Eveningness chronotype, insomnia symptoms, and emotional and behavioural problems in adolescents

Chronotype, sleep quality and academic performances among Mizo students

Sleep is an essential component of the daily cycle. Age and puberty-related declines in sleep duration, delays in chronotype, and an increase in social jet lag have been consistently reported. This study examined chronotype and gender-based differences in adolescents' sleep quality, depression level, and academic achievements. Eight hundred fifteen school students (372 male and 443 female) aged 14 to 20 years voluntarily participated in this study. Horne and Östberg Morningness-Eveningness Questionnaire (MEQ) was used to measure their chronotype. Sleep duration, sleep quality, and daytime sleepiness were assessed by the Pediatric Daytime Sleepiness Scale (PDSS) and Epworth Sleepiness Scale (ESS). Pittsburgh's Sleep Quality Index (PSQI) was used to evaluate sleep habits. Cleveland Adolescent Sleepiness Questionnaire (CASQ) was used to measure the sleep pattern of the students. Zung Self-Rating Depression Scale (SDS) was used to assess the level of depression for the students. Our results show neither type of students dominated the population studied but interestingly, in comparison to evening type, morning type individuals were higher among the population. Chronotype-based sleep quality and academic performances were observed, and higher depression levels, poor sleep quality, poor academic performances were observed in evening type compared to neither type and morning type. In contrast to males, females had a poor sleep pattern (CASQ) and a higher depression level (SDS). Altogether, our study shows the effect of chronotype and gender on sleep quality and depression levels among school students.

The trajectories and associations of eveningness and insomnia with daytime sleepiness, depression and suicidal ideation in adolescents: A 3-year longitudinal study

BACKGROUND

Eveningness and insomnia are highly comorbid and closely related to psychopathology in adolescents. We aimed to prospectively investigate the trajectories and associations of eveningness and insomnia with daytime functioning, depression and suicidal risk in adolescents.

METHODS

A 3-year longitudinal study was conducted among 414 Chinese adolescents. The associations of eveningness and insomnia with daytime functioning, depression and suicidal ideation were analyzed using logistic regressions.

RESULTS

The prevalence rates of eveningness were similar at baseline and follow-up (19.3% vs 22.5%; p = 0.27), while the prevalence of insomnia increased at follow-up (29.2% vs 40.8%; p < 0.001). Among those eveningness adolescents (n=80) at baseline, 46.2% remained as stable evening-type at follow-up, and among those insomnia adolescents (n=121) at baseline, 64.5% had persistent insomnia at follow-up. Logistic regressions showed that stable, incident, and resolved eveningness were associated with excessive daytime sleepiness (EDS) at follow-up, while only persistent and incident insomnia increased the risk of EDS. Persistent and incident insomnia, as well as stable eveningness were independently associated with depression at follow-up. Persistent and incident insomnia, but not eveningness, were associated with suicidal ideation.

LIMITATIONS

The outcome assessments were based on self-reported questionnaires and the sample size is modest.

CONCLUSIONS

Persistent eveningness and insomnia are significantly associated with greater risks of EDS and depression in adolescents, while both persistent and incident insomnia, but not eveningness, increased the risk of suicidal ideation. These findings underscore the importance of addressing sleep and circadian factors in the management of adolescent mood and daytime functioning.

Chronotypes, sleep problems and trauma reactions in adolescents with anxiety disorders during the COVID-19 pandemic

This study aims to investigate the relationship between chronotype preferences/sleep problems and trauma symptoms during the COVID-19 outbreak of adolescents diagnosed with Anxiety Disorder (AD) in the pre-COVID-19 period. The sample of this study consisted of 71 adolescents with AD. Trauma symptoms were evaluated using the Children's Event Impact Scale (CRIES-13); sleep habits were assessed using the Pittsburgh Sleep Quality Index (PSQI); and chronotype was evaluated using the Children's Chronotype Questionnaire (CCQ). The CRIES-13 arousal scores and PSQI sleep latency scores were significantly higher in the eveningness type group compared with the non-eveningness type group. The CRIES-13 arousal scores of adolescents with AD were related to the CCQ and PSQI scores. In linear regression analysis, sleep problems were found to be an associated factor on the CRIES-13 scores. The findings of the present study suggest that during the COVID-19 pandemic, the chronotype may play an important role in the adversities experienced by adolescents with AD. In addition, it was thought that the association between sleep problems and trauma in adolescents with AD who spent a lot of time in the home environment during the pandemic period needs further evaluation.

Neural Response to Rewards in Youths with Insomnia

STUDY OBJECTIVES

Insomnia and depression are common comorbid conditions in youths. Emerging evidence suggests that disrupted reward processing may be implicated in the association between insomnia and the increased risk for depression. Reduced reward positivity (RewP) as measured by event-related potential (ERP) has been linked to depression, but has not been tested in youths with insomnia.

METHODS

Twenty-eight participants with insomnia disorder and without any comorbid psychiatric disorders and 29 healthy sleepers aged between 15-24 completed a monetary reward task, the Cued Door task, whilst electroencephalographic activity was recorded. RewP (reward minus non-reward difference waves) was calculated as the mean amplitudes within 200ms to 300ms time window at FCz. Two analyses of covariance (ANCOVAs) were conducted with age as a covariate on RewP amplitude and latency, respectively.

RESULTS

Participants with insomnia had a significantly lower RewP amplitude regardless of cue types (Gain, Control, and Loss) than healthy sleepers, F (1, 51) = 4.95, p = .031, indicating blunted reward processing. On the behavioural level, healthy sleepers were more prudential (slower reaction time) in decision making towards Loss/Gain cues than their insomnia counterparts. Trial-by-trial behavioural adjustment analyses showed that, compared with healthy sleepers, participants with insomnia were less likely to dynamically change their choices in response to Loss cues.

CONCLUSIONS

Dysfunctional reward processing, coupled with inflexibility of behavioural adjustment in decision-making, is associated with insomnia disorder among youth, independent of mood disorders. Future studies with long-term follow-up are needed to further delineate the developmental trajectory of insomnia-related reward dysfunctions in youth.

Relationship Between Chinese Adolescents' Sleep Status and Problem Behaviors: The Mediating Role of Mental Health

Adolescents’ problem behaviors constitute a critical indicator of crime, and they play an important role in the growth and development of adolescents and social stability. Using the 2014–2015 school year follow-up data from the China Education Panel Survey, this study investigated the relationship between sleep time, sleep disorders, and adolescents’ problem behaviors. Further, we analyzed the mediating effect of mental health status, a key factor influencing adolescent growth and development. The results showed that the frequency of problem behaviors among adolescents was significantly and positively associated with sleep disorders and short sleep time. In addition, mental health status is a channel through which sleep time and sleep disorders affect adolescents’ problem behaviors.

How does the COVID-19 affect mental health and sleep among Chinese adolescents: a longitudinal follow-up study

OBJECTIVE

The Corona Virus Disease-19 (COVID-19) pandemic has evolved into the largest public health event in the world. Earlier COVID-19 studies have reported that the pandemic caused widespread impacts on mental health and sleep in the general population. However, it remains largely unknown how the prevalence of mental health problems and sleep disturbance developed and interacted in adolescents at different times in the epidemic.

METHODS

831 teenagers (aged 14-19) underwent a longitudinal follow-up study to evaluate the prevalence of mental health problems and sleep disturbance among adolescents before, during, and after the COVID-19 breakout in China and to explore the interaction between mental health and sleep across the three measurements. The chronotype, anxiety and depression level, sleep quality, and insomnia were investigated during each measurement.

RESULTS

The adolescents had delayed sleep onset and sleep offset time, longer sleep duration during the quarantine than before and after the epidemic, whereas their chronotype tended to morning type during the epidemic. Yet, the highest prevalence of anxiety, depression, poor sleeper, and insomnia symptoms were observed before but not during the COVID-19 breakout. The females and adolescents who were eveningness type showed significantly higher anxiety and depression levels, poorer sleep quality, and severe insomnia status than the males and the intermediate and morning types. Sleep disturbance was positively associated with mental problems among three measurements. Pre-measured depression level significantly predicted sleep disturbance level at follow-ups.

CONCLUSION

These findings suggested that adolescents' high prevalence of mental health and sleep problems occurred before the COVID breakout and decreased during and after the epidemic. Gender and chronotype were significant risk factors associated with affective and sleep disturbances. Depression positively predicted later sleep problems, but not vice versa.

Linking RDoC and HiTOP: A new interface for advancing psychiatric nosology and neuroscience

The Research Domain Criteria (RDoC) and the Hierarchical Taxonomy of Psychopathology (HiTOP) represent major dimensional frameworks proposing two alternative approaches to accelerate progress in the way psychopathology is studied, classified, and treated. RDoC is a research framework rooted in neuroscience aiming to further the understanding of transdiagnostic biobehavioral systems underlying psychopathology and ultimately inform future classifications. HiTOP is a dimensional classification system, derived from the observed covariation among symptoms of psychopathology and maladaptive traits, which seeks to provide more informative research and treatment targets (i.e., dimensional constructs and clinical assessments) than traditional diagnostic categories. This article argues that the complementary strengths of RDoC and HiTOP can be leveraged in order to achieve their respective goals. RDoC's biobehavioral framework may help elucidate the underpinnings of the clinical dimensions included in HiTOP, whereas HiTOP may provide psychometrically robust clinical targets for RDoC-informed research. We present a comprehensive mapping between dimensions included in RDoC (constructs and subconstructs) and HiTOP (spectra and subfactors) based on narrative review of the empirical literature. The resulting RDoC-HiTOP interface sheds light on the biobehavioral correlates of clinical dimensions and provides a broad set of dimensional clinical targets for etiological and neuroscientific research. We conclude with future directions and practical recommendations for using this interface to advance clinical neuroscience and psychiatric nosology. Ultimately, we envision that this RDoC-HiTOP interface has the potential to inform the development of a unified, dimensional, and biobehaviorally-grounded psychiatric nosology.

Pathways to adolescents' health: chronotype, bedtime, sleep quality and mental health

The strong relationship between sleep and health is defined in the literature. While the need for sleep increases in adolescence with the effect of physiological and hormonal changes, the studies have highlighted the serious sleeping problems of adolescents compared to childhood and adulthood. This study aimed to examine the relationship between chronotype, bedtime, sleep quality and mental health among adolescents. This research was a descriptive-relational study. A total of 1083 students constituted the group of the research. The data were collected through the Morningness-Eveningness Questionnaire (MEQ) and General Health Questionnaire and a questionnaire consisting of some questions about sleep. In the evaluation of data, multiple regression, mediation and path analysis were performed. Age, having problems affecting sleep, difficulties falling asleep, sharing the room with someone else and lack of leisure activities were related to bedtime. It was found that determinants of sleep quality were the variables related to sleep itself. Being a male student, having problems affecting sleep, difficulties falling at sleep, waking up during the night, getting support in the morning for waking up and lack of leisure activities negatively affected mental health. MEQ scale was interpreted as a determinant of sleep time, sleep quality, and mental health level. Although the MEQ score directly affected sleep quality, bedtime had a partial mediation role between MEQ score and sleep quality. Sleep quality had a full mediation role between MEQ score and mental health score. School health workers, especially nurses, should consider chronotype-focused measures to improve adolescents' sleep quality and psychosocial health.

Circadian typology and implications for adolescent sleep health. Results from a large, cross-sectional, school-based study

STUDY OBJECTIVES

To investigate circadian typology in a large, representative sample of Norwegian adolescents, and its implications for sleep health.

METHODS

The sample included 3920 1^st year high school students aged 16-17 years. Respondents completed a web-based survey, including the short version of the Horne-Ostberg Morningness-Eveningness Questionnaire (rMEQ), the Munich Chronotype Questionnaire (MCTQ) and items on sleep-related behaviors (eg electronic media usage in bed, consumption of caffeinated beverages), sleep beliefs and daytime sleepiness. Data were analyzed using one-way ANOVAs and Chi-squared tests.

RESULTS

In all, 7.8% were categorized as morning, 52.3% as intermediate and 39.9% as evening types, respectively. Evening types had later sleep timing, longer sleep latency, more social jetlag and shorter school day sleep duration than morning types, with intermediate types displaying a sleep pattern between these two extremes. None of the circadian types met the minimum recommended amount of sleep on school nights (ie 8+ hours), and only morning types had a mean sleep duration of 7+ hours (7:19 h, nearly 1 h more than evening types who slept 6:20 h, p < 0.001). Evening types reported more use of electronic media in bed, more consumption of caffeinated beverages and more daytime sleepiness than the other circadian types. They were also less satisfied with their school day sleep duration and perceived it more difficult to change their sleep pattern.

CONCLUSIONS

Results from this study suggest that eveningness represents a sleep health challenge for older adolescents.

Network outcome analysis identifies difficulty initiating sleep as a primary target for prevention of depression: a 6-year prospective study

Study Objectives

Major depressive disorder (MDD) is the leading cause of disability worldwide. Its high recurrence rate calls for prevention of first-onset MDD. Although meta-analysis suggested insomnia as the strongest modifiable risk factor, previous studies insufficiently addressed that insomnia might also occur as a residual symptom of unassessed prior depression, or as a comorbid complaint secondary to other depression risks.

Methods

In total, 768 participants from the Netherlands Study of Depression and Anxiety who were free from current and lifetime MDD were followed-up for four repeated assessments, spanning 6 years in total. We performed separate Cox proportional hazard analyses to evaluate whether baseline insomnia severity, short-sleep duration, and individual insomnia complaints prospectively predicted first-onset MDD during follow-up. The novel method of network outcome analysis (NOA) allowed us to sort out whether there is any direct predictive value of individual insomnia complaints among several other complaints that are associated with insomnia.

Results

Over 6-year follow-up, 141 (18.4%) were diagnosed with first-onset MDD. Insomnia severity but not sleep duration predicted first-onset MDD (HR = 1.11, 95% CI: 1.07–1.15), and this was driven solely by the insomnia complaint difficulty initiating sleep (DIS) (HR = 1.10, 95% CI: 1.04–1.16). NOA likewise identified DIS only to directly predict first-onset MDD, independent of four other associated depression complaints.

Conclusions

We showed prospectively that DIS is a risk factor for first-onset MDD. Among the different other insomnia symptoms, the specific treatment of DIS might be the most sensible target to combat the global burden of depression through prevention.

Biological Rhythm and Chronotype: New Perspectives in Health

The circadian rhythm plays a fundamental role in regulating biological functions, including sleep–wake preference, body temperature, hormonal secretion, food intake, and cognitive and physical performance. Alterations in circadian rhythm can lead to chronic disease and impaired sleep. The circadian rhythmicity in human beings is represented by a complex phenotype. Indeed, over a 24-h period, a person’s preferred time to be more active or to sleep can be expressed in the concept of morningness–eveningness. Three chronotypes are distinguished: Morning, Neither, and Evening-types. Interindividual differences in chronotypes need to be considered to reduce the negative effects of circadian disruptions on health. In the present review, we examine the bi-directional influences of the rest–activity circadian rhythm and sleep–wake cycle in chronic pathologies and disorders. We analyze the concept and the main characteristics of the three chronotypes.

Sleep deficits and cannabis use behaviors: an analysis of shared genetics using linkage disequilibrium score regression and polygenic risk prediction

STUDY OBJECTIVES

Estimate the genetic relationship of cannabis use with sleep deficits and an eveningness chronotype.

METHODS

We used linkage disequilibrium score regression (LDSC) to analyze genetic correlations between sleep deficits and cannabis use behaviors. Secondly, we generated sleep deficit polygenic risk score (PRS) and estimated their ability to predict cannabis use behaviors using linear and logistic regression. Summary statistics came from existing genome-wide association studies of European ancestry that were focused on sleep duration, insomnia, chronotype, lifetime cannabis use, and cannabis use disorder (CUD). A target sample for PRS prediction consisted of high-risk participants and participants from twin/family community-based studies (European ancestry; n = 760, male = 64%; mean age = 26.78 years). Target data consisted of self-reported sleep (sleep duration, feeling tired, and taking naps) and cannabis use behaviors (lifetime ever use, number of lifetime uses, past 180-day use, age of first use, and lifetime CUD symptoms).

RESULTS

Significant genetic correlation between lifetime cannabis use and an eveningness chronotype (rG = 0.24, p < 0.001), as well as between CUD and both short sleep duration (<7 h; rG = 0.23, p = 0.017) and insomnia (rG = 0.20, p = 0.020). Insomnia PRS predicted earlier age of first cannabis use (OR = 0.92, p = 0.036) and increased lifetime CUD symptom count (OR = 1.09, p = 0.012).

CONCLUSION

Cannabis use is genetically associated with both sleep deficits and an eveningness chronotype, suggesting that there are genes that predispose individuals to both cannabis use and sleep deficits.

The influence of intensity and timing of daily light exposure on subjective and objective sleep in adolescents with an evening circadian preference

STUDY OBJECTIVES

The aim of the present study is to examine the relationship between light and sleep, in adolescents with an evening circadian preference.

METHODS

For a period of seven days, ninety-nine adolescents wore a wrist actigraph to assess light exposure and objective sleep and completed a sleep diary to assess subjective sleep.

RESULTS

Lower average light intensity across the preceding 24 h was associated with a later sleep onset (p < 0.01) and a later next-day sleep offset (p < 0.05). A later time of last exposure to more than 10 lux was associated with a later sleep onset (p < 0.001) and a shorter objective total sleep time (p < 0.001), as well as a later bedtime (p < 0.001) and a shorter subjective total sleep time (p < 0.001). Furthermore, exploratory analyses found that lower average early morning light exposure (between 4 and 9 AM) was associated with later sleep onset (p < 0.05), a later next-day sleep offset (p < 0.05), and a later next-day waketime (p < 0.01), lower average afternoon light exposure (between 2 and 7 PM) was associated with a later next-day sleep offset (p < 0.05), and lower average evening light exposure (between 7 PM and 12 AM) was associated with longer subjective total sleep time (p < 0.01).

CONCLUSION

This study highlights the importance of light exposure, particularly the timing of light exposure, for establishing healthy patterns of sleep among adolescents with a propensity for a delayed bedtime and waketime. These findings provide additional evidence for targeting light exposure when designing interventions to improve adolescent sleep.

The effect of age and chronotype on seasonality, sleep problems, and mood

Seasonal affective disorder has been associated with sleep problems, young age, and an evening chronotype. A chronotype refers to an individual's preference in the timing of their sleep-wake cycle, as well as the time during the sleep-wake cycle when a person is most alert and energetic. Seasonality refers to season-dependent fluctuations in sleep length, social activity, mood, weight, appetite, and energy level. Evening chronotype is more common in young adults and morning chronotype more common in the elderly. This study aimed to estimate the differential contribution of chronotype and age on seasonality. A sample of n=410 participants were included in the study. The age groups showed significantly different results according to sleep parameters, depression, anxiety, stress, seasonality, and chronotype. The oldest group (>59 years) showed the lowest scores on all of these scales. According to a path analysis, chronotype and age predict propensity for seasonality. However, sleep problems were linked to chronotype but not to age. Older adults seem to be more resistant to seasonal changes that are perceived as a problem than young and middle aged adults. Future studies would benefit from considering cultural aspects and examine seasonality, chronotype, depression, and insomnia in longitudinal designs.

Associations of sleep phenotypes with severe intentional self-harm: a prospective analysis of the UK Biobank cohort

STUDY OBJECTIVES

We aimed to investigate the prospective associations of sleep phenotypes with severe intentional self-harm (ISH) in middle-aged and older adults.

METHODS

A total of 499,159 participants (mean age: 56.55 ± 8.09 years; female: 54.4%) were recruited from the UK Biobank between 2006 and 2010 with follow-up until February 2016 in this population-based prospective study. Severe ISH was based on hospital inpatient records or a death cause of ICD-10 codes X60-X84. Patients with hospitalized diagnosis of severe ISH before the initial assessment were excluded. Sleep phenotypes, including sleep duration, chronotype, insomnia, sleepiness, and napping, were assessed at the initial assessments. Cox regression analysis was used to estimate temporal associations between sleep phenotypes and future risk of severe ISH.

RESULTS

During a follow-up period of 7.04 years (SD: 0.88), 1,219 participants experienced the first hospitalization or death related to severe ISH. After adjusting for demographics, substance use, medical diseases, mental disorders, and other sleep phenotypes, short sleep duration (HR: 1.50, 95% CI: 1.23-1.83, P < .001), long sleep duration (HR: 1.56, 95% CI: 1.15-2.12, P = .004), and insomnia (usually: HR: 1.57, 95% CI: 1.31-1.89, P < .001) were significantly associated with severe ISH. Sensitivity analyses excluding participants with mental disorders preceding severe ISH yielded similar results.

CONCLUSION

The current study provides the empirical evidence of the independent prediction of sleep phenotypes, mainly insomnia, short and long sleep duration, for the future risk of severe ISH among middle-aged and older adults.

Reduced Sleep Duration and Sleep Efficiency Were Independently Associated With Frequent Nightmares in Chinese Frontline Medical Workers During the Coronavirus Disease 2019 Outbreak

Objectives

Nightmares were related to emotion and behavioral problems and also emerged as one of the core features of post-traumatic stress disorder (PTSD). Our study aimed to investigate the associations of frequent nightmares with sleep duration and sleep efficiency among frontline medical workers in Wuhan during the coronavirus disease 2019 (COVID-19) outbreak.

Methods

A total of 528 health-care workers from the province of Fujian providing medical aid in Wuhan completed the online questionnaires. There were 114 doctors and 414 nurses. The age, sex, marital status, and work situation were recorded. A battery of scales including the Pittsburgh Sleep Quality Index (PSQI) and the 12-item General Health Questionnaire (GHQ-12) were used to evaluate subjects’ sleep and general mental health. Frequent nightmares were defined as the response of at least once a week in the item of “nightmare” of PSQI.

Results

Frequent nightmares were found in 27.3% of subjects. The frequent nightmare group had a higher score of PSQI-sleep duration and PSQI-habitual sleep efficiency (frequent nightmares vs. non-frequent nightmares: PSQI-sleep duration, 1.08 ± 0.97 vs. 0.74 ± 0.85, P < 0.001; PSQI-habitual sleep efficiency, 1.08 ± 1.10 vs. 0.62 ± 0.88, P < 0.001). Reduced sleep duration and reduced sleep efficiency were independently associated with frequent nightmares after adjustment for age, sex, poor mental health, and regular sleeping medication use (reduced sleep duration: OR = 1.96, 95% CI = 1.07–3.58, P = 0.029; reduced sleep efficiency: OR = 2.17, 95% CI = 1.09–4.32, P = 0.027). Subjects with both reduced sleep duration and sleep efficiency were also associated with frequent nightmares (OR = 2.70, 95% CI = 1.57–4.65, P < 0.001).

Conclusion

The present study found that sleep duration and sleep efficiency were both independently associated with frequent nightmares among frontline medical workers in Wuhan during the COVID-19 pandemic. We should pay attention to nightmares and even the ensuing PTSD symptoms among subjects with reduced sleep duration or sleep efficiency facing potential traumatic exposure.

Association of P10L Polymorphism in Melanopsin Gene with Chronic Insomnia in Mexicans

The aim of this pilot study was to determine the association of the P10L (rs2675703) polymorphism of the OPN4 gene with chronic insomnia in uncertain etiology in a Mexican population. A case control study was performed including 98 healthy subjects and 29 individuals with chronic insomnia not related to mental disorders, medical condition, medication or substance abuse. Samples were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Genetic analyses showed that the T allele of P10L increased risk to chronic insomnia in a dominant model (p = 1 ×10⁻⁴; odds ratio (OR) = 9.37, CI = 8.18–335.66, Kelsey statistical power (KSP) = 99.9%), and in a recessive model (p = 7.5 × 10⁻⁵, OR = 9.37, KSP = 99.3%, CI = 2.7–34.29). In the insomnia group, we did not find a correlation between genotypes and chronotype (p = 0.219 Fisher’s exact test), severity of chronic insomnia using ISI score (p = 0.082 Fisher’s exact test) and ESS score (p ˃ 0.999 Fisher’s exact test). However, evening chronotype was correlated to daytime sleepiness severity, individuals with an eveningness chronotype had more severe drowsiness according to their insomnia severity index (ISI) score (p = 0.021 Fisher’s exact test) and Epworth sleepiness scale (ESS) score (p = 0.015 Fisher’s exact test) than the morningness and intermediate chronotype. We demonstrated that the T allele of the P10L polymorphism in the OPN4 gene is associated with chronic insomnia in Mexicans. We suggest the need to conduct larger studies in different ethnic populations to test the probable association and function of P10L and other SNPs in the OPN4 gene and in the onset of chronic insomnia.

Non-pharmacological Approaches for Management of Insomnia

Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Social Jetlag Changes During the COVID-19 Pandemic as a Predictor of Insomnia - A Multi-National Survey Study

PURPOSE

Lifestyle and work habits have been drastically altered by restrictions due to the COVID-19 pandemic. Whether the associated changes in sleep timing modulate the risk of suffering from symptoms of insomnia, the most prevalent sleep disorder, is however incompletely understood. Here, we evaluate the association between the early pandemic-associated change in 1) the magnitude of social jetlag (SJL) - ie, the difference between sleep timing on working vs free days - and 2) symptoms of insomnia.

PATIENTS AND METHODS

A total of 14,968 anonymous participants (mean age: 40 years; 64% females) responded to a standardized internet-based survey distributed across 14 countries. Using logistic multivariate regression, we examined the association between the degree of social jetlag and symptoms of insomnia, controlling for important confounders like social restriction extension, country specific COVID-19 severity and psychological distress, for example.

RESULTS

In response to the pandemic, participants reported later sleep timing, especially during workdays. Most participants (46%) exhibited a reduction in their SJL, whereas 20% increased it; and 34% reported no change in SJL. Notably, we found that both increased and decreased SJL, as a result of the COVID-19 pandemic, were associated with later sleep midpoint (indicating a later chronotype) as well as more recurrent and moderate-to-severe symptoms of insomnia (about 23-54% higher odds ratio than subjects with unchanged SJL). Primarily those with reduced SJL shifted their bedtimes to a later timepoint, compared with those without changes in SJL.

CONCLUSION

Our findings offer important insights into how self-reported changes to the stability of sleep/wake timing, as reflected by changes in SJL, can be a critical marker of the risk of experiencing insomnia-related symptoms - even when individuals manage to reduce their social jetlag. These findings emphasize the clinical importance of analyzing sleep-wake regularity.

Higher prevalence of intentional self-harm in bipolar disorder with evening chronotype: A finding from the APPLE cohort study

BACKGROUND

Patients with bipolar disorder (BD) frequently self-harm, and this is strongly associated with subsequent suicide. This study investigated the association between chronotype and intentional self-harm in patients with BD.

METHODS

Two-hundred and five outpatients with BD participated in this cross-sectional study. Each participant's chronotype was evaluated using the Morningness-Eveningness Questionnaire, dividing the scores into three types: evening, 16-41 points; intermediate, 42-58 points; and morning, 59-86 points. Intentional self-harm over the past year were self-reported by questionnaire. Propensity score for evening chronotype was estimated from age, sex, socioeconomic factors, mood symptoms, total sleep time, age at the onset of BD, psychiatric inpatient history, family history of suicide, psychiatric comorbidity, and use of lithium.

RESULTS

Thirty-six (18%) of the 205 participants reported self-harm. A substantially higher proportion of the evening chronotype group self-harmed compared to the other groups (evening, 37%; intermediate, 13%; morning 10%). In multivariable analysis adjusted for propensity score, the odds ratio (OR) for self-harming significantly increased from morning to intermediate to evening chronotype (ORs: morning, 1.00; intermediate, 1.56; evening, 3.61; P for trend = 0.038).

LIMITATIONS

This study was a cross-sectional and small sample size.

CONCLUSIONS

Although a third factors, such as personality disorder or disrupted circadian rhythm, may have influenced, these findings suggest association between chronotype and intentional self-harm in BD patients.

Relationships Among Delayed Sleep Phase Disorder, Emotional Dysregulation, and Affective Temperaments in Adults With Attention Deficit Hyperactivity Disorder and Cyclothymia

This study aims to explore the relationships between delayed sleep phase disorder (DSPD) and emotional dysregulation in 240 patients (134 with cyclothymia, 81 with attention deficit hyperactivity disorder [ADHD] and 25 with both conditions). DSPD was assessed using the Morningness-Eveningness Questionnaire, followed by a clinical evaluation. Affective temperaments and emotional dysregulation were also investigated through the brief version of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego and the Reactivity, Intensity, Polarity, Stability questionnaires, respectively. Clinical variables were compared in patients with and without DSPD, and a logistic regression model was used to identify the predictive value of the clinical characteristics on the presence of DSPD. DSPD patients (19% of the total sample) were significantly younger than patients without DSPD, showed an about 4 times higher lifetime history of comorbid ADHD and cyclothymia, and reported higher scores in the irritable and cyclothymic temperamental subscales and in the affective instability and impulsivity dimensions. In the multiple logistic regression, we found a negative predictive value of increasing age on the presence of DSPD, whereas comorbid cyclothymia and ADHD and cyclothymic temperament seem to represent risk factors for DSPD.

Sleep Quality of Students from Elementary School to University: A Cross-Sectional Study

BACKGROUND

Sleep affects a wide array of health outcomes and is associated with the quality of life. Among students, sleep quality is affected by school stage and grade; however, data regarding the different sleep-related problems students experience at different school stages are limited. In this study, we aimed to explore sleep quality among a student sample ranging from elementary school to university level.

METHODS

Overall, data were examined for 9392 subjects aged 9-22 years. Information on sociodemographic characteristics and other variables were collected through self-administered questionnaires. Sleep quality on school nights was evaluated using the standard Pittsburgh Sleep Quality Index; global score >5 was classified as poor sleep quality. For the high school sample, logistic regression analysis was used to estimate associations between sleep quality and certain factors.

RESULTS

Of the elementary school, middle school, vocational high school, senior high school, and university students, 7.5%, 19.2%, 28.6%, 41.9%, and 28.5%, respectively, showed poor sleep quality. The high school students reported the highest prevalence of shorter sleep duration (70.8%), day dysfunction (84.7%), and subjective poor sleep quality (17.2%). The elementary school students showed the highest prevalence of poor sleep efficiency (17.9%). The university students showed the highest prevalence of sleep medication use (6.4%). The vocational high school students reported the highest prevalence of sleep latency (6.3%) and sleep disturbance (7.4%). Logistic regression modeling indicated that sleep quality is positively associated with school stage, grade, family atmosphere, academic pressure, and number of friends.

CONCLUSION

Sleep quality and sleep features change greatly from elementary school to university. Interventions to improve sleep quality should consider targeting the specific issues students experience at each school stage. Alarmed by the high prevalence of poor sleep quality among high school students, it is recommended that high school students should be informed of their sleep matter and the consequences.

Insomnia in Relation to Academic Performance, Self-Reported Health, Physical Activity, and Substance Use Among Adolescents

Purpose: Insomnia affects up to one in four adolescents and has been shown to have a negative impact on their mental and physical health. This study aimed to investigate the association between insomnia, academic performance, self-reported health, physical activity, school start time, and substance use among adolescents. Methods: A survey with a cross-sectional design was completed by adolescents (15–17 years old; n = 1504) in southern Sweden. The Minimal Insomnia Symptoms Scale (MISS) was used to operationalize insomnia. A multiple logistic regression analysis was used to analyze the relationship between insomnia and self-reported health, failed school courses, substance use, school start time, family financial situation, screen time, and gender. Results: Insomnia (MISS ≥ 6) was associated with poor self-reported health (OR: 4.35), failed school courses (OR: 1.47), and use of alcohol and/or cigarettes (OR: 1.43). When the combined effect of self-reported health and physical activity were investigated, a combination of low physical activity (≤1 time/week) and poor self-reported health was strongly associated with insomnia (OR: 18.87). Conclusions: Insomnia was associated with other problems that in themselves are risk factors for poor health. This highlights the need for a holistic health-promoting approach to prevent insomnia, such as efforts to promote physical activity, school success, and the reduction of alcohol/cigarette use.

Anger-Related Characteristics According to Chronotypes in Bipolar or Depressive Disorders

OBJECTIVE

Though anger was highly associated with eveningness in general population, there is no study on the relationship between chronotype and anger-related characteristics in bipolar or depressive disorders. This study aimed to investigate the difference of anger-related characteristics according to chronotypes in bipolar or depressive disorders.

METHODS

Patients with bipolar or depressive disorders (n=238) were included in this study. Their chronotypes and anger-related characteristics were assessed with a self-evaluation of the Composite Scale of Morningness (CSM), the State Trait Anger Expression Inventory (STAXI) and the Anger Coping Scale (ACS).

RESULTS

The eveningness group in patients with mood disorders showed the highest scores of anger-trait (p<0.001), anger-expression (p=0.002) and anger-in (p<0.001) in STAXI subscales, verbal aggression (p=0.010) in ACS subscales among three groups, but the morningess group showed the lowest scores of these subscales among three groups. However, there were no significant differences in all subscales of the STAXI and ACS according to diagnostic subtypes in the Friedman test.

CONCLUSION

The results of this study suggested that eveningness in patients with mood disorders might be related to anger proneness and maladaptive anger coping. To manage anger emotion in the patients with mood disorders, therapeutic interventions to modulate eveningness might be helpful.

Testing the Bidirectional Associations of Mobile Phone Addiction Behaviors With Mental Distress, Sleep Disturbances, and Sleep Patterns: A One-Year Prospective Study Among Chinese College Students

BACKGROUND

Mobile phone addiction behaviors (MPAB) are extensively associated with several mental and sleep problems. Only a limited number of bidirectional longitudinal papers have focused on this field. This study aimed to examine the bidirectional associations of MPAB with mental distress, sleep disturbances, and sleep patterns.

METHODS

A total of 940 and 902 (response rate: 95.9%) students participated at baseline and one-year follow-up, respectively. Self-reported severity of mobile phone addiction was measured using Mobile Phone Involvement Questionnaire (MPIQ). Mental distress was evaluated by using Beck Depression Inventory (BDI) and Zung Self-Rating Anxiety Scale (SAS). Sleep disturbances were assessed by using Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). Sleep patterns were evaluated by using reduced Morningness-Eveningness Questionnaire (rMEQ), weekday sleep duration, and weekend sleep duration.

RESULTS

Cross-lagged analyses revealed a higher total score of BDI, SAS, and ISI predicted a greater likelihood of subsequent MPAB, but not vice versa. We found the bidirectional longitudinal relationships between MPAB and the total score of PSQI and ESS. Besides, a higher score of MPIQ at baseline predicts a subsequent lower total score of rMEQ and shorter weekday sleep duration.

CONCLUSIONS

The current study expands our understanding of causal relationships of MPAB with mental distress, sleep disturbances, and sleep patterns.

Which sleep hygiene factors are important? comprehensive assessment of lifestyle habits and job environment on sleep among office workers

BACKGROUND

Although several lifestyle habits are associated with sleep, it is unclear which factors are important. Among office workers, the effect of job environment should also be considered. The multivariate analyses on the effects of lifestyle habits and job environment on sleep among office workers was conducted.

METHODS

A cross-sectional survey of 6,342 employees from 29 companies was conducted in 2017-2019. Complete responses and informed consent were provided by 5,640 participants. The survey examined demographic variables, sleep schedules, Pittsburgh Sleep Quality Index (PSQI), Brief Job Stress Questionnaire (BJSQ), and lifestyle habits.

RESULTS

Mean values were as follows: age, 36.9 years (±10.2); PSQI, 6.52 (±2.83); and total sleep time, 6h06m (±1h40m) on work days and 7h39m (±1h58m) on free days. After adjusting for job environment and demographic variables, irregular meal time (1.45-2.86), not eating vegetables every day (1.35), nightcap (2.74-3.55), weight gain (1.20-1.42), lack of sunlight in the morning in the bedroom (1.48-1.60), waking up before dawn (2.18), electronic display use in bed (1.50), and daily caffeine intake (1.27) were significantly associated with sleep disturbance. Irregular meal time (1.51-2.37), lack of morning breakfast (1.74-2.95), having dinner within 2 hours before bed time (0.49-0.64), not eating vegetables every day (1.52), lack of sunlight exposure in the morning (1.43-2.01), and caffeine use every day (1.42) were also associated with eveningness (p<.01).

CONCLUSION

Each sleep hygiene factor had a different effect size. Sleep hygiene interventions to promote worker sleep health should prioritize factors in accordance with effect size.

Circadian typology is related to emotion regulation, metacognitive beliefs and assertiveness in healthy adults

Circadian typology has been related to several mental health aspects such as resilience, perceived well-being, emotional intelligence and psychological symptoms and disorders. However, the relationship between circadian typology and emotion regulation, metacognitions and assertiveness, which constitute core constructs related to psychological well-being and psychopathology, remain unexplored. This study aims to analyze whether circadian typology is related with those three constructs, considering the possible influence of sex. 2283 participants (833 women), aged 18–60 years (30.37 ± 9.26 years), completed the reduced Morningness-Eveningness Questionnaire, the Emotion Regulation Questionnaire, the Meta-Cognitions Questionnaire 30, and the Rathus Assertiveness Schedule. Main effects were observed between circadian typology and cognitive reappraisal, metacognitions, negative beliefs of uncontrollability and danger, cognitive confidence, cognitive self-consciousness, and assertiveness (F_(2,2276) > 4.80, p < 0.009, η_p² > 0.004, in all cases). Morning-type participants scored lower than evening-type in general metacognitive beliefs, negative beliefs of uncontrollability and danger, cognitive confidence, and cognitive self-consciousness, and higher than evening-type in cognitive reappraisal and assertiveness, while neither-type exhibited intermediate scores (p < 0.033 in all cases). According to the results, evening-type individuals might display a higher tendency to support maladaptive beliefs about thinking itself as well as a lesser tendency to reappraise a potentially emotion eliciting situations in order to modify its meaning and its emotional impact and to exert their rights respectfully. This new evidence improves the understanding of the relationships between circadian typology and psychological factors related to psychological well-being and psychopathology. Results implications for the onset and maintenance of psychological problems are discussed. Although future longitudinal studies are needed, results emphasize evening-type as a risk factor for the development of psychological disturbances and morning-type as a protective factor against those.

The impact of social jetlag and chronotype on attention, inhibition and decision making in healthy adults

Sleep and circadian clock disruption are associated with neuropsychiatric disorders, such as attention deficit hyperactivity disorder, but the impact on neurocognitive performance is unclear. We assessed whether chronotype and everyday circadian misalignment manifested as social jetlag were associated with inter-individual neurocognitive performance across domains of attention, inhibitory control and decision making. One hundred and eighty-eight healthy young adults were assessed for sleep and circadian properties and performed two neurocognitive tasks, the Continuous Performance Test and the Iowa Gambling Task. Social jetlag was associated with significantly faster and less variable reaction times and commission errors on the Continuous Performance Test. Poorer subjective sleep quality was associated with poorer decision making on the Iowa Gambling Task. No effects were present for polymorphisms in the circadian clock genes CLOCK and PER3. We conclude that circadian disruption shaped by everyday environmental factors may impact on attentional/inhibitory performance but not on a measure of risky decision making.

The Brain-Derived Neurotrophic Factor: Missing Link Between Sleep Deprivation, Insomnia, and Depression

The brain-derived neurotrophic factor (BDNF) mediates the plasticity-related changes that associate with memory processing during sleep. Sleep deprivation and chronic stress are associated with propensity to depression, anxiety, and insomnia. We propose a model by which explain alterations in the CNS and serum expression of BDNF associated with chronic sleep deprivation, depression, and insomnia. Mild sleep deprivation activates the cerebral cortex and brainstem to generate the physiologic drive for non-rapid eye movement (NREM) and rapid eye movement (REM) sleep drive respectively, associated with BDNF upregulation in these regions. This physiological response loses effectiveness with longer episodes or during chronic of total or selective REM sleep loss, which are associated with impaired hippocampal BDNF expression, impaired memory and cognition. Chronic sleep deprivation and insomnia can act as an external stressors and result in depression, characterized by hippocampal BDNF downregulation along with disrupted frontal cortical BDNF expression, as well as reduced levels and impaired diurnal alterations in serum BDNF expression. Acute REM sleep deprivation breaks the cycle by restoration of hippocampal, and possibly restoration of cortical and serum expression of BDNF. The BDNF Val66Met polymorphism alters susceptibility to depression, anxiety, and insomnia by altering availability and expression of BDNF in brain and blood. The proposed model is testable and implies that low levels and low variability in serum BDNF are associated with poor response to anti-depressive medications, electroconvulsive therapy, and REM sleep deprivation, in patients with depression. Our mode is also backed up by the existing clinical evidence but is yet to be investigated.

Genetic polymorphisms associated with sleep-related phenotypes; relationships with individual nocturnal symptoms of insomnia in the HUNT study

Background

In recent years, several GWAS (genome wide association studies) of sleep-related traits have identified a number of SNPs (single nucleotides polymorphism) but their relationships with symptoms of insomnia are not known. The aim of this study was to investigate whether SNPs, previously reported in association with sleep-related phenotypes, are associated with individual symptoms of insomnia.

Methods

We selected participants from the HUNT study (Norway) who reported at least one symptom of insomnia consisting of sleep onset, maintenance or early morning awakening difficulties, (cases, N = 2563) compared to participants who presented no symptoms at all (controls, N = 3665). Cases were further divided in seven subgroups according to different combinations of these three symptoms. We used multinomial logistic regressions to test the association among different patterns of symptoms and 59 SNPs identified in past GWAS studies.

Results

Although 16 SNPS were significantly associated (p < 0.05) with at least one symptom subgroup, none of the investigated SNPs remained significant after correction for multiple testing using the false discovery rate (FDR) method.

Conclusions

SNPs associated with sleep-related traits do not replicate on any pattern of insomnia symptoms after multiple tests correction. However, correction in this case may be overly conservative.

Imbalance of nonparametric rest-activity rhythm and the evening-type of chronotype according to frailty indicators in elderly community dwellers

Background: Sleep health-related issues, such as poor subjective sleep quality during the night and nocturnal wakefulness, have been a focus of recent research on frailty. However, current trends regarding the chronotypes of older individuals with frailty have not been well documented, and information on the impact of frailty on circadian rest-activity patterns is limited. The aim of this research was to clarify the relationship among frailty, nonparametric rest-activity patterns, and chronotype in older community-dwelling subjects. Method: A survey was conducted between June and December 2018, and the participants of this study were recruited from among community-dwellers aged 60 years or older living in Akita prefecture, Japan. The frailty phenotype defined by the National Center for Geriatrics and Gerontology Study of Geriatric Syndromes (NCGG-SGS) was used to evaluate the frailty status of each participant. To evaluate nonparametric rest-activity rhythm (RAR) parameters (e.g., interdaily stability [IS], intradaily variability [IV], and relative amplitude [RA]), each participant wore an Actiwatch Spectrum Plus device on his or her non-dominant wrist for seven continuous days without removal. The Munich chronotype questionnaire-Japanese version (MCTQ-J) was also used to measure the midpoint of sleep in free days (MSF). Results: The final study cohort was composed of 105 participants (85.7% women) and was divided into 58 non-frail subjects, 45 pre-frail subjects, and 2 frail subjects. According to a binomial logistic regression analysis, the pre-frail individuals had a weaker grip strength (coefficient [beta], -0.18; odds ratio, 0.84; 95% confidence interval [CI], 0.76-0.93; p = .001) and a lower RA (beta, -8.78; odds ratio, 0.0002; 95% CI, 0.00-0.15; p = .01). In addition, correlation analyses also showed that the MSF was negatively associated with the RA in the pre-frail group (r = -0.30, p < .05) and positively correlated with the RA in the non-frail group (r = 0.26, p < .05); furthermore, the MSF of the pre-frail group occurred at a later time than that of the non-frail one (p = .03). Conclusion: The present study provides grounds for our proposal that pre-frailty is significantly associated with a low grip power and relative imbalance between rest and active statuses as indexed using nonparametric RAR parameters. Furthermore, elderly individuals with pre-frailty or frailty may have a later MSF time. However, these potential findings need to be validated in future research.

Effects of Duration and Midpoint of Sleep on Corticolimbic Circuitry in Youth

INTRODUCTION

Adequate sleep is essential for cognitive and emotion-related functioning, and 9 to 12 hr of sleep is recommended for children ages 6 to 12 years and 8 to 10 hr for children ages 13 to 18 years. However, national survey data indicate that older youth sleep for fewer hours and fall asleep later than younger youth. This shift in sleep duration and timing corresponds with a sharp increase in onset of emotion-related problems (e.g., anxiety, depression) during adolescence. Given that both sleep duration and timing have been linked to emotion-related outcomes, the present study tests the effects of sleep duration and timing, and their interaction, on resting-state functional connectivity (RS-FC) of corticolimbic emotion-related neural circuitry in children and adolescents.

METHODS

A total of 63 children and adolescents (6-17 years, 34 females) completed a weekend overnight sleep journal and a 10-min resting-state functional magnetic resonance imaging scan the next day (Sunday). Whole-brain RS-FC of the amygdala was computed, and the effects of sleep duration, timing (i.e., midpoint of sleep), and their interaction were explored using regression analyses.

RESULTS

Overall, we found that older youth tended to sleep later and for fewer hours than younger youth. Controlling for age, shorter sleep duration was associated with lower RS-FC between the amygdala and regions implicated in emotion regulation, including ventral anterior cingulate cortex, precentral gyrus, and superior temporal gyrus. Interestingly, midpoint of sleep was associated with altered connectivity in a distinct set of brain regions involved in interoception and sensory processing, including insula, supramarginal gyrus, and postcentral gyrus. Our data also indicate widespread interactive effects of sleep duration and midpoint on brain regions implicated in emotion regulation, sensory processing, and motor control.

CONCLUSION

These results suggest that both sleep duration and midpoint of sleep are associated with next-day RS-FC within corticolimbic emotion-related neural circuitry in children and adolescents. The observed interactive effects of sleep duration and timing on RS-FC may reflect how homeostatic and circadian process interact in the brain and explain the complex patterns observed with respect to emotional health when considering sleep duration and timing. Sleep-related changes in corticolimbic circuitry may contribute to the onset of emotion-related problems during adolescence.

Eveningness diurnal preference associated with poorer socioemotional cognition and social functioning among healthy adolescents and young adults

Recently there has been growing interest in associations between sleep, emotion, and social functioning. Less is known about relationships between chronotype preference and socioemotional cognition and functioning, particularly among adolescents, who experience dramatic normative shifts in diurnal preference, affective functioning, and social competence. Fifty-five healthy adolescents and young adults completed a self-report chronotype preference measure, a computerized measure of socioemotional cognition, and a semi-structured clinical interview assessing interpersonal functioning. Greater eveningness preference was associated with poorer socioemotional cognition and social functioning in this age group. Future studies should assess these relationships across development and using objective measures of circadian timing.