleep and actigraphy over the past 16 years, the trend of sleep and actigraphy studies have shifted from a focus on sleeprelated psychiatric disorders to a focus on cognitive behavioral therapy for children and adolescents and, more recently, the measurement of sleep quality.

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic in self-reported good and poor sleepers (Sleep COVID-19): study protocol for a randomised controlled trial

Background

Theoretical models of insomnia suggest that stressful life events, such as the COVID-19 pandemic, can cause acute insomnia (short-term disruptions to sleep). Early interventions may prevent short-term sleep problems from progressing to insomnia disorder. Although cognitive behavioural therapy for insomnia (CBT-I) is effective in treating insomnia disorder, this can be time and resource-intensive. Further, online interventions can be used to deliver treatment to a large number of individuals. The objective of this study is to investigate if an online behavioural intervention, in the form of a leaflet, which has been successfully used alongside CBT-I for acute insomnia, can reduce symptoms of acute insomnia in poor sleepers.

Methods

A total of 124 self-reported good and poor sleepers will be enrolled in an online stratified randomised controlled trial. After baseline assessments (T1), participants will complete a 1-week pre-intervention sleep monitoring period (T2) where they will complete daily sleep-diaries. Poor sleepers (n = 62) will be randomly allocated to an invention or wait-list group, where they will receive the intervention (T3), or will do so after a 28-day delay. Good sleepers (n = 62) will be randomly assigned to an intervention or no intervention group. All participants will complete a 1-week post intervention sleep monitoring period using daily sleep diaries (T4). Participants will be followed up at 1 week (T5), 1 month (T6) and 3 months (T7) post intervention. The primary outcome measure will be insomnia severity, measured using the Insomnia Severity Index. Secondary outcome measures will include subjective mood and subjective sleep continuity, measured using sleep diaries. Data will be analysed using an intention-to-treat approach.

Discussion

It is expected that this online intervention will reduce symptoms of acute insomnia in self-reported short-term poor sleepers, and will also prevent the transition to poor sleep in good sleepers. We expect that this will demonstrate the feasibility of online interventions for the treatment and prevention of acute insomnia. Specific advantages of online approaches include the low cost, ease of administration and increased availability of treatment, relative to face-to-face therapy.

Trial registration

ISRCTN43900695 (Prospectively registered 8th of April 2020).

Mode of delivery of Cognitive Behavioral Therapy for Insomnia: a randomized controlled non-inferiority trial of digital and face-to-face therapy

STUDY OBJECTIVES

Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) has demonstrated efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary services. We undertook a randomized controlled trial to test whether fully automated dCBT-I is non-inferior to individual FtF CBT-I in reducing insomnia severity.

METHODS

Eligible participants were adult patients with a diagnosis of insomnia disorder recruited from a sleep clinic provided via public mental health services in Norway. The Insomnia Severity Index (ISI) was the primary outcome measure. The non-inferiority margin was defined a priori as 2.0 points on the ISI at week 33.

RESULTS

Individuals were randomized to FtF CBT-I (n = 52) or dCBT-I (n = 49); mean baseline ISI scores were 18.4 (SD 3.7) and 19.4 (SD 4.1), respectively. At week 33, the mean scores were 8.9 (SD 6.0) and 12.3 (SD 6.9), respectively. There was a significant time effect for both interventions (p < 0.001); and the mean difference in ISI at week 33 was -2.8 (95% CI: -4.8 to -0.8; p = 0.007, Cohen's d = 0.7), and -4.6 at week 9 (95% CI -6.6 to -2.7; p < 0.001), Cohen's d = 1.2.

CONCLUSIONS

At the primary endpoint at week 33, the 95% CI of the estimated treatment difference included the non-inferiority margin and was wholly to the left of zero. Thus, this result is inconclusive regarding the possible inferiority or non-inferiority of dCBT-I over FtF CBT-I, but dCBT-I performed significantly worse than FtF CBT-I. At week 9, dCBT-I was inferior to FtF CBT-I as the 95% CI was fully outside the non-inferiority margin. These findings highlight the need for more clinical research to clarify the optimal application, dissemination, and implementation of dCBT-I. Clinicaltrials.gov: NCT02044263: Cognitive Behavioral Therapy for Insomnia Delivered by a Therapist or on the Internet: a Randomized Controlled Non-inferiority Trial.

Co-morbid insomnia and obstructive sleep apnoea is associated with all-cause mortality

STUDY OBJECTIVES

Increased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of co-morbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk.

METHODS

Insomnia was defined as difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep ≥16 times a month and daytime impairment. OSA was defined as an apnoea-hypopnoea index ≥15 events/h sleep. COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazard models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up.

RESULTS

5236 participants were included. 2708 (52%) did not have insomnia/OSA (control), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone, and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (ORs [95%CI]; 2.00 [1.39, 2.90]) and cardiovascular disease compared to controls (1.70 [1.11, 2.61]). Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not cardiovascular disease compared to controls. Compared to controls, COMISA was associated with a 47% (HR, 95% CI; 1.47 (1.06, 2.07)) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia.

CONCLUSIONS

Co-morbid insomnia and sleep apnoea was associated with higher rates of hypertension and cardiovascular disease at baseline, and an increased risk of all-cause mortality compared to no insomnia/OSA.

An Association Rule Analysis of the Acupressure Effect on Sleep Quality

BACKGROUND

Sleep is recognized as an all-important physiological process, which also contributes to maintaining several bodily functions and systems. According to the Pittsburgh Sleep Quality Index (PSQI), also known as the most widely used tool in the field of subjective assessment of self-perceived sleep quality, a combination of acupoints could be more effective than single acupoint treatment in improving sleep quality.

METHODS

The present study was based on the extracted eligible studies rooted in a previous meta-analysis that worked on the basis of association rule mining and examined the potential kernel acupoint combinations for improving sleep quality.

RESULTS

Depending on the Apriori algorithm, we summarized 26 acupoints as binary data from the 32 eligible studies based on a previous meta-analysis and analyzed them. The top 10 most frequently selected acupoints were HT7, SP6, PC6, KI1, GV20, EM5, EX-HN3, EX-HN16, KI3, and MA-TF1. Furthermore, as deduced from 21 association rules, the primary relevant rules in the combination of acupoints are (EX-HN3, EX-HN16)=>(GV20) and (HT7, KI1)=>(PC6).

CONCLUSIONS

In order to use acupuncture to improve sleep quality, integrating (EX-HN3, EX-HN16, GV20) with (HT7, KI1, PC6) acupoints could be deemed as the kernel acupoint combination.

Structural validity of the Insomnia Severity Index: A systematic review and meta-analysis

The factor structure of the Insomnia Severity Index (ISI) is discussed, with examples being drawn from about 13 disparate reported models. A systematic appraisal of procedural details of studies investigating the dimensionality of the ISI was performed. The databases CINAHL, Cochrane Library, Embase, Medline, and PsycINFO were searched thoroughly, and all articles in English, published, and/or available online as of 14th March 2019, were included. Meta-analyses of Cronbach's alpha and structural validity measures were performed. Several inadequacies or omissions were found in analyses using the three groups of measures. Fifteen out of 20 studies did not employ either EFA or CFA, 10 studies did not report CFA, while five did not report EFA. The most common omissions related to multivariate normality, final model selection based on consideration of fit indices, parsimony, and failure to consider the theoretical construct in the final model selection. Meta-analysis showed that CFA outcome is more robust compared to EFA, two-factor solution is the vigorous presentation of dimensionality compared to a three-factor solution, and ISI has a high pooled Cronbach's alpha. Further validation of the disparate models of the ISI is needed with more comprehensive reporting guidelines, such as the one suggested in the present review.

Thermal Comfort and Sleep Quality of Indonesian Students Living in Japan during Summer and Winter

Thermal comfort is crucial in satisfaction and maintaining quality sleep for occupants. In this study, we investigated the comfort temperature in the bedroom at night and sleep quality for Indonesian students during summer and winter. Eighteen male Indonesian students aged 29 ± 4 years participated in this study. The participants had stayed in Japan for about six months. We evaluated the sleep parameters using actigraphy performed during summer and winter. All participants completed the survey regarding thermal sensation, physical conditions, and subjective sleepiness before sleep. The temperature and relative humidity of participants’ bedrooms were also measured. We found that the duration on the bed during winter was significantly longer than that during summer. However, sleeping efficiency during winter was significantly worse than that during summer. The bedroom temperature of the participants was in the range of comfort temperature in Indonesia. With the average bedroom air temperature of 22.2 °C, most of the participants still preferred “warm” and felt “slightly comfortable” during winter. The average comfort temperature each season calculated using the Griffiths method was 28.1 °C during summer and 23.5 °C during winter. In conclusion, differences in adaptive action affect bedroom thermal conditions. Furthermore, habits encourage the sleep performance of Indonesian students.

Effect of Continuous Positive Airway Pressure on Symptoms and Prevalence of Insomnia in Patients With Obstructive Sleep Apnea: A Longitudinal Study

Objective

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders. Continuous positive airway pressure (CPAP) is considered first-line treatment for OSA. In the present study, we assess the effect of CPAP on symptoms and prevalence of insomnia in patients with OSA. We hypothesized a decrease in insomnia symptoms from CPAP initiation to follow-up, and that this decrease would depend on CPAP adherence.

Materials and methods

The sample included 442 patients diagnosed with OSA [mean age 54.9 years (SD = 12.1), 74.4% males] who started treatment with CPAP at a university hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean apnea-hypopnea index (AHI) was 30.1 (SD = 21.1) at baseline. Insomnia was assessed prior to CPAP treatment (baseline) and at follow-up after a median of 19.9 weeks (range 6–52 weeks) with the Bergen Insomnia Scale (BIS). CPAP adherence was defined as an average use of ≥ 4 h per night, whereas non-adherence was defined as < 4 h per night.

Results

There was a significant decrease in BIS scores from baseline (mean = 18.8, SD = 9.8) to follow-up (mean = 12.9, SD = 9.9), p < 0.001. Cohen’s d(0.65) indicated a moderate effect size. The reduction in BIS scores was depending on CPAP adherence (interaction effect F(1,440) = 12.4, p < 0.001), with larger reduction in the adherent group than in the non-adherent group. The proportion of patients with chronic insomnia was significantly reduced from 51.1% at baseline to 33.0% at follow-up (p < 0.001).

Conclusion

Overall, there was a significant reduction in insomnia symptoms from baseline to follow-up. The improvement was significant in both adherence groups, but the degree of improvement was larger among patients who were adherent to CPAP. Furthermore, there was a significant reduction in the prevalence of chronic insomnia at follow-up compared to baseline. This suggests that CPAP effectively reduces both the presence of insomnia and the severity of insomnia symptoms in some patients with OSA.

Insomnia Prevalence among Italian Night-Shift Nurses

BACKGROUND

Insomnia is one of the major health problems related with a decrease in quality of life (QOL) and also in poor functioning in night-shift nurses, that also may negatively affect patients' care. The aim of this study is to evaluate the prevalence of insomnia in night shift nurses. This observational online web-based survey using Google®® modules specifically aimed to investigate the prevalence and risk factors for insomnia among Italian nurses.

METHODS

Data collection for this study lasted one month, with the questionnaire available from 1 March 2021 to 1 April 2021. Continuous variables were considered as either mean ± standard deviation (SD) or median and interquartile range (IQR) based on their distribution. Comparison among insomnia categories was assessed by one-way ANOVA or Kruskal-Wallis test according to variable distribution. Categorical variables were analyzed using chi-square test.

RESULTS

A total of 2355 responses were included in the final analysis, with 917 from the Northern zone, 815 from the Western zone, and 623 from the Southern zone of Italy. The prevalence of insomnia in the overall population was 65.4% (1524 out 2355 nurses suffered from insomnia).

CONCLUSIONS

Nursing is a high-pressure profession, with heavy duties and high professional risks. We found an important prevalence of insomnia in night shift nurses, and we hope it may help to solicit further studies aimed to identify the risk factors for this working disorder among nurses.

The Effect of Reducing Insomnia Severity on Work- and Activity-Related Impairment

OBJECTIVE/BACKGROUND

The effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I) for alleviating sleep problems is well established. However, few studies have explored its impact on work productivity and activity.

PARTICIPANTS

Seventy-seven currently employed adults with insomnia disorder (59 females) recruited to a randomized trial of digital versus face-to-face CBT-I.

METHODS AND MATERIALS

The general health version of the Work Productivity and Activity Impairment questionnaire was used to measure absenteeism, presenteeism, total work impairment, and activity impairment. We assessed changes in work productivity and activity pre-to-post-therapy for the total sample and then for subgroups categorized according to response or remission of insomnia disorder (evaluated using the Insomnia Severity Index).

RESULTS

Study participants showed significant improvements in presenteeism (p = .001; Cohen's d= 0.46), total work impairment (p < .001; d= 0.48), and activity (p < .001; d= 0.66), but not absenteeism (p = .51; d= 0.084) between baseline and follow-up assessment. Individuals meeting criteria for remission showed significantly greater improvement in presenteeism (p = .002), total work impairment (p < .001), and activity (p = .006), but not absenteeism (p = .064).

CONCLUSION

This study suggests that the benefits of CBT-I extend beyond improvement in sleep to encompass moderate-to-large improvements in work productivity and activity levels particularly for individuals who achieve remission from insomnia. Given the importance of these behaviors, there is a need for future large-scale randomized trials and cohort studies which should strive to include objective measurement of daytime activity and work performance more frequently.

Genetics of Sleep and Insights into Its Relationship with Obesity

Considerable recent advancements in elucidating the genetic architecture of sleep traits and sleep disorders may provide insight into the relationship between sleep and obesity. Despite the considerable involvement of the circadian clock in sleep and metabolism, few shared genes, including FTO, were implicated in genome-wide association studies (GWASs) of sleep and obesity. Polygenic scores composed of signals from GWASs of sleep traits show largely null associations with obesity, suggesting lead variants are unique to sleep. Modest genome-wide genetic correlations are observed between many sleep traits and obesity and are largest for snoring.Notably, U-shaped positive genetic correlations with body mass index (BMI) exist for both short and long sleep durations. Findings from Mendelian randomization suggest robust causal effects of insomnia on higher BMI and, conversely, of higher BMI on snoring and daytime sleepiness. Bidirectional effects between sleep duration and daytime napping with obesity may also exist. Limited gene-sleep interaction studies suggest that achieving favorable sleep, as part of a healthy lifestyle, may attenuate genetic predisposition to obesity, but whether these improvements produce clinically meaningful reductions in obesity risk remains unclear. Investigations of the genetic link between sleep and obesity for sleep disorders other than insomnia and in populations of non-European ancestry are currently limited. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A study of the association of cognitive abilities and emotional function with allergic disorders in young women

Background

Allergic disorders may have a bidirectional causal relationship with mental disorders. In this cross-sectional study, we aimed to assess the associations between cognitive abilities and emotional function tests and quality of life with the presence of allergic disease in young women.

Methods

A diagnosis of allergic disorders, comprising allergic rhinitis (AR), asthma and atopic dermatitis (AD), was confirmed by a specialist in allergy. The presence and severity of depression, anxiety, stress, insomnia and sleepiness were evaluated using validated questionnaires. Cognitive abilities and quality of life were assessed using standard instruments.

Results

Among 181 female young participants, the prevalence of AR, asthma and AD were 26.5%, 2.8%, and 14.9% respectively. The AR group had higher scores than the non-AR group for depression, anxiety, insomnia, and lower scores for physical and mental health-related quality of life. Moreover, the AD cases had higher scores on the depression and stress scale compared to those without it (p < 0.05). Asthmatic patients also had significantly higher insomnia severity and lower physical health-related quality of life than non-asthmatic.

Conclusion

There was a high prevalence of psychological/psychiatric disorders that included: anxiety, and sleep problems among allergic women, and a reduced quality of life that may be associated with it.

The effect of sleep-wake intraindividial variability in digital cognitive behaviour therapy for insomnia: A mediation analysis of a large-scale RCT

Study Objectives

Digital cognitive behavioral therapy for insomnia (dCBT-I) is an effective treatment for insomnia. However, less is known about mediators of its benefits. The aim of the present study was to test if intraindividual variability in sleep (IIV) was reduced with dCBT-I, and whether any identified reduction was a mediator of dCBT-I on insomnia severity and psychological distress.

Methods

In a two-arm randomized controlled trial (RCT), 1720 adults with insomnia (dCBT-I = 867; patient education about sleep = 853) completed the Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS) and sleep diaries, at baseline and 9-week follow-up. Changes in IIV were analyzed using linear mixed modeling followed by mediation analyses of ISI, HADS, and IIV in singular sleep metrics and composite measures (behavioral indices (BI-Z) and sleep disturbance indices (SI-Z)).

Results

dCBT-I was associated with reduced IIV across all singular sleep metrics, with the largest between-group effect sizes observed for sleep onset latency (SOL). Reduced IIV for SOL and wake after sleep onset had the overall greatest singular mediating effect. For composite measures, SI-Z mediated change in ISI (b = −0.74; 95% confidence interval (CI) −1.04 to −0.52; 13.3%) and HADS (b = −0.40; 95% CI −0.73 to −0.18; 29.2%), while BI-Z mediated minor changes.

Conclusion

Reductions in IIV in key sleep metrics mediate significant changes in insomnia severity and especially psychological distress when using dCBT-I. These findings offer important evidence regarding the therapeutic action of dCBT-I and may guide the future development of this intervention.

Clinical trials

Name: Overcoming Insomnia: Impact on Sleep, Health and Work of Online CBT-I

Registration number: NCT02558647

URL: https://clinicaltrials.gov/ct2/show/NCT02558647?cond=NCT02558647&draw=2&rank=1

Neurocognitive effects of melatonin treatment in healthy adults and individuals with Alzheimer's disease and insomnia: A systematic review and meta-analysis of randomized controlled trials

Endogenous melatonin levels are inversely associated with age and cognitive deficits. Although melatonin can improve psychopathological behavior disturbances in clinical trials, whether melatonin may also enhance cognitive function remains elusive. This study examined cognitive outcomes from randomized trials of melatonin treatment for Alzheimer's disease (AD), insomnia, and healthy-subjects. Twenty-two studies met the inclusion criteria (AD = 9, insomnia = 2, healthy-subjects = 11). AD patients receiving >12 weeks of melatonin treatment improved mini-mental state examination (MMSE) score [MD: 1.82 (1.01; 2.63) p < 0.0001]. Importantly, melatonin significantly improved MMSE score in mild stage of AD [MD: 1.89 (0.96; 2.82) p < 0.0001]. In healthy-subjects, although daytime melatonin treatment notably decreased in accuracy by correct responses [SMD: -0.74 (-1.03; -0.45) p < 0.00001], the reaction-time score on different stimuli (p = 0.37) did not increased. Additionally, by pooling of short-term, spatial, and visual memory scores, melatonin did not reduce memory function (p = 0.08). Meta-analysis of MMSE score suggested that melatonin is effective in treatment for mild stage of AD. Additionally, we propose that melatonin may be preferable to traditional hypnotics in management of insomnia.

Mid-Pregnancy Insomnia and its Association with Perinatal Depressive Symptoms: A Prospective Cohort Study

Objective/Background: Insomnia and depression are disorders that affect many perinatal women and that often are interrelated. The present study aimed to examine concurrent and prospective associations between mid-pregnancy insomnia and depression during mid-pregnancy and 8 weeks postpartum. Furthermore, differences in depression and in the sleep-related characteristics insomnia, chronotype, and sleep efficiency were explored between the two time points (mid-pregnancy versus 8 weeks postpartum), and between primiparous and multiparous participants.Participants/Methods: The study was part of the Norwegian population-based Depression and Anxiety in the Perinatal Period (DAPP) prospective cohort study. Among 539 women that were recruited for participation when receiving a routine ultrasound examination, we analyzed data from hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8. We used the Edinburgh Postnatal Depression Scale to measure depression. The Bergen Insomnia Scale, the reduced Horne-Östberg Morningness-Eveningness Questionnaire, and three questions from the Pittsburgh Sleep Quality Index were used to measure the sleep-related characteristics.Results: Mid-pregnancy insomnia was significantly associated with concurrent depression (p < .001), but not with postpartum depression (p = .288), in a linear mixed model with adjustment for several reproductive and psychosocial variables. Sleep efficiency was reduced from mid-pregnancy to postpartum (from 88% to 77%), and primiparous women reported less efficient sleep than multiparous women after childbirth.Conclusions: The results indicate that mid-pregnancy insomnia may be a marker for concurrent depression but not a predictor of postpartum depression. Future research should examine the extent to which treatment of insomnia from mid-pregnancy on reduces both perinatal insomnia and depression.

Predictive factors of insomnia during the COVID-19 pandemic in Bangladesh: a GIS-based nationwide distribution

Background

In a densely populated country like Bangladesh, mental health-related burden and associated adverse outcomes are quite prevalent. However, exploration of sleep-related issues in general, and more specifically of insomnia during the COVID-19 pandemic has been scarce and restricted to a single location. The present study investigated the prevalence of insomnia and its predictive factors in the general population, and included Geographic Information System (GIS) analysis to identify regional heterogeneities of insomnia in Bangladesh.

Methods

This cross-sectional study was conducted during the early period of the COVID-19 pandemic. Information related to socio-demographics, knowledge of COVID-19, behaviors related to COVID-19, fear of COVID-19, and insomnia were included in a questionnaire, and coupled with GIS-based spatial analysis to identify regional susceptibility to insomnia.

Results

Approximately 30.4%, 13.1% and 2.8% of participants reported sub-threshold, moderate, and severe forms of insomnia, respectively. Independent predictive risk factors of insomnia symptoms included female gender, college education, urban residence, presence of comorbidities, using social media, taking naps during daytime, and fear of COVID-19. District-wide variations in the spatial distribution of fear of COVID-19 and insomnia were significantly associated.

Conclusion

Insomnia is frequently present during a pandemic, and exhibits regional variability along with multifactorial determinants. These analytic approaches should enable improved detection and targeting of at-risk sectors of the population, and enable implementation of appropriate measures to ensure improved sleep quality.

Efficacy of Triprolidine in the Treatment of Temporary Sleep Disturbance

Triprolidine, a first-generation antihistamine for allergic rhinitis, has a shorter half-life and fewer persistent effects relative to other antihistamines and may be useful in the treatment of temporary sleep disturbance. Patients aged ≥18 years old were randomized 1:1:1 to receive either triprolidine 2.5 mg (n = 65), triprolidine 5 mg (n = 66), or placebo (n = 67) on 3 consecutive nights. Sleep disturbance index was monitored via wrist actimeter. Subjective measures were assessed via diary card. Triprolidine 2.5 mg had a significantly lower sleep disturbance index versus placebo on night 1 (P = .02); however, when adjusted for outliers, sleep disturbance index did not significantly differ between either dose of triprolidine versus placebo on night 1. Adjusted sleep disturbance index was significantly lower with triprolidine 2.5 and 5 mg versus placebo on night 3 (P = .0017 and P = .011, respectively) and for the mean of all 3 nights (P = .01 and P = .015, respectively). Sleep latency was significantly improved for triprolidine 2.5 mg versus placebo on nights 2 and 3 and for the mean of all 3 nights and for triprolidine 5 mg versus placebo for the mean of all 3 nights. Subjective measures showed those on both doses of triprolidine felt more refreshed on awakening versus placebo for the mean of all 3 nights, with no increase in daytime sleepiness. The frequency of adverse events was similar across groups. The optimum dose of triprolidine for treatment of temporary sleep disturbance was 2.5 mg. There were improvements in both objective and subjective measures of sleep quality versus placebo, with no safety concerns raised.

Insomnia among employees in occupations with critical societal functions during the COVID-19 pandemic

Objective

This study investigates insomnia among employees in occupations critical to the functioning of society (e.g health, education, welfare and emergency services) during the COVID-19 pandemic. Many of these workers experience higher job pressure and increased risk of infection due to their work. It is crucial to investigate which factors that can contribute to insomnia in these important sectors.

Methods

Data was collected using an online survey administered in June 2020. The questionnaire measured demographic variables, sleep, stress, psychosocial factors and health concerns (i.e worrying about health consequences related to the pandemic). The sample in the present study consisted of 1327 (76% females) employees in organizations with societal critical functions.

Results

The employees reported higher levels of insomnia symptoms compared to normative data collected before the pandemic. Health concerns specifically related to COVID-19 had the strongest association to insomnia, followed by work stress. Job demands (i.e workload, time pressure and overtime) had merely a weak association to insomnia.

Conclusion

Worrying about consequences the pandemic can have on your own health and the health of your family or colleagues have a stronger negative impact on sleep than work pressure during the COVID-19 pandemic. Impaired sleep can have detrimental effects on performance and health, and a stronger focus on preventing insomnia as a mean of sustaining critical societal functions both during and after the pandemic is warranted. Organizations should consider interventions aimed at reducing health concerns among their employees during the COVID-19 pandemic.

Insomnia - A Heterogenic Disorder Often Comorbid With Psychological and Somatic Disorders and Diseases: A Narrative Review With Focus on Diagnostic and Treatment Challenges

Patients with insomnia complain of problems with sleep onset or sleep maintenance or early morning awakenings, or a combination of these, despite adequate opportunity and circumstances for sleep. In addition, to fulfill the diagnostic criteria for insomnia the complaints need to be associated with negative daytime consequences. For chronic insomnia, the symptoms are required to be present at least 3 days per week for a duration of at least 3 months. Lastly, for insomnia to be defined as a disorder, the sleep complaints and daytime symptoms should not be better explained by another sleep disorder. This criterion represents a diagnostic challenge, since patients suffering from other sleep disorders often complain of insomnia symptoms. For instance, insomnia symptoms are common in e.g., obstructive sleep apnea and circadian rhythm sleep-wake disorders. It may sometimes be difficult to disentangle whether the patient suffers from insomnia disorder or whether the insomnia symptoms are purely due to another sleep disorder. Furthermore, insomnia disorder may be comorbid with other sleep disorders in some patients, e.g., comorbid insomnia and sleep apnea (COMISA). In addition, insomnia disorder is often comorbid with psychological or somatic disorders and diseases. Thus, a thorough assessment is necessary for correct diagnostics. For chronic insomnia disorder, treatment-of-choice is cognitive behavioral therapy, and such treatment is also effective when the insomnia disorder appears comorbid with other diagnoses. Furthermore, studies suggest that insomnia is a heterogenic disorder with many different phenotypes or subtypes. Different insomnia subtypes may respond differently to treatment, but more research on this issue is warranted. Also, the role of comorbidity on treatment outcome is understudied. This review is part of a Research Topic on insomnia launched by Frontiers and focuses on diagnostic and treatment challenges of the disorder. The review aims to stimulate to more research into the bidirectional associations and interactions between insomnia disorder and other sleep, psychological, and somatic disorders/diseases.

Sleep-related disorders and sleep quality among adults living in Parakou, a sub-Saharan African city

PURPOSE

To determine the prevalence of sleep-related disorders, poor sleeping, and factors associated with poor sleep quality among inhabitants of Parakou, Benin.

METHODS

This was a cross-sectional study conducted from April-August 2018 on 930 randomly selected adults (age ≥ 18 years). Using the Pittsburg Sleep Quality Index, the Insomnia Severity Index, and the Epworth Sleepiness Scale, subjects were questioned on their sleep, on parasomnias, and on movement-related sleep disorders.

RESULTS

Overall, the prevalence of insomnia was 22% (95% CI, 19.1-24.4) and severe insomnia was 0.8%. The prevalence of excessive daytime sleepiness was 15% (95% CI, 12.5-17.0). Daily nightmares (2%) and rhythmic movements (6%) were those most commonly reported among parasomnias and movement-related sleep disorders. No major differences were found between men and women. The prevalence of poor sleeping (PSQI > 5) was 39% (95%CI, 36.3-42.5). Adjusted analyses showed a higher risk of poor sleeping in those aged 45-54 years (aOR = 1.78, p = 0.032) or ≥ 55 years (aOR = 3.61, p < 0.001), those overweight or obese (aOR = 1.53, p = 0.007), those underweight (aOR = 2.90, p = 0.030), and among females (aOR = 1.84, p < 0.001). Being divorced was associated with a lower risk of poor sleeping (aOR = 0.18, p = 0.036). Poor sleepers were more commonly found among those who had excessive daytime sleepiness (65% versus 36%, p < 0.001) and insomnia (86% versus 27%, p < 0.001).

CONCLUSION

Sleep-related disorders were common in Parakou city, Benin, with four out of ten persons having poor sleep quality. There is a need to improve the management of sleep-related disorders and promote better sleep practices for the community.

Students' top 10 priorities of research uncertainties on students' sleep: a pragmatic James Lind Alliance approach

OBJECTIVES

Inspired by the James Lind Alliance (JLA) user involvement approach, the aim of the present study was to identify the top 10 uncertainties for sleep research raised by students in higher education, and to discuss our experiences with adapting the JLA method to a student population.

DESIGN

The study design is a pragmatic JLA approach, including a priority setting partnership within the field of sleep, collection of sleep-related research uncertainties as reported by students in higher education, sorting of the uncertainties and a final identification of the top 10 uncertainties through collaborative work between researchers, students, stakeholders and experts in the field. Uncertainties were collected using a one-question online survey: 'as a student, which question(s) do you consider to be important with regards to sleep?'. A variety of approaches were applied to promote the survey to the students, including social media, radio, the university website, stands in university cafeterias and a sleep stunt. NVivo V.12 was used to code and sort the questions.

SETTING

A higher education institution in Norway.

PARTICIPANTS

555 students.

RESULTS

The data collection provided 608 uncertainties, and the following prioritised top 10: (1) screen time, (2) stress, (3) educational achievements, (4) social relations, (5) mental health, (6) physical activity, (7) indoor environment, (8) substance abuse, (9) shift work and (10) sleep quality. Despite successful data collection, we found sleep to be a broad topic, and defining specific questions throughout the sorting and verification process proved difficult.

CONCLUSIONS

We identified the prioritised top 10 research uncertainties as reported by students in higher education, ranking screen time first. However, the process was time and resource consuming. The research uncertainties addressed by the students showed great diversity, characterised by heterogeneity and a lack of specificity, making verification of the uncertainties challenging.

Insomnia Symptoms in the General Population During the COVID-19 Pandemic

This empirical study aims to investigate factors associated with insomnia symptoms during the COVID-19 pandemic in 4,921 Norwegian adults. Participants were queried across two time-points, between March 31^st and April the 7th 2020, and between June 22nd and July 13th, 2020. Relevant risk factors and psychological correlates at the first time-point and insomnia symptoms were measured 3 months later, allowing for the investigation of concurrent associations as well as associations across time. Insomnia symptoms were measured with the Bergen Insomnia Scale. The results revealed that individuals reported higher mean levels of insomnia symptoms during the COVID-19 lockdown, compared to pre-pandemic surveys from 2008 (p < 0.0001, Cohen's d = 0.29). Individuals who predominantly socially distanced reported higher mean levels of insomnia symptoms than those who did not predominantly distance. Females, individuals with lower education levels, individuals who had lost their job, and individuals who declared having been diagnosed with an unspecified pre-existing psychiatric disorder reported the most symptoms. The regression model (R² = 0.44) showed that physical exercise, was associated with less symptoms of insomnia. Symptoms of health Anxiety, symptoms of depression, unhelpful coping strategies, worry about job and economy, and older age were all associated with higher levels of insomnia symptoms. These findings highlight particularly vulnerable subgroups, as well as providing clinicians with key areas of intervention to help individuals suffering from insomnia symptoms.

Problematic Gaming and Sleep: A Systematic Review and Meta-Analysis

Problematic gaming has been linked to poor sleep outcomes; however, these associations have not yet been synthesized quantitatively. This review employed a meta-analysis to investigate the relationship between problematic gaming and sleep-related outcomes. A search of Medline, Embase, Web of Science, PsycINFO, and Google Scholar identified a total of 763 studies, including 34 studies (n = 51,901 participants) eligible for inclusion. Papers were included if available in any European language, addressed problematic gaming, contained original data, and provided sufficient data for calculation of effect sizes. Two researchers independently extracted data using pre-defined fields including quality assessment. Sleep-related outcomes were meta-analyzed for sleep parameters that were reported by 5 or more papers. Significant overall effects were found for sleep duration (g = -0.238, 95% CI = -0.364, -0.112), poor sleep quality (OR = 2.02, 95% CI = 1.47, 2.78), daytime sleepiness (OR = 1.57, 95% CI = 1.00, 2.46) and sleep problems (OR = 2.60, 95% CI = 1.94, 3.47). Between-study heterogeneity was detected for all meta-analyses. Subgroup analyses showed a higher inverse effect size for adolescent samples compared to adult or non-specific age samples in terms of sleep duration. For daytime sleepiness, a larger effect size was found for studies based on single-item sleep measures compared to multi-item sleep measures. For sleep problems, the subgroup analysis showed the opposite with a higher effect size for studies based on single-item sleep measures than multi-item sleep measures. Across all sleep parameters, problematic gamers consistently reported a more adverse sleep status than non-problematic gamers. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/; record ID: CRD42020158955.

Insomnia Disorder in Adult Attention-Deficit/Hyperactivity Disorder Patients: Clinical, Comorbidity, and Treatment Correlates

Introduction: Several investigations have been performed on insomnia symptoms in adult attention-deficit/hyperactivity disorder (ADHD). However, the relationship between insomnia disorder and adult ADHD has been neglected in research. The main objective of the current study is to analyze the differences between adult ADHD patients with and without insomnia disorder, in terms of ADHD clinical severity, medical and psychiatric comorbidity, psychopharmacological treatment, and quality of life. Material and Methods: Two hundred and fifty-two adult patients with ADHD (mean age 37.60 ± 13.22 years; ADHD presentations-combined: 56.7%, inattentive: 39.7%, hyperactive/impulsive: 3.6%) were evaluated with an exhaustive clinical and psychological evaluation protocol including semistructured interviews (for comorbidities and ADHD assessment) and symptom rating scales for ADHD. The diagnosis of ADHD and insomnia disorder was made according to DSM-5 criteria. Furthermore, the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Epworth Sleepiness Scale were administered. Results: Insomnia disorder was found in 44.4% of adult ADHD patients and was more common in combined presentation (64.3%) and in patients with more ADHD severity. Comorbidities (both medical and psychiatric), especially mood disorders (42%), anxiety disorder (26.8%), personality disorder (39.3%), and any substance use disorder (11.6%), were associated with a higher insomnia disorder prevalence. ADHD stimulant treatment was related to lower insomnia disorder compared to patients without medication, as well as ADHD stable treatment. Additionally, worse health-related quality of life was associated with insomnia disorder. Conclusion: Insomnia disorder is highly prevalent in adult ADHD and is related to higher ADHD severity and more psychiatric and medical comorbidities. Some stimulants and stable pharmacological ADHD treatment are associated with better outcomes of insomnia disorder.

The Prevalence and Stability of Sleep-Wake Disturbance and Fatigue throughout the First Year after Mild Traumatic Brain Injury

In this prospective, longitudinal study, we aimed to determine the prevalence and stability of sleep-wake disturbance (SWD) and fatigue in a large representative sample of patients (Trondheim mild traumatic brain injury [mTBI] follow-up study). We included 378 patients with mTBI (age 16-60), 82 matched trauma controls with orthopedic injuries, and 83 matched community controls. Increased sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue were assessed at 2 weeks, 3 months, and 12 months after injury. Mixed logistic regression models were used to evaluate clinically relevant group differences longitudinally. Prevalence of increased sleep need, poor sleep quality, and fatigue was significantly higher in patients with mTBI than in both trauma controls and community controls at all time points. More patients with mTBI reported problems with excessive daytime sleepiness compared to trauma controls, but not community controls, at all time points. Patients with complicated mTBI (intracranial findings on computed tomography or magnetic resonance imaging) had more fatigue problems compared to those with uncomplicated mTBI, at all three time points. In patients with mTBI who experienced SWDs and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third at 12 months. Interestingly, we observed limited overlap between the different symptom measures; a large number of patients reported one specific problem with SWD or fatigue rather than several problems. In conclusion, our results provide strong evidence that mTBI contributes significantly to the development and maintenance of SWDs and fatigue.

Evaluation of sedative effects of an intranasal dosage form containing saffron, lettuce seeds and sweet violet in primary chronic insomnia: A randomized, double-dummy, double-blind placebo controlled clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Persian Medicine (TPM) has been established as a valuable source of medicinal plants for the treatment of insomnia for thousands of years. Accordingly, oil extracts from plants' parts have been widely used to alleviate central nervous system (CNS) ailments including sleep disorders. A number of preparations have been recommended by TPM for the treatment of insomnia. Among them, an intranasal formulation containing oily macerates of Viola odorata L., Crocus sativus L. and Lactuca sativa L. stands out.

AIM OF THE STUDY

In the present double-dummy, double-blind placebo controlled clinical trial, we aim to evaluate the effectiveness of a combination of violet oil, saffron oil, and lettuce seeds oil nasal drop compared with the placebo (sesame oil).

MATERIALS AND METHODS

Fifty patients with primary chronic insomnia were randomly assigned in TPM-treatment or placebo groups, received either two drops of the herbal oil or placebo into each nostril every noon and evening for 8 weeks. Before the study commencement and after 1, 4 and 8 weeks of treatment, Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) questionnaires were completed by all patients. The primary outcome measure was considered as any changes in ISI scores between the first visit and after 8 weeks. Changes in PSQI scores during the study and possible side effects were also assessed. The multicompound herbal oil was standardized using HPLC analysis and contained 0.02 mg/mL crocin and 4 μg/mL isoquercitrin.

RESULTS

Our study revealed a significant reduction in the ISI and PSQI scores from baseline by the study endpoint (P ≤ 0.01). The mean ISI scores in week 8 decreased significantly for the intervention group (P = 0.001) and also the placebo group (P < 0.01) when compared with baseline. Moreover, the use of hypnotic drugs in the intervention group was significantly reduced (P < 0.001), while in the control group was maintained at baseline level.

CONCLUSIONS

It seems that intranasal use of the multi-herbal preparation can be used to improve chronic insomnia and to reduce the dose of conventional hypnotic medications in insomniac patients.

[Adult attention deficit hyperactivity disorder and comorbidity: new findings on epidemiological and genetic factors]

All large population-based administrative studies currently indicate a significant comorbidity of adult attention deficit hyperactivity disorder (ADHD) with addictive, anxiety and in particular affective disorders. In these investigations the risk for one of these comorbid disorders increased with increasing age of the ADHD patients. The most recent genome-wide association and correlation studies also revealed indications for joint genetic risk factors of ADHD with, in particular unipolar depression, bipolar disorder, autism spectrum disorders, Tourette's syndrome and to a lesser extent schizophrenia. The only psychiatric disorder that was negatively correlated with ADHD was anorexia nervosa. Additionally, cannabis and cocaine use were significantly positively genetically correlated with ADHD. Furthermore, an increased occurrence of some specific somatic diseases could be found in patients with adult ADHD. In particular, obesity, migraine, sleep disorders, asthma and celiac disease showed a significantly positive association with ADHD in several studies. No association was found between ADHD and cardiovascular disease. Here as well there are initial indications of joint genetic risk variants; however, data are still sparse and additional studies are needed before valid conclusions can be drawn. To some extent these associated somatic diseases might be differential diagnoses rather than true comorbidities, for example, obstructive sleep apnea syndrome (OSAS) can lead to ADHD-like symptoms that disappear when the OSAS is sufficiently treated. Therefore, it is important to keep the co-occurrence of psychiatric and somatic disorders in mind during the diagnostics and treatment of adult ADHD patients to improve their general health and quality of life.

Validation of insomnia questionnaires in the general population: The Nord-Trøndelag Health Study (HUNT)

The primary aim was to validate questionnaire-based insomnia diagnoses from a modified Karolinska Sleep Questionnaire (KSQ) and the Insomnia Severity Index (ISI), by age category (< or >65 years), against a semi-structured face-to-face interview. Secondary aims were to split validity by diagnostic certainty of the interview and to compare prevalence estimates of questionnaire- and interview-based diagnoses. A total of 232 out of 1,200 invited (19.3%) from the fourth Nord-Trøndelag Health Study (HUNT4) completed questionnaires, including the KSQ and ISI, shortly before attending a face-to-face diagnostic interview for insomnia based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Both a tentative (DSM-5 criteria A-E) and a definite (criteria A-H) interview diagnosis was evaluated. Cohen's kappa statistic quantified questionnaire validity. In all, 33% (95% confidence interval 27-39%) of participants had definite insomnia: 40% of women and 21% of men. The ISI (cut-off 12) and several KSQ-based diagnoses showed very good validity (κ ≤0.74) against the tentative, versus good validity (κ ≤0.61) against the definite interview diagnosis. Short questionnaires, requiring a daytime symptom at least three times a week, may underestimate insomnia prevalence. Validity was consistently higher for persons aged below versus above 65 years (definite insomnia: κ ≤0.64 vs. κ ≤0.56). Our results have implications for epidemiological population-based studies utilising insomnia questionnaires.

Perinatal Insomnia and Mental Health: a Review of Recent Literature

PURPOSE OF REVIEW

The perinatal period is a time of high risk for insomnia and mental health conditions. The purpose of this review is to critically examine the most recent literature on perinatal insomnia, focusing on unique features of this period which may confer specific risk, associations with depression and anxiety, and emerging work on perinatal insomnia treatment.

RECENT FINDINGS

A majority of perinatal women experience insomnia, which may persist for years, and is associated with depression and anxiety. Novel risk factors include personality characteristics, nocturnal perinatal-focused rumination, and obesity. Mindfulness and physical activity may be protective. Cognitive-behavioral therapy for insomnia is an effective treatment. Perinatal insomnia is exceedingly common, perhaps due to factors unique to this period. Although closely linked to perinatal mental health, more work is needed to establish causality. Future work is also needed to establish the role of racial disparities, tailor treatments, and determine whether insomnia treatment improves perinatal mental health.

The European Portuguese version of the insomnia severity index

Insomnia is the most prevalent sleep complaint, but remains largely an unidentified public health issue. The Insomnia Severity Index (ISI) is a brief self-report questionnaire to assess insomnia, long-established both in clinical and research settings. The present study aimed to analyse the reliability, validity, and accuracy of the ISI European Portuguese version. After the translation protocol, 1,274 participants (65.54% female), with a mean (SD, range) age of 37.52 (16.82, 18-95) years, completed the ISI. This sample included 250 patients with insomnia from a Sleep Medicine Centre, presenting a diagnosis of insomnia disorder (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; International Classification of Sleep Disorders, Third Edition), and 1,024 individuals from the community. A group of 30 patients with obstructive sleep apnea (OSA) was also recruited. Cronbach's α was 0.88 (internal consistency), and corrected item-total correlations ranged from 0.56 to 0.83. An exploratory factor analysis (oblique rotation) revealed a two-factor solution for both clinical and community samples. The ISI total score significantly differentiated insomnia disorder, no insomnia, and OSA subgroups with a large effect size (η ²  = 0.42). The correlation between ISI and Pittsburgh Sleep Quality Index supported concurrent validity (0.82), and discriminant validity was confirmed by a moderate correlation between ISI and Beck Depression Inventory Second Edition (0.32). The area under the curve was 0.88, and the optimal cut-off to detect clinical insomnia was 14 (82.1% sensitivity, 79.5% specificity). In conclusion, the Portuguese version of the ISI is a reliable and valid measure of insomnia in clinical and non-clinical populations. Our present study also contributes to relevant data for the international literature regarding the cut-off score of the scale for the detection of clinical insomnia.

Relationship between Mental Health, the CLOCK Gene, and Sleep Quality in Surgical Nurses: A Cross-Sectional Study

Nursing is a high-risk occupation with high exposure to stress. The physical and mental health of nurses is directly related to the quality of medical services. Therefore, the sleep quality of nurses should not be ignored. In this study, the method of cluster random sampling was adopted from May to September 2019, and a questionnaire survey was conducted among 521 surgical nurses from five affiliated hospitals of Xinjiang Medical University. The relationship between mental health and sleep quality was analyzed, and 20% of the participants with sleep disorders were randomly selected. The sleep disorders used 1 : 1 matching, finally providing a sample with 60 cases and 60 controls for measurement of the CLOCK gene (rs1801260, rs6850524), to analyze the effect of the interaction between mental health and the CLOCK gene on sleep. The mental health and sleep quality of the surgical nurses were evaluated using the Symptom Checklist 90 (SCL-90) and Pittsburgh Sleep Quality Index (PSQI). The study found that surgical nurses had poor sleep, and there were differences associated with age, years working, frequency of night shifts, and incidence of sleep disorders under marital status (p < 0.05). The PSQI scores of the positive psychological symptoms were higher than those of the negative psychological symptoms. The rank sum test was used to compare the sleep quality scores of different genotypes in CLOCK rs1801260 and rs6850524; the results indicated that the PSQI scores were different among different genotypes at the rs1801260 and rs6850524 loci. The logistic regression results suggested that CLOCK gene rs1801260 (TC) and positive psychological symptoms were influential factors for sleep disorders, and the interaction of positive psychological symptoms∗rs1801260 (TT) was a risk factor for sleep disorders (OR = 10.833, 95% CI: 2.987-39.288). The sleep quality of nurses is not only affected by demographic characteristics but also affected by mental health status and the CLOCK gene.

Factors associated with insomnia among Chinese front-line nurses fighting against COVID-19 in Wuhan: A cross-sectional survey

Aim

To investigate the prevalence of insomnia among front‐line nurses fighting against COVID‐19 in Wuhan, China, and analyse its influencing factors.

Background

Insomnia is an important factor that can affect the health and work quality of nurses. However, there is a lack of big‐sample studies exploring factors that affect the insomnia of nurses fighting against COVID‐19.

Method

This cross‐sectional study using the Ascension Insomnia Scale, Fatigue Scale‐14 and Perceived Stress Scale took place in March 2020. Participants were 1,794 front‐line nurses from four tertiary‐level general hospitals.

Results

The prevalence of insomnia among participants was 52.8%. Insomnia was predicted by gender, working experience, chronic diseases, midday nap duration, direct participation in the rescue of patients with COVID‐19, frequency of night shifts, professional psychological assistance during the pandemic, negative experiences (such as family, friends or colleagues being seriously ill or dying due to COVID‐19), the degree of fear of COVID‐19, fatigue and perceived stress.

Conclusion

The level of insomnia among participants was higher than the normal level. Interventions based on influencing factors should be implemented to ensure nurses’ sleep quality.

Implications for Nursing Management

An in‐depth understanding of the influencing factors of insomnia among front‐line nurses can help nurse managers develop solutions to improve front‐line nurses’ sleep quality, which will enhance the physical and mental conditions of nurses and promote the quality of care.

Brain mechanisms of insomnia: new perspectives on causes and consequences

While insomnia is the second most common mental disorder, progress in our understanding of underlying neurobiological mechanisms has been limited. The present review addresses the definition and prevalence of insomnia and explores its subjective and objective characteristics across the 24-hour day. Subsequently, the review extensively addresses how the vulnerability to develop insomnia is affected by genetic variants, early life stress, major life events, and brain structure and function. Further supported by the clear mental health risks conveyed by insomnia, the integrated findings suggest that the vulnerability to develop insomnia could rather be found in brain circuits regulating emotion and arousal than in circuits involved in circadian and homeostatic sleep regulation. Finally, a testable model is presented. The model proposes that in people with a vulnerability to develop insomnia, the locus coeruleus is more sensitive to-or receives more input from-the salience network and related circuits, even during rapid eye movement sleep, when it should normally be sound asleep. This vulnerability may ignite a downward spiral of insufficient overnight adaptation to distress, resulting in accumulating hyperarousal, which, in turn, impedes restful sleep and moreover increases the risk of other mental health adversity. Sensitized brain circuits are likely to be subjectively experienced as "sleeping with one eye open". The proposed model opens up the possibility for novel intervention studies and animal studies, thus accelerating the ignition of a neuroscience of insomnia, which is direly needed for better treatment.

Expert Opinions and Consensus Recommendations for the Evaluation and Management of Insomnia in Clinical Practice: Joint Statements of Five Italian Scientific Societies

BACKGROUND

Insomnia is the most commonly reported sleep problem in industrialized countries worldwide being present in about 36.8% of the general population. In Italy, such a percentage seems to be even higher. Although insomnia can be an independent disorder, it is most frequently observed as a comorbid condition and may precipitate, exacerbate, or prolong a broad range of comorbid conditions including physical and mental illnesses. Evaluating and targeting insomnia in the Italian clinical practice should be a priority.

METHODS

The present expert options and recommendations development process was based on the RAND/UCLA Appropriateness Method for conceptualizing, designing, and carrying out the appropriateness of procedures for the diagnosis and treatment. Only available options in Italy were taken into considerations.

RESULTS

We evaluated 12 international guidelines and 12 most recent systematic reviews for insomnia evaluation and treatment produced in the last 10 years.

CONCLUSIONS

Our findings suggested that symptoms of insomnia must always be assessed in the Italian clinical practice by evaluating nocturnal and daytime symptoms, comorbid conditions and lifestyle. In a patient with chronic insomnia with and without comorbidity, insomnia treatment should be always initiated. CBT-Insomnia therapy should be the first option accordingly to availability. The choice of the drug should be based on different factors such as type of insomnia, age, comorbidities, and potential side effects. Melatonin 2 mg prolonged release should be the first choice in subjects >55 years. If the choice would be a Z-drug or a short-acting benzodiazepine (in subjects <65 years old) or a sedating antidepressant, the use should be in the short term (≤4 weeks) and then proceeds to tapering under clinical monitoring.

Pharmacological interventions for the treatment of insomnia: quantitative comparison of drug efficacy

PURPOSE

Although different forms of pharmacological intervention are often prescribed for insomnia disorder, the comparative efficacies among various drugs remain unclear. We therefore conducted this study to quantitatively compare the efficacy of various pharmacotherapies for insomnia by modeling.

METHODS

We searched PubMed, EMBASE and Cochrane Library databases for randomized placebo-controlled trials of insomnia medications that were conducted within a designated time period (from the inception dates to May 16, 2019). Pharmacodynamic models were established to describe the time course of changes from baseline in selected sleep parameters. Sleep quality and dropout rates were also compared by a single-arm meta-analysis.

RESULTS

In sum, 43 studies covering 44 trials (14,535 patients) were included in the analysis. The drugs evaluated included flurazepam, quazepam, temazepam, triazolam, eszopiclone, zaleplon, zolpidem, extended-release zolpidem, suvorexant, ramelteon and doxepin. The established models revealed eszopiclone had the highest efficacy in terms of sleep latency (SL), total sleep time (TST), and sleep quality, and was also associated with the lowest dropout rates. The effect of suvorexant on the parameter 'wake after sleep onset' (WASO) was significantly higher than that of the other drugs analyzed.

CONCLUSIONS

Each drug has its own characteristics in the treatment of insomnia, and this needs to be taken into consideration to meet individual clinical needs. These results serve as a quantitative supplement for clinical practice by reflecting the difference in efficacy of various drugs in the treatment of insomnia.

The Prevalence and Incidence of Insomnia in Korea during 2005 to 2013

OBJECTIVE

The aim of this study was to estimate the progress of insomnia prevalence and incidence over the past several years. Also, this study compared survival rates between individuals with and without insomnia.

METHODS

The National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002-2013 was used for this study. Prevalent cases of insomnia were defined using ICD-10 codes F51.0 or G47.0, or a prescription of sedatives. Cox's proportional hazard analysis was conducted to compare survival rates between insomnia patients and people without insomnia.

RESULTS

In 2013, there were 46,167 (5.78%) insomnia patients over 20 years old in this cohort. Insomnia was more common among women and the elderly. Annual incidence over the past several years remained steady but the prevalence increased. The survival of insomnia patients was lower than that of people without insomnia, and the hazard ratio for overall mortality was 1.702 (p<0.001).

CONCLUSION

This large-scale population-based cohort study provided current epidemiologic indicators of insomnia in the Korean general population.

Sleep patterns and insomnia in a large population-based study of middle-aged and older adults: The Tromsø study 2015-2016

Epidemiological studies assessing adult sleep duration have yielded inconsistent findings and there are still large variations in estimation of insomnia prevalence according to the most recent diagnostic criteria. Our objective was to describe sleep patterns in a large population of middle-aged and older adults, by employing accurate measures of both sleep duration and insomnia. Data stem from the Tromsø Study (2015-2016), an ongoing population-based study in northern Norway comprising citizens aged 40 years and older (n = 21,083, attendance = 64.7%). Sleep parameters were reported separately for weekdays and weekends and included bedtime, rise time, sleep latency and total sleep time. Insomnia was defined according to recent diagnostic criteria (International Classification of Sleep Disorders; ICSD-3). The results show that 20% (95% confidence interval,19.4-20.6) fulfilled the inclusion criteria for insomnia. The prevalence was especially high among women (25%), for whom the prevalence also increased with age. For men, the prevalence was around 15% across all age groups. In all, 42% of the women reported sleeping <7 hr (mean sleep duration of 7:07 hr), whereas the corresponding proportion among males was 52% (mean sleep duration of 6:55 hr). We conclude that the proportion of middle-aged and older adults not getting the recommended amount of sleep is worryingly high, as is also the observed prevalence of insomnia. This warrants attention as a public health problem in this population.

The prevalence of common sleep disorders in young adults: a descriptive population-based study

Sleep disorders in adults are associated with adverse health effects including reduced quality of life and increased mortality. However, there is little information on sleep disorders in young adults. A cross-sectional observational study was undertaken in 1,227 young adults participating in the Western Australian Pregnancy (Raine) Study (2012–2014) to describe the prevalence of common sleep disorders. In-laboratory polysomnography (PSG) and validated survey methods were used, including the Epworth Sleepiness Scale, Pittsburgh Sleep Symptom Questionnaire-Insomnia, and International Restless Legs Syndrome Study Group criteria. A total of 1,146 participants completed a core questionnaire, 1,051 completed a sleep-focused questionnaire and 935 had analyzable PSG data. Participants had a mean age of 22.2 years and female to male ratio of 1.1 to 1. The respective sleep disorder prevalences in females and males were: obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI]: ≥5 events/hour) 14.9% (95% CI: 11.8–18.5) and 26.9% (95% CI: 22.9–31.2); chronic insomnia, 19.3% (95% CI: 16.7–23.9) and 10.6% (95% CI: 8.3–13.9); restless legs syndrome, 3.8% (95% CI: 2.4–5.6) and 1.9% (95% CI: 0.9–3.4); and abnormal periodic leg movements during sleep (&gt;5 movements/hour), 8.6% (95% CI: 6.3–11.5) and 9.6% (95% CI: 7.1–12.7). There were statistically significant differences in prevalence between sexes for OSA and insomnia, which persisted after adjustment for body mass index and education. In those with complete data on all sleep-related assessments (n = 836), at least one sleep disorder was present in 41.0% of females and 42.3% of males. Sleep disorders are very common in young adults. Health practitioners should be aware of these high prevalences, as early identification and treatment can improve quality of life and may reduce later morbidity and mortality.

Psychometric Properties of the Athens Insomnia Scale in Occupational Computer Users

Background: Various studies have shown that insomnia is associated with computer use. The Athens Insomnia Scale (AIS) is an 8-item tool that has been widely used for screening insomnia. No studies have investigated the psychometric validity of AIS in occupational computer users. Objective: the current research aimed to test the psychometric properties of the AIS among occupational computer users. Materials and Methods: a sample of four hundred and twenty-four occupational computer users (age: 20-65 years and body mass index: 21.6 ± 3.5 kg/m2) completed an AIS and a socio-demographic questionnaire in this cross-sectional study. Results: a confirmatory factor analysis demonstrated that the three-factor model had an adequate fit (the goodness of fit index (0.95), incremental fit index (0.90) and χ2/df (2.61)). Evidence was found for configural, scalar and metric invariance of the 3-factor model across gender groups. A moderate level of internal consistency was implied by a Cronbach's alpha of 0.66. Conclusion: the findings of the present research support the validity of AIS for screening insomnia, as demonstrated by the scale's psychometric properties; its internal consistency, internal homogeneity, item discrimination, and factorial validity.

The Prevalence of Insomnia Subtypes in Relation to Demographic Characteristics, Anxiety, Depression, Alcohol Consumption and Use of Hypnotics

Objective

The aim of the present study was to examine the prevalence of insomnia subtypes in relation to several demographic characteristics, as well as to investigate the prevalence of possible anxiety and depression, alcohol consumption and use of hypnotics within the different insomnia subtypes.

Methods

The present study was based on an extensive web-based survey made publicly available in 2012. The data was downloaded in January 2019, after 113 887 people had responded to parts of, or the entire questionnaire. The 64 503 participants who met the criteria for chronic insomnia disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) comprised the study population. The present study divided insomnia into seven subtypes based on type of sleep difficulty reported; sleep onset insomnia (SOL-insomnia), sleep maintenance insomnia (WASO-insomnia), early morning awakening insomnia (EMA-insomnia) and combinations of these. Data were analyzed with chi-square tests and logistic regression analyses adjusted for sex, age, level of education and marital status.

Results

More than 60% of the study population met the criteria of either SOL-insomnia or a mixed insomnia subtype consisting of SOL-, WASO- and EMA-insomnia (SOL + WASO + EMA-insomnia). The percentage distribution of insomnia subtypes within the demographic characteristics showed that participants with female sex, high age, low level of education and who were divorced, separated or a widow/widower had a higher prevalence of SOL + WASO + EMA-insomnia compared to their respective demographic counterparts. The prevalence of possible anxiety, possible depression and use of hypnotics were higher among participants with SOL + WASO + EMA-insomnia compared to the other insomnia subtypes. The combination of WASO- and EMA-insomnia (WASO + EMA-insomnia) was associated with the most frequent alcohol consumption.

Conclusion

Our findings suggest that there are major differences between the insomnia subtypes, both regarding demographics, but also in terms of how the complaints may affect daily life. Participants with combinations of SOL, WASO and EMA were more likely than participants with the other subtypes to have possible anxiety and possible depression, high alcohol consumption and to use hypnotics.