Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline

Digital cognitive behavioural therapy for insomnia reduces insomnia in nurses suffering from shift work disorder: A randomised-controlled pilot trial

Insomnia is a primary symptom of shift work disorder, yet it remains undertreated. This randomised-controlled pilot trial examined the efficacy of a digital, guided cognitive behavioural therapy for insomnia adapted to shift work (SleepCare) in nurses with shift work disorder. The hypothesis was that SleepCare reduces insomnia severity compared with a waitlist control condition. A total of 46 unmedicated nurses suffering from shift work disorder with insomnia (age: 39.7 ± 12.1 years; 80.4% female) were randomised to the SleepCare group or the waitlist control group. The primary outcome measure was the Insomnia Severity Index. Other questionnaires on sleep, mental health and occupational functioning, sleep diary data and actigraphy data were analysed as secondary outcomes. Assessments were conducted before (T0), after the intervention/waitlist period (T1), and 6 months after treatment completion (T2). The SleepCare group showed a significant reduction in insomnia severity from T0 to T1 compared with the control condition (β = -4.73, SE = 1.12, p < 0.001). Significant improvements were observed in sleepiness, dysfunctional beliefs about sleep, pre-sleep arousal, sleep effort, self-reported sleep efficiency and sleep onset latency. No significant effect was found in actigraphy data. Depressive and anxiety symptoms, cognitive irritation and work ability improved significantly. Overall, satisfaction and engagement with the intervention was high. SleepCare improved insomnia severity, sleep, mental health and occupational functioning. This is the first randomised-controlled trial investigating the efficacy of digital cognitive behavioural therapy for insomnia in a population suffering from shift work disorder with insomnia. Future research should further explore these effects with larger sample sizes and active control conditions.

Mindfulness-based therapy for insomnia in Black women: a pilot randomized controlled trial

The purpose of the study was to evaluate the feasibility, acceptability, and preliminary efficacy of mindfulness-based therapy for insomnia (MBT-I) among Black women. The MBT-I group received weekly sessions that included mindfulness meditation and behavioral sleep strategies. The time and attention control group received lifestyle health education (HE) that included healthy eating, physical activity, and sleep hygiene. The primary outcome was post-intervention changes in insomnia severity score by the Insomnia Severity Index (ISI) at week 10. Other measures included: Pittsburgh Sleep Quality Index, Sleep Hygiene Practice, Spielberger State-Trait Anxiety Inventory (STAI), and Patient Health Questionnaire-9 (PHQ-9). Objective sleep was measured by Actiwatch™ at baseline and week 10. Thirty Black women completed the interventions with no attrition. About 97% of all participants attended 6-8 out of 8 sessions. The ISI scores were reduced at week 10 (MBT-I vs. HE: -7.67 vs. -7.22, p < .05). Anxiety and depression symptoms were significantly improved only in the MBT-I group. This is the first MBT-I for Black women with insomnia. Online MBT-I may be feasible and acceptable for Black women. The MBT-I and HE showed a clinically significant improvement in insomnia symptoms (ISI reduction > 7). MBT-I may be more effective in improving anxiety and depression symptoms than HE. Our findings encourage further study efforts with a longer follow-up and larger sample size to address sleep health disparities among Black women.

Digital cognitive-behavioral therapy for insomnia in patients with multiple sclerosis: A multiple baseline single-case pilot study

Insomnia has an estimated prevalence of over 20 % in patients with multiple sclerosis (MS) and preliminary evidence suggests that treating insomnia through cognitive behavioral therapy for insomnia (CBT-I) can alleviate fatigue and other secondary symptoms in this population. Video-based CBT-I, an emerging remote treatment modality, has shown promise in previous studies for addressing insomnia in various populations, indicating its potential as an efficient treatment approach for individuals with MS. This pilot study aimed to assess the impact of video-based cognitive behavioral therapy for insomnia (VCBT-I) on individuals with comorbid insomnia and multiple sclerosis (MS). Out of the ten participants, six experienced statistically significant reductions in total wake time during the night, while seven demonstrated clinically significant improvements in waking time, and eight achieved insomnia remission based on the Insomnia Severity Index (ISI). These findings align with prior research indicating the effectiveness of CBT-I in addressing sleep disturbances and its promising potential for insomnia in MS. Moreover, improvements in depression symptoms, as measured by the PHQ-9, and reductions in worry, as assessed by the GAD-7, were observed. Although fatigue outcomes varied, suggesting a potential need for optimal sleep duration, participants reported enhanced quality of life and high treatment satisfaction. These results suggest that VCBT-I is a well-tolerated and effective treatment option for individuals with comorbid MS and insomnia, highlighting its potential to alleviate both sleep-related and psychological symptoms.

Nurse-delivered brief behavioral treatment for insomnia in cancer survivors: a randomized controlled trial

PURPOSE

To determine the efficacy of nurse-delivered brief behavioral treatment for insomnia (BBTI) compared to an attention control, in a heterogeneous sample of cancer survivors to reduce insomnia symptom severity.

METHODS

We recruited 132 participants from cancer care clinics, who had an Insomnia Severity Index (ISI) score ≥ 8. Participants were randomized into two groups: an experimental BBTI group and a healthy eating attention control group. Demographics survey at baseline, and sleep-related questionnaires, self-reported sleep diaries, and wrist-worn actigraphy at baseline, 1, 3, and 12 months were collected. Statistical analyses used analysis of covariance (ANCOVA) models with two-sided 0.05 nominal significance level for treatment effect for primary outcome of insomnia severity at 1 month.

RESULTS

Participants were cancer survivors with a mean age of 63.7 years, 55% female, 88.6% white, with breast, prostate, colorectal, and lung cancer. Statistically significant group differences were observed at all time points for ISI and sleep quality (ISI effect sizes 0.56, 0.59, and 0.54 respectively). Additionally, at 1 month, those in insomnia remission (ISI ≤ 8) were higher for the BBTI (55.1%) compared to the control group (43.3%). Secondary outcomes from sleep diary measures (i.e., sleep efficiency, sleep onset latency, wake after sleep onset) were significant at 1 month.

CONCLUSION

The BBTI group was significantly effective in reducing insomnia severity and improving sleep quality over time compared to the control among cancer survivors.

CLINICAL TRIAL REGISTRATION

Clinical trials identifier: http://ClinicalTrials.gov , NCT03810365.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing BBTI in survivorship settings can effectively address and manage insomnia symptoms, thus bridging a crucial gap in care for cancer survivors.

Integrating digital behavioural therapy for insomnia into primary care: A feasibility mixed-methods study

Digital cognitive behavioural therapy for insomnia has been developed to increase capacity and scalability for patients with insomnia, but implementation in primary care remains limited. The aim of the trial was to evaluate the implementation of digital insomnia therapy into primary care practice for patients with insomnia. We conducted a single-arm feasibility trial of digital behavioural therapy for insomnia (SleepFix) providing sleep restriction therapy with insomnia patients in primary care. Healthcare professionals (comprising General Practitioners, community pharmacists and nurses) were enrolled into the trial and, when deemed clinically appropriate, prescribed SleepFix to patients with insomnia. The primary outcome was uptake assessed by the number of downloads of SleepFix. Interviews with primary care healthcare professionals explored their attitudes towards implementing/using insomnia digital therapeutics in clinical practice, and patients about their experiences with SleepFix. Insomnia symptoms, mood and sleep quality were measured before and after the trial. This trial was prospectively registered (ACTRN12620000055909). Thirty healthcare professionals and 105 patients were enrolled into the trial. Fourteen healthcare professionals administered at least one insomnia digital therapeutic prescription between November 2021 and March 2022. Fifty patients downloaded and used SleepFix (47.6% uptake). In post-trial interviews, healthcare professionals felt they could incorporate digital sleep health into clinical practice and patients found SleepFix acceptable. There were significant improvements in insomnia symptoms, mood and sleep quality at week 6 (all p < 0.05). This trial shows a real-world implementation of a digital insomnia therapy into primary care that could provide a framework for prescribing digital sleep interventions.

Effect of daridorexant on sleep architecture in patients with chronic insomnia disorder: a pooled post hoc analysis of two randomized phase 3 clinical studies

STUDY OBJECTIVES

Post hoc analysis to evaluate the effect of daridorexant on sleep architecture in people with insomnia, focusing on features associated with hyperarousal.

METHODS

We studied sleep architecture in adults with chronic insomnia disorder from two randomized phase 3 clinical studies (Clinicaltrials.gov: NCT03545191 and NCT03575104) investigating 3 months of daridorexant treatment (placebo, daridorexant 25 mg, daridorexant 50 mg). We analyzed sleep-wake transition probabilities, EEG spectra, and sleep spindle properties including density, dispersion, and slow oscillation phase coupling. The wake EEG similarity index (WESI) was determined using a machine learning algorithm analyzing the spectral profile of the EEG.

RESULTS

At month 3, daridorexant 50 mg decreased wake-to-wake transition probabilities (p < .05) and increased the probability of transitions from wake-to-N1 (p < .05), N2 (p < .05), and REM sleep (p < .05), as well as from N1-to-N2 (p < .05) compared to baseline and placebo. Daridorexant 50 mg decreased relative beta power during wake (p = .011) and N1 (p < .001) compared to baseline and placebo. During the wake, relative alpha power decreased (p < .001) and relative delta power increased (p < .001) compared to placebo. Daridorexant did not alter EEG spectra bands in N2, N3, and REM stages or in sleep spindle activity. Daridorexant decreased the WESI score during wake compared to baseline (p = .004). Effects with 50 mg were consistent between months 1 and 3 and less pronounced with 25 mg.

CONCLUSIONS

Daridorexant reduced EEG features associated with hyperarousal as indicated by reduced wake-to-wake transition probabilities and enhanced spectral features associated with drowsiness and sleep during wake and N1.

CLINICAL TRIALS

ClinicalTrials.gov NCT03545191: study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants with insomnia disorder. URL: Study Details | study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants with insomnia disorder | ClinicalTrials.gov ClinicalTrials.gov NCT03575104:study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants who experience difficulties sleeping. URL: study details | study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants who experience difficulties sleeping | ClinicalTrials.gov.

Changes in insomnia and binge-eating symptom severity before and after treatment of eating disorders in individuals with non-low-weight binge-spectrum disorders

Although emerging research suggests insomnia is a significant problem among people with eating disorders, little is known about how insomnia symptoms may serve as risk factors for eating disorder symptoms, treatment outcome, and relapse. University students with non-low-weight eating disorders (N = 89) completed a mobile guided self-help cognitive behavioural intervention for eating disorders. Insomnia and binge-eating symptoms were assessed at pre-treatment and end-of-treatment using the Insomnia Severity Index and Eating Pathology Symptoms Inventory. Multiply imputed datasets were used to test associations between insomnia and binge eating before, during and after treatment. Insomnia was positively associated with binge-eating symptoms prior to treatment (r = 0.47). Baseline insomnia symptoms were associated with binge-eating symptoms at end-of-treatment (est = 0.269). Eating disorder treatment modestly reduced insomnia (d = -0.38); however, about half of people with clinically significant insomnia prior to treatment remained symptomatic. Insomnia symptoms and binge-eating symptoms did not change concurrently during treatment. Overall, results support an association between insomnia and binge eating. Although eating disorder treatment may impact insomnia, many individuals remained symptomatic for sleep problems, suggesting the need for follow-up treatments, such as cognitive behavioural therapy for insomnia, or the development of integrated insomnia-eating disorder treatments. Future studies are needed to examine causal links between insomnia and eating disorder symptoms, and test if insomnia predicts relapse after eating disorder treatment.

Comparison of Product Features and Clinical Trial Designs for the DTx Products with the Indication of Insomnia Authorized by Regulatory Authorities

BACKGROUND

Digital therapeutics (DTx) have attracted attention as the substitutes or add-ons to conventional pharmacotherapy and the number of DTx products authorized with the regulatory reviews of the clinical evidence is increasing. Insomnia is one of the major targets of the DTx due to the benefit from cognitive behavioral interventions and several products have been launched in the market with regulatory reviews. However, common features of the products and the clinical evidence required by each regulatory agency have not been investigated.

METHODS

In this study, we identified the DTx products with the primary indication of insomnia authorized with regulatory reviews of clinical evidence by literature and website searches, and investigated the common features of the products and of the study designs for the pivotal clinical trials.

RESULTS

The total of 6 DTx products were identified. The components of cognitive behavioral therapy for insomnia (CBT-I) were identified as common features of the products. All the pivotal clinical trials were randomized, parallel-group, blind studies against insomnia patients. No products have been authorized in multiple countries regardless of the similarity of the features of the products and of the study designs for the pivotal clinical trials.

CONCLUSIONS

Our study revealed that the components of CBT-I and gold standard design in pivotal clinical trials were adopted in all the DTx products for insomnia authorized with reviews of clinical evidence. At the same time, our findings suggest the needs of internationally harmonized regulatory review and authorization system to facilitate the early patient access to the promising DTx products.

Nurse-Supported Self-Directed Cognitive Behavioral Therapy for Insomnia: A Randomized Clinical Trial

Importance

Cognitive behavioral therapy for insomnia (CBTi) is the standard of care for treating insomnia disorder, but access is limited. Alternative approaches are needed to expand access to the standard of care.

Objective

To examine the effectiveness of a nurse-supported, self-directed behavioral insomnia intervention for decreasing insomnia severity and improving sleep outcomes among veterans, a population with considerable mental health comorbidity.

Design, Setting, and Participants

This randomized clinical trial included 178 patients with insomnia disorder who were recruited from a Veterans Affairs hospital (Durham VA Healthcare System) from September 2019 to April 2022 and randomized following baseline assessment; follow-ups were conducted at 8 weeks (primary end point) and 6 months. Data analysis was primarily conducted during the summer of 2023 and concluded in May 2024.

Intervention

Six weekly phone calls from a nurse interventionist plus assigned treatment manual readings covering CBTi treatment components. The health education manual focused on health topics but not sleep.

Main Outcomes and Measures

The primary outcome was the Insomnia Severity Index (score range, 0-28; remission <8; differential improvement of 3 points targeted) score assessed at 8 weeks postrandomization. Secondary outcomes were sleep outcomes, depression, fatigue, treatment response, and remission.

Results

Of 178 study participants, the mean (SD) age was 55.1 (13.2) years, and 128 (71.9%) identified as men. At 8 weeks, Insomnia Severity Index scores decreased by an estimated mean (SE) of 5.7 (0.51) points in the intervention group and 2.0 (0.47) points in the control group, a differential mean improvement of 3.7 points (95% CI, -5.0 to -2.4; P < .001). Differences were sustained at 6 months (mean, -2.8; 95% CI, -4.4 to -1.3; P < .001). The intervention also resulted in greater improvements at 8 weeks postrandomization in diary sleep onset latency, wake after sleep onset, and sleep efficiency and actigraphy sleep efficiency; these differences were sustained at 6 months. At 8 weeks, depression and fatigue were significantly reduced, and the odds of treatment response and remission were greater in the intervention group compared with controls.

Conclusions and Relevance

This randomized clinical trial found that despite greater prevalence of mental health conditions and sleep difficulties among veterans, a nurse-supported self-directed CBTi was more effective than health education control for reducing insomnia severity and improving sleep outcomes. Although less effective than therapist-delivered CBTi, findings were comparable with other trials using modified CBTi protocols.

Trial Registration

ClinicalTrials.gov Identifier: NCT03727438.

Effects of nurse-led brief behavioral treatment for insomnia in adults: a randomized controlled trial

STUDY OBJECTIVES

We examined the effects of nurse-led brief behavioral treatment for insomnia (BBTI) on insomnia severity, sleep status, daytime function, quality of life, psychological distress levels, treatment response, and insomnia remission in young and middle-aged Asian adults with insomnia symptoms.

METHODS

This 2-parallel, randomized controlled trial recruited 42 participants with insomnia symptoms randomly allocated to the nurse-led BBTI group or sleep hygiene group. The outcome measurements included the Insomnia Severity Index, sleep diary, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Brief Fatigue Inventory, RAND-36 Health Status Inventory, and the Depression, Anxiety, and Stress Scale-21. The measurement time points included baseline, the end of each week of the intervention period, and 1-month follow-up.

RESULTS

Compared with the sleep hygiene group, participants in the BBTI group had significantly improved insomnia severity, sleep onset latency, sleep efficiency, sleep quality, daytime sleepiness, and the mental components of quality of life after completing nurse-led BBTI immediately and 1 month later (P < .05). In addition, 52.4% and 71.4% of the participants achieved remission after completing nurse-led BBTI immediately and 1 month later, which was significantly higher than in the sleep hygiene group (14.3%, P = .02; 14.3%, P < .001, respectively).

CONCLUSIONS

We suggested the relative effects of BBTI on declined insomnia severity and improved sleep status among young and middle-aged Asian adults with insomnia symptoms and confirmed the benefits of nurse-led BBTI in alleviating insomnia. Nurses should incorporate BBTI into insomnia care further to enhance the daytime function and quality of life of the population with insomnia symptoms.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Effects of Nurse-led Brief Behavioral Treatment for Insomnia: A Feasibility Randomized Controlled Trial; URL: https://clinicaltrials.gov/study/NCT05310136; Identifier: NCT05310136.

CITATION

Chang K-M, Lin C-J, Jan Y-W, et al. Effects of nurse-led brief behavioral treatment for insomnia in adults: a randomized controlled trial. J Clin Sleep Med. 2024;20(11):1763-1772.

Validation of the Korean version of the Sleep Hygiene Practice Scale in a Non-Clinical Population

OBJECTIVES

This study aimed to validate the Korean version of the sleep hygiene practice scale (SHPS-K) and determine its effectiveness in screening poor sleepers with insomnia.

METHODS

Online survey was conducted using translated SHPS in Korean, the Korean versions of the Pittsburgh Sleep Quality Index (PSQI-K), Insomnia Severity Index (ISI-K), and Epworth Sleepiness Scale (KESS) in a non-clinical population. The internal consistency and test-retest reliability of the SHPS-K were assessed using Cronbach's alpha and intraclass correlation coefficients (ICC), respectively. Construct validity was evaluated using correlation analyses with other questionnaires and confirmatory factor analysis. We determined the cutoff values that could identify poor sleepers with insomnia symptoms (PSQI-K > 5 and ISI-K ≥ 15) using receiver operating characteristic analysis.

RESULTS

A total of 484 participants (242 women, mean age of 43.8 years) were enrolled. The average SHPS-K score was 71.2, with no significant sex differences. Women had poorer sleep scheduling and timing behaviors, and men had poorer eating and drinking behaviors. Good internal consistency (Cronbach's alpha = 0.88) and test-retest reliability (ICC = 0.80) were observed. The SHPS-K was positively correlated with the PSQI-K (r = 0.55), ISI-K (r = 0.54), and KESS (r = 0.42). A cutoff value of 73 identified poor sleepers with insomnia (area under the curve = 0.828).

CONCLUSIONS

The SHPS-K is a reliable instrument for evaluating sleep hygiene in non-clinical Korean populations.

Sleep disorders and risk of alzheimer's disease: A two-way road

Substantial sleep impairment in patients with Alzheimer's disease (AD) is one of the emerging points for continued efforts to better understand the disease. Individuals without cognitive decline, an important marker of the clinical phase of AD, may show early alterations in the sleep-wake cycle. The objective of this critical narrative review is to explore the bidirectional pathophysiological correlation between sleep disturbances and Alzheimer's Disease. Specifically, it examines how the disruption of sleep homeostasis in individuals without dementia could contribute to the pathogenesis of AD, and conversely, how neurodegeneration in individuals with Alzheimer's Disease might lead to dysregulation of the sleep-wake cycle. Recent scientific results indicate that sleep disturbances, particularly those related to impaired glymphatic clearance, may act as an important mechanism associated with the genesis of Alzheimer's Disease. Additionally, amyloid deposition and tau protein hyperphosphorylation, along with astrocytic hyperactivation, appear to trigger changes in neurotransmission dynamics in areas related to sleep, which may explain the onset of sleep disturbances in individuals with AD. Disruption of sleep homeostasis appears to be a modifiable risk factor in Alzheimer's disease. Whenever possible, the use of non-pharmacological strategies becomes important in this context. From a different perspective, additional research is needed to understand and treat the dysfunction of the sleep-wake cycle in individuals already affected by AD. Early recognition and correction of sleep disturbances in this population could potentially mitigate the progression of dementia and improve the quality of life for those with AD.

Cognitive behavior therapy for insomnia in university students delivered via videoconferencing groups: A pilot study

INTRODUCTION

Sleep difficulties are common amongst university students and are associated with mental illness and reduced wellbeing. This paper reports a pilot study of Cognitive Behavior Therapy for Insomnia (CBT-I) tailored specifically for university students. It was hypothesized that the intervention would be feasible, acceptable, and improve sleep, anxiety, depression, and wellbeing.

METHOD

Students aged 18-25 participated via videoconferencing small group sessions of CBT-I. Feasibility was assessed through sign-up, consent rates, and study attrition, while acceptability was assessed using intervention adherence and a measure of intervention acceptability. Outcome measures included sleep quality, insomnia, suicidal ideation, symptoms of depression, anxiety, and wellbeing, and were assessed at baseline and post-intervention.

RESULTS

Participants were 44 students (M = 21.8 years). Feasibility was confirmed by sign-up and consent rates (80% of the students who expressed interest agreed to participate); overall study attrition was 48%, comprised largely of participants not commencing treatment (27%). Participants perceived the program as effective and logical and made use of the skills suggested. In terms of adherence, 82% of the participants who engaged with treatment attended two or more sessions and 63% attended all four sessions; and 92% were either very satisfied or mostly satisfied. Sleep quality, insomnia, depression, anxiety, and wellbeing all significantly improved from pre- to post-intervention.

DISCUSSION

There was evidence that the CBT-I intervention tailored for university students was acceptable to participants and could be feasible to deliver. Sleep quality, depression, anxiety, and wellbeing improved significantly. These findings suggest that the intervention is suitable for evaluation in a fully powered randomized controlled trial.

Patient accessibility and utilization of behavioral sleep medicine referrals in an academic center

STUDY OBJECTIVES

Behavioral sleep medicine (BSM) is a subspecialty that combines behavioral psychology and sleep medicine specialties. The objective of this study was to analyze referral patterns to a BSM clinic. The 3 specific aims were: (1) describe factors that predict referral acceptance, (2) identify barriers to attending initial appointment, and (3) describe variables associated with the number of visits attended.

METHODS

Retrospective chart reviews were conducted as part of a quality improvement project by this study team's clinical setting. Adults over 21 years of age who were referred to a BSM clinic in an urban Midwestern academic health care system between 2014 and 2019 were included in this study.

RESULTS

Sleep medicine was the main referral source for patients with BSM (74.2%), followed by internal medicine (9.3%) and neurology/psychiatry (7.3%). Thirty-eight percent of patients did not schedule an appointment after a referral for BSM was initiated. Younger age, longer distance from clinic, commercial insurance, and out-of-network insurance were all significantly greater for nonschedulers. Eighty-three percent of patients did attend the initial intake session with BSM providers. Older age was associated with lower likelihood of not attending scheduled BSM appointments.

CONCLUSIONS

Patient characteristics of older age, closer distance from clinic, and in-network insurance coverage were found to significantly increase the likelihood of BSM scheduling, while younger age, Black race and not getting a primary sleep disorder diagnosis (vs a diagnosis of insomnia disorder) and shorter days from referral to appointment were associated with an increased likelihood of not attending the scheduled BSM treatment engagement.

CITATION

Chernyak Y, Ofner S, Williams MK, Bolarinwa C, Manchanda S, Otte JL. Patient accessibility and utilization of behavioral sleep medicine referrals in an academic center. J Clin Sleep Med. 2024;20(11):1793-1806.

Boosting Brain Health: Interventions for the Prevention and Treatment of Mild Cognitive Impairment and Early Neurodegenerative Disease

Mild Cognitive Impairment (MCI) and dementia are becoming more common with an aging population, and the numbers are expected to rise. These conditions can have a significant impact on patients, family, and health care systems. Lifestyle changes including physical activity, nutrition, quality sleep, socialization, cognitive activity and mental stimulation, routine medical care, and mental health care have the potential to prevent cognitive and functional decline and optimize daily living in all individuals, including those with MCI and early neurodegenerative disease. Brain Boosters is an important group intervention used to provide psychoeducation on lifestyle factors and strategies that can improve brain health, cognition, and functioning.

Neurophysiology and Molecular Basis of Cognitive Behavioral Therapy for Patients with Insomnia: Implications for Non-Pharmacological Approaches

Cognitive behavioral therapy for insomnia (CBT-I) is a widely used psychological intervention known for its effectiveness in improving insomnia symptoms. However, the neurophysiological mechanisms underlying the cognitive-behavioral treatment of insomnia remain unclear. This narrative review aimed to elucidate the neurophysiological and molecular mechanisms of CBT-I, focusing on the fields of psychology, neurophysiology, neuroendocrinology, immunology, medical microbiology, epigenetics, neuroimaging and brain function. A comprehensive search was conducted using databases including: PubMed, Embase, PsycINFO and Web of Science, with customized search strategies tailored to each database that included controlled vocabulary and alternative synonyms. It revealed that CBT-I may have a beneficial effect on the central nervous system, boost the immune system, upregulate genes involved in interferon and antibody responses, enhance functional connectivity between the hippocampus and frontoparietal areas and increase cortical gray matter thickness. In conclusion, an integrated model is proposed that elucidates the mechanisms of CBT-I and offers a new direction for investigations into its neurophysiological mechanisms.

Efficacy of non-invasive brain stimulation for post-stroke sleep disorders: a systematic review and meta-analysis

Objective

This study aimed to systematically assess the clinical efficacy of non-invasive brain stimulation (NIBS) for treating post-stroke sleep disorders (PSSD).

Methods

We conducted thorough literature search across multiple databases, including PubMed, Web of Science, EmBase, Cochrane Library, Scopus, China Biology Medicine (CBM); China National Knowledge Infrastructure (CNKI); Technology Periodical Database (VIP), and Wanfang Database, focusing on RCTs examining NIBS for PSSD. Meta-analyses were performed using RevMan 5.4 and Stata 14.

Results

Eighteen articles were reviewed, including 16 on repetitive Transcranial Magnetic Stimulation (rTMS), one on Theta Burst Stimulation (TBS), and two on transcranial Direct Current Stimulation (tDCS). Meta-analysis results indicated that rTMS within NIBS significantly improved the Pittsburgh Sleep Quality Index (PSQI) score (MD = -1.85, 95% CI [-2.99, -0.71], p < 0.05), the 17-item Hamilton Depression Rating Scale (HAMD-17) score [MD = -2.85, 95% CI (-3.40, -2.30), p < 0.05], and serum brain-derived neurotrophic factor (BDNF) levels [MD = 4.19, 95% CI (2.70, 5.69), p < 0.05], while reducing the incidence of adverse reactions [RR = 0.36, 95% CI (0.23, 0.55), p < 0.05]. TBS significantly improved the PSQI score in patients with PSSD (p < 0.05). Conversely, tDCS significantly improved the HAMD-17 score in PSSD patients [MD = -1.52, 95% CI (-3.41, -0.64), p < 0.05]. Additionally, rTMS improved sleep parameters, including Stage 2 sleep (S2%) and combined Stage 3 and 4 sleep (S3 + S4%) (p < 0.05), while tDCS improved total sleep time (TST) and sleep efficiency (SE) (p < 0.05).Subgroup analysis results indicated: (1) Both LF-rTMS and HF-rTMS improved PSQI scores (p < 0.05). (2) Both rTMS combined with medication and rTMS alone improved PSQI scores (p < 0.05). Compared to the sham/blank group, the rTMS group showed improvements in SE, sleep latency (SL), S1%, S3 + S4%, and REM sleep (REM%). The rTMS combined with medication group showed improved SL compared to the medication-only group (p < 0.05).

Conclusion

NIBS effectively improves sleep quality, structure, depression levels, and BDNF levels in PSSD patients, while also being safe. Further investigations into the potential of NIBS in PSSD treatment may provide valuable insights for clinical applications.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42023485317.

Sleep Awareness of Japanese Outpatients: A Survey at a Psychiatry Department of a University Hospital

Background: Insomnia is common in patients with psychiatric disorders. However, patients' awareness of sleep has seldom been examined in detail. In this study, we investigated sleep awareness in outpatients at the psychiatry department of a university hospital. Methods: The participants (n = 241) were recruited at the psychiatry department of Ehime University Hospital between 11 October and 5 November 2021. The following questionnaires were used: Clinical Global Impression Scale of Severity (CGI-S), Global Assessment of Functioning (GAF), General Health Questionnaire (GHQ-30), Athens Insomnia Scale (AIS), and Epworth Sleepiness Scale (ESS). Psychiatric disorders were diagnosed by certified psychiatrists using the International Statistical Classification of Diseases and Related Health Problems 10. Participants with an AIS score of ≥6 were allocated to the insomnia group for statistical analysis. A logistic regression analysis was conducted to identify which items of sleep hygiene the patients with insomnia practiced using the Sleep Guidelines for Health Promotion. Results: Of 241 participants, 133 (55.2%) were allocated to the insomnia group. The mean scores for the CGI were significantly higher and the GAF scores were significantly lower in the insomnia group than in the healthy sleep group (p < 0.01). Of the 12 sleep guidelines proposed by the Japanese Government, "Do not go to bed until you are sleepful, do not delay getting up", was the item that maximally influenced insomnia. Conclusions: The insomnia group had worse scores on various medical assessment scales compared to the healthy sleep group. Based on a survey of outpatients at the psychiatry department of the university hospital, appropriate stimulus control techniques may help clinicians to treat outpatients with insomnia.

Factors associated with hypnotics polypharmacy in the Japanese population

OBJECTIVE

Insomnia disorder is a global public health issue, commonly treated with hypnotics. However, long-term use of benzodiazepine derivatives (BZDs), especially polypharmacy with this kind of drug, carries risks for dependence and abuse. This study using large-scale medical insurance records investigated the causes of polypharmacy through the treatment of insomnia disorder.

METHODS

A cross-sectional study analyzed anonymized medical record data from July 2014 to March 2018 provided by a nationwide Japanese health insurance association covering 405,952 individuals. Outpatients prescribed at least one sleep medication were included. Demographic data, pharmacological classification of the drugs, and comorbidities were assessed using hierarchical logistic regression analysis to explore their associations with polypharmacy.

RESULTS

Of the 33,212 outpatients who were prescribed sleep medications, 32.5 % were prescribed multiple types. After adjusting for demographics and type of sleep medications as covariates, hypnotic polypharmacy was significantly associated with younger age, the presence of certain kinds of comorbidities, and using BZD anxiolytics before bedtime with the highest adjusted odds ratios (8.01-9.39) when referenced with BZD hypnotics. On the other hand, usage of orexin receptor antagonists, melatonin receptor agonists, and Z-drugs indicated lower odds ratios (0.74-0.87).

CONCLUSIONS

Hypnotic polypharmacy is relatively common in the Japanese general population. With the introduction of non-pharmacological therapy in mind, assessing patients' comorbidities and avoiding the use of benzodiazepines, especially BZD anxiolytics, before bedtime would be recommended to prevent polypharmacy.

Sleep disorders in chronic kidney disease

Sleep disorders are highly prevalent in chronic kidney disease (CKD) but are often under-recognized. Restless legs syndrome, which is common in CKD owing to issues with dopamine metabolism and is exacerbated by iron deficiency and uraemia, can lead to poor sleep quality and increased daytime fatigue. Insomnia is also prevalent in CKD, particularly in patients requiring dialysis, with increased sleep latency and sleep fragmentation being reported. The cause of insomnia in CKD is multifactorial - poor sleep habits and frequent napping during dialysis, uraemia, medications and mood disorders have all been suggested as potential contributing factors. Sleep apnoea and CKD are also now recognized as having a bi-directional relationship. Sleep apnoea is a risk factor for accelerated progression of CKD, and fluid overload, which is associated with kidney failure, can lead to both obstructive and central sleep apnoea. The presence of obstructive sleep apnoea in CKD can exacerbate the already heightened cardiovascular morbidity and mortality in these patients, as well as leading to daytime fatigue and reduced quality of life. Increased awareness, timely diagnosis and appropriate therapeutic interventions are essential to reduce the negative impact of sleep disorders in patients with kidney disease.

Sleep interventions in pediatric oncology: A systematic review of the evidence

Sleep concerns are common during pediatric cancer treatment and can last into survivorship. The current systematic review sought to identify intervention studies that addressed sleep as a primary or secondary outcome during pediatric cancer treatment up to 5 years after completing treatment. Quality assessment was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The review identified 16 studies with a total of 943 participants that tested a wide range of interventions including psycho-educational, stress management techniques, medications, and physical activity. Most studies included tested interventions in small samples. None of the included studies had a high risk of bias for all domains, but all included studies had a high risk of bias for at least two risk domains. Several feasible pilot studies were identified that warrant further research to test efficacy. Implications for future research and clinical practice to manage sleep concerns are discussed.

Construction of an index system of core competence assessment for sleep medicine nurse specialists in China: a Delphi study

AIM

To construct an evaluation index system for the core competence of nurses in sleep medicine specialties.

BACKGROUND

Specialized nurses in sleep medicine must handle treatment, nursing, and management well, which requires nurses to have excellent competence in knowledge, skills, and ability. However, a competency evaluation system for sleep medicine nurses has not been established in China.

METHODS

We used a literature review and an expert meeting to establish a draft indicator system. Subsequently, two rounds of correspondence were conducted with 27 experts from 5 provinces using the Delphi method to solicit their opinions on the core competency evaluation indicators for sleep medicine nurse specialists and to qualitatively evaluate the experts' scores. The consensus was defined in advance as a mean score of 4.0 or above, with at least 75% agreement among participants. In this way, the final indicator framework was determined.

RESULTS

The final evaluation indexes of the core competencies for sleep medicine Nurse Specialists included 6 first-level indexes (Practical ability, Theoretical Knowledge, Critical thinking, Communication and coordination, Nursing Management, and Professional Development), 16 s-level indexes, and 64 third-level indexes. The effective response rates of the two expert consultation rounds were 100%. The expert authority coefficients were 0.878 and 0.865 in the first and second rounds of consultation, respectively. In the second round of consultation, the first, second, and third indexes of Kendall's coefficient of concordance were 0.373, 0.351, and 0.286, respectively (P < 0.05).

CONCLUSION

The core competence evaluation index system for sleep medicine nurses established in this study is scientific and reliable and can provide a theoretical reference for the training, assessment, and evaluation of sleep medicine nurses in the future.

IMPLICATIONS FOR NURSING MANAGEMENT

The evaluation index system of sleep medicine nurses' core competence will provide an effective practical framework for nursing management to evaluate, train, and examine the core competence of sleep medicine nurses.

Perceptions and Effectiveness of a Fully Automated Brief Behavioral Insomnia Therapy, Delivered by a Virtual Companion, in Older and Young Adults

Background and Objectives

One of the most common sleep disturbances in older people is insomnia. Cognitive-behavioral therapy is the first-line treatment for this condition in older adults, but in-person treatment is costly and often unavailable. In this study, in a group of older and young subjects, we aimed to compare: (a) their initial perceptions of a fully automated mobile health intervention to manage insomnia, (b) how these perceptions related to treatment completion, and (c) the effects of the intervention on insomnia severity and related outcomes.

Research Design and Methods

A case-series study was conducted with a self-selected sample of older (≥65 years) and young (18-35 years) adults (n = 5,660) who downloaded a free app, available in France, that delivers a brief behavioral intervention for insomnia aided by a virtual companion (VC). The 17-day intervention included sleep hygiene and stimulus control recommendations. Primary outcome was treatment completion (yes/no). At the beginning of the intervention, treatment acceptability and trust in the VC were assessed with 2 short questionnaires (completion rate: 1,597 users). Insomnia was evaluated with the Insomnia Severity Index.

Results

Logistic regression analyses showed that higher credibility and trust in the app's VC were associated with higher odds of treatment completion, but only in older adults (trust scores × age group: odds ratio [OR] = 1.12; 95% confidence interval [CI] = 1.01-1.25; p < .05, and credibility scores × age group: OR = 1.25 [95% CI = 1.06-1.47], p < .01). Within the subset of users who completed the intervention (n = 289), insomnia remission (χ2 = 2.72, NS) and insomnia response rates (χ2 = 2.34, NS) were comparable across both groups.

Discussion and Implications

This brief behavioral intervention appears to be efficacious for the self-management of insomnia symptoms in older adults. The integration of persuasive interaction elements, such as avatars and virtual coaches, in fully automated interventions could be particularly useful to stimulate older adults' engagement.

Clinical Trials Registration Number

NCT05074901.

Harnessing the Power of Integrated Behavioral Health to Enhance Insomnia Intervention in Primary Care

Insomnia is prevalent in primary care and associated with co-morbid physical and mental health conditions and poor health outcomes. While there are effective treatments for insomnia in specialty mental health care, many patients have difficulty accessing these interventions. To begin, patients do not always report their sleep challenges to physicians; meanwhile, primary care providers often do not screen for insomnia symptoms. Furthermore, patients may experience several barriers to accessing specialty care for insomnia treatment, such as a limited number of available providers, financial burden, lack of transportation, and low perceptions of treatment effectiveness. Primary care behavioral health (PCBH) is well-equipped to address the challenges of accessing evidence-based care for insomnia through (1) identifying sleep issues, (2) providing psychoeducation on the possible treatments for insomnia, (3) intervening with poor sleep habits and acute insomnia early to prevent chronic insomnia, and (4) delivering appropriate evidence-based interventions for chronic insomnia. Primary care clinics should leverage behavioral health providers to increase screening and embed interventions into routine care for the benefit of improved outcomes for patients with insomnia and other sleep challenges.

Orexin receptor antagonists in the treatment of insomnia associated with psychiatric disorders: a systematic review

Insomnia is highly comorbid in patients with psychiatric disorders, including depression, bipolar disorder, and substance use disorders, and should be treated as an independent condition. Dual orexin receptor antagonists (DORAs) have been investigated as a treatment for chronic insomnia. The objective of this systematic review was to examine evidence for two DORAs, lemborexant and suvorexant, as treatments for insomnia comorbid with a psychiatric disorder. We searched PubMed, Cochrane, and Embase from their inception until January and April 2023, and included studies examining suvorexant and lemborexant for treating insomnia comorbid with psychiatric disorders. We also manually searched clinical trial registries ( https://clinicaltrials.gov and https://www.umin.ac.jp/ctr ). Randomized clinical trials and observational/cohort studies were included. We identified 18 studies from PubMed, Cochrane, and Embase and three studies from clinicaltrials.gov and UMIN. Of the 21 reports, four were completed/terminated randomized clinical trials, eight were ongoing clinical trials, and nine were observational studies. We identified evidence for switching from benzodiazepine receptor agonists to a DORA, or using a DORA as add-on therapy and, therefore, discuss this topic as well. Two studies examined switching to or adding on a DORA in patients being treated with a benzodiazepine receptor agonist. DORAs may be as effective and safe for treating psychiatric comorbid insomnia (for most psychiatric conditions) as they are for treating primary insomnia. However, the evidence is limited to a few small studies. Further investigation of DORAs for the treatment of comorbid insomnia in those with coexisting psychiatric conditions is warranted.

Effect of a prescription digital therapeutic for chronic insomnia on post-treatment insomnia severity, depression, and anxiety symptoms: results from the real-world DREAM study

Introduction

Chronic insomnia is a substantial public health burden that often presents with co-occurring depression and anxiety. Randomized clinical trials and preliminary real-world evidence have shown that digitally delivered cognitive-behavioral therapy for insomnia (dCBT-I) is associated with improvements in insomnia, but real-world evidence is needed to determine the true impact of digital CBT-I. This pragmatic study aimed to evaluate the benefits of treating chronic insomnia with a tailored prescription digital therapeutic in a real-world population.

Methods

This prospective, single-arm clinical study involved adults aged 22-75 with chronic insomnia living in the US who had access to a mobile device. Participants accessed the FDA-cleared prescription digital therapeutic (PDT; Somryst®) over a 9-week intervention period. The PDT delivers cognitive-behavioral therapy for insomnia via six interactive treatment cores and daily sleep diaries used for tailoring treatment. Participants completed validated patient-reported instruments at baseline, before completing treatment cores, immediately post-intervention, and at 6-month and 1-year follow-ups. The Insomnia Severity Index [ISI], the 8-item Patient Health Questionnaire [PHQ-8], and the Generalized Anxiety Disorder-7 scale [GAD-7] were used to determine the effect of the PDT on insomnia, depression, and anxiety.

Results

After screening, 1565 adults accessed the PDT. 58% of those who began the program completed Core 4, established as exposure to all mechanisms of action in the digital therapeutic. For those who completed assessments for all 6 cores (48.4%), the ISI was lowered from 18.8 to a mean of 9.9 (P <.001). These scores continued to be lower than baseline at immediate post (11.0), 6-month (11.6), and 1-year follow-ups (12.2) (P <.001). The results of the PHQ-8 and GAD-7 also show significant decreases at all measured timepoints from baseline (P <.001). Of the patients that began the program, 908 (58.0%) were considered adherent and 733 (46.8%) completed all 6 cores.

Conclusion

Data from the DREAM study contributes to the growing body of clinical evidence of how patients are utilizing a PDT in the real world, outside of controlled settings, offering insights for clinicians who use these therapeutics in practice.

Clinical trial registration

ClinicalTrials.gov, identifier NCT04325464.

Effects of mindfulness-based music listening on conflict control in young adults with insomnia disorder: behavioral and event-related potential evidence

Introduction

Insomnia Disorder (ID) has become the second most prevalent mental disorder, with significant negative effects on daytime cognitive functions. Previous studies suggested that mindfulness-based music listening (MBML) can effectively improve conflict control and attentional processing in healthy adults. However, the behavioral and neurophysiological characteristics of MBML in young adults with ID remain unclear.

Methods

To explore the behavioral and neurophysiological characteristics of MBML in regulating negative emotions among young Chinese adults with ID, 60 young adults with ID were asked to complete an emotion-word Stroop task under three mood states while recording event-related potentials (ERPs).

Results

Task and questionnaire results showed that (1) negative emotion induced by the negative simulated video significantly suppressed the attentional processing of emotional faces and words in the conflict control task among young people with ID, (2) MBML reduced cognitive and physical arousal levels, enhanced positive mood, and improved attentional control abilities in young adults with ID. The ERP results showed that a greater N3 effect and the smaller P3 and late positive component (LPC) effects reflected that MBML effectively regulated negative emotions induced by the negative simulated video and attentional processing abilities for conflict control in young adults with ID.

Discussion

Maintaining mindfulness while listening to music may enhance positive emotional experiences and improve cognitive ability, and exhibit larger N3 effects and smaller P3 and LPC effects in the electrophysiology mechanism, with a reduction in the hyperarousal level in young adults with insomnia disorders.

Cognitive Behavioral Therapy for Insomnia Self-Management Mobile Apps: A Review of Efficacy and Quality

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia, yet multiple barriers limit utilization. Digital CBT-I may present a solution, though related reviews have focused on Internet-based delivery rather than app use. The high utilization of health apps and prevalence of sleep apps indicate the need to equip clinicians with app-specific research. Toward this end, we reviewed efficacy and quality data on self-management CBT-I smartphone apps, revealing efficacy research on eleven apps, five of which were publicly available. While preliminary, these efficacy studies showed consistent positive findings. When examining quantitative quality indicators for the five publicly available apps, two had consistent data. Overall, two apps, CBTi Coach and Insomnia Coach, had positive, empirical findings across all efficacy and quality assessment approaches. We provide recommendations to guide clinician decision making regarding CBT-I self-management apps based on the literature and publicly available methods of app evaluations.

Mindful Night-to-Day: A Pilot Feasibility Trial of a Mindfulness-Based Insomnia and Symptom Management Intervention for Patients with Hematologic Cancer

OBJECTIVES

Patients with hematologic cancer experience severe symptoms (i.e. insomnia, fatigue, pain, distress). Few interventions addressing insomnia and other symptoms exist for this population. Mindfulness-Based Therapy for Insomnia (MBTI) may be appropriate but has only been tested in healthy outpatients. This study aimed to develop and test an adapted MBTI protocol for hematologic cancer patients.

METHODS

Patient (n = 3) and clinician (n = 1) focus groups, and user-testing (N = 5) informed adaptation of Mindful Night-to-Day (MBTI+). A single-arm pilot trial (N = 32) evaluated feasibility (accrual, attrition, adherence), acceptability (intervention satisfaction), and changes to insomnia symptom severity (Insomnia Severity Index; primary outcome) and secondary outcomes (fatigue, pain, distress, pre-sleep arousal, mindfulness, symptom management self-efficacy) at baseline, post-intervention, and 1-month post-intervention. Descriptive statistics and paired sample t-tests were conducted.

RESULTS

Qualitative feedback informed MBTI+ content, format, and delivery. Mindfulness was used to increase symptom awareness (sleepiness vs. fatigue). Meditations and behavioral skills were applied to inpatient treatment. MBTI+ met feasibility (N = 32/12 months; 8.1% attrition; 83.8% adherence) and acceptability (M = 3.52/4.00) benchmarks. Insomnia symptom severity decreased (d = 1.20) from baseline to post-intervention, as did most secondary outcomes.

CONCLUSIONS

MBTI+ was feasible, acceptable, and showed promise for benefits throughout inpatient and outpatient treatment. Findings warrant further evaluation in a randomized trial.

Predicting response to stepped-care cognitive behavioral therapy for insomnia using pre-treatment heart rate variability in cancer patients

OBJECTIVE

This study examined whether high frequency heart-rate variability (HF-HRV) and HF-HRV reactivity to worry moderate response to cognitive behavioural therapy for insomnia (CBT-I) within both a standard and stepped-care framework among cancer patients with comorbid insomnia. Biomarkers such as HF-HRV may predict response to CBT-I, a finding which could potentially inform patient allocation to different treatment intensities within a stepped-care framework.

METHODS

177 participants (86.3 % female; Mage = 55.3, SD = 10.4) were randomized to receive either stepped-care or standard CBT-I. 145 participants had their HRV assessed at pre-treatment during a rest and worry period. Insomnia symptoms were assessed using the Insomnia Severity Index (ISI) and daily sleep diary across five timepoints from pre-treatment to a 12-month post-treatment follow-up.

RESULTS

Resting HF-HRV was significantly associated with pre-treatment sleep efficiency and sleep onset latency but not ISI score. However, resting HF-HRV did not predict overall changes in insomnia across treatment and follow-up. Similarly, resting HF-HRV did not differentially predict changes in sleep diary parameters across standard or stepped-care groups. HRV reactivity was not related to any of the assessed outcome measures in both cross-sectional and longitudinal analyses.

CONCLUSION

Although resting HF-HRV was related to initial daily sleep parameters, HF-HRV measures did not significantly predict longitudinal responses to CBT-I. These findings suggest that HF-HRV does not predict treatment responsiveness to CBT-I interventions of different intensity in cancer patients.

Integrative Modeling of Accelerometry-Derived Sleep, Physical Activity, and Circadian Rhythm Domains With Current or Remitted Major Depression

Importance

Accelerometry has been increasingly used as an objective index of sleep, physical activity, and circadian rhythms in people with mood disorders. However, most prior research has focused on sleep or physical activity alone without consideration of the strong within- and cross-domain intercorrelations; and few studies have distinguished between trait and state profiles of accelerometry domains in major depressive disorder (MDD).

Objectives

To identify joint and individual components of the domains derived from accelerometry, including sleep, physical activity, and circadian rhythmicity using the Joint and Individual Variation Explained method (JIVE), a novel multimodal integrative dimension-reduction technique; and to examine associations between joint and individual components with current and remitted MDD.

Design, Setting, and Participants

This cross-sectional study examined data from the second wave of a population cohort study from Lausanne, Switzerland. Participants included 2317 adults (1164 without MDD, 185 with current MDD, and 968 with remitted MDD) with accelerometry for at least 7 days. Statistical analysis was conducted from January 2021 to June 2023.

Main Outcomes and Measures

Features derived from accelerometry for 14 days; current and remitted MDD. Logistic regression adjusted for age, sex, body mass index, and anxiety and substance use disorders.

Results

Among 2317 adults included in the study, 1261 (54.42%) were female, and mean (SD) age was 61.79 (9.97) years. JIVE reduced 28 accelerometry features to 3 joint and 6 individual components (1 sleep, 2 physical activity, 3 circadian rhythms). Joint components explained 58.5%, 79.5%, 54.5% of the total variation in sleep, physical activity, and circadian rhythm domains, respectively. Both current and remitted depression were associated with the first 2 joint components that were distinguished by the salience of high-intensity physical activity and amplitude of circadian rhythm and timing of both sleep and physical activity, respectively. MDD had significantly weaker circadian rhythmicity.

Conclusions and Relevance

Application of a novel multimodal dimension-reduction technique demonstrates the importance of joint influences of physical activity, circadian rhythms, and timing of both sleep and physical activity with MDD; dampened circadian rhythmicity may constitute a trait marker for MDD. This work illustrates the value of accelerometry as a potential biomarker for subtypes of depression and highlights the importance of consideration of the full 24-hour sleep-wake cycle in future studies.

Efficacy of eHealth Versus In-Person Cognitive Behavioral Therapy for Insomnia: Systematic Review and Meta-Analysis of Equivalence

BACKGROUND

Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive behavioral therapy for insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person-delivered CBTI (ipCBTI), electronically delivered eHealth CBTI (eCBTI), ranging from telephone- and videoconference-delivered interventions to fully automated web-based programs and mobile apps, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined.

OBJECTIVE

This study aims to test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized controlled trials directly comparing the 2 delivery formats.

METHODS

A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and nonsleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences. Supplementary Bayesian analyses were conducted to determine the strength of the available evidence.

RESULTS

The meta-analysis included 15 studies with a total of 1083 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the 2 delivery formats were statistically significantly equivalent (P<.05) for most sleep and nonsleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements (P<.05) in insomnia severity; sleep quality; and secondary outcomes such as fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and dropout rates as potential moderators of the differences in treatment efficacy.

CONCLUSIONS

eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and dropout rates on efficacy.

TRIAL REGISTRATION

PROSPERO CRD42023390811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=390811.

Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial

BACKGROUND

Digital cognitive behavioral therapy for insomnia (dCBTi) is an effective intervention for treating insomnia. The findings regarding its efficacy compared to face-to-face cognitive behavioral therapy for insomnia are inconclusive but suggest that dCBTi might be inferior. The lack of human support and low treatment adherence are believed to be barriers to dCBTi achieving its optimal efficacy. However, there has yet to be a direct comparative trial of dCBTi with different types of coaching support.

OBJECTIVE

This study examines whether adding chatbot-based and human coaching would improve the treatment efficacy of, and adherence to, dCBTi.

METHODS

Overall, 129 participants (n=98, 76% women; age: mean 34.09, SD 12.05 y) whose scores on the Insomnia Severity Index [ISI] were greater than 9 were recruited. A randomized controlled comparative trial with 5 arms was conducted: dCBTi with chatbot-based coaching and therapist support (dCBTi-therapist), dCBTi with chatbot-based coaching and research assistant support, dCBTi with chatbot-based coaching only, dCBTi without any coaching, and digital sleep hygiene and self-monitoring control. Participants were blinded to the condition assignment and study hypotheses, and the outcomes were self-assessed using questionnaires administered on the web. The outcomes included measures of insomnia (the ISI and the Sleep Condition Indicator), mood disturbances, fatigue, daytime sleepiness, quality of life, dysfunctional beliefs about sleep, and sleep-related safety behaviors administered at baseline, after treatment, and at 4-week follow-up. Treatment adherence was measured by the completion of video sessions and sleep diaries. An intention-to-treat analysis was conducted.

RESULTS

Significant condition-by-time interaction effects showed that dCBTi recipients, regardless of having any coaching, had greater improvements in insomnia measured by the Sleep Condition Indicator (P=.003; d=0.45) but not the ISI (P=.86; d=-0.28), depressive symptoms (P<.001; d=-0.62), anxiety (P=.01; d=-0.40), fatigue (P=.02; d=-0.35), dysfunctional beliefs about sleep (P<.001; d=-0.53), and safety behaviors related to sleep (P=.001; d=-0.50) than those who received digital sleep hygiene and self-monitoring control. The addition of chatbot-based coaching and human support did not improve treatment efficacy. However, adding human support promoted greater reductions in fatigue (P=.03; d=-0.33) and sleep-related safety behaviors (P=.05; d=-0.30) than dCBTi with chatbot-based coaching only at 4-week follow-up. dCBTi-therapist had the highest video and diary completion rates compared to other conditions (video: 16/25, 60% in dCBTi-therapist vs <3/21, <25% in dCBTi without any coaching), indicating greater treatment adherence.

CONCLUSIONS

Our findings support the efficacy of dCBTi in treating insomnia, reducing thoughts and behaviors that perpetuate insomnia, reducing mood disturbances and fatigue, and improving quality of life. Adding chatbot-based coaching and human support did not significantly improve the efficacy of dCBTi after treatment. However, adding human support had incremental benefits on reducing fatigue and behaviors that could perpetuate insomnia, and hence may improve long-term efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136638; https://www.clinicaltrials.gov/study/NCT05136638.

Cognitive Behavioral Therapy for Insomnia in Pain Management for Nonspecific Chronic Spinal Pain: A Randomized Clinical Trial

Importance

Insomnia is highly prevalent in patients with nonspecific chronic spinal pain (nCSP). Given the close interaction between insomnia and pain, targeting sleep problems during therapy could improve treatment outcomes.

Objective

To evaluate the effectiveness of cognitive behavioral therapy for insomnia (CBTi) integrated in best-evidence pain management (BEPM) vs BEPM only in patients with nCSP and insomnia.

Design, Setting, and Participants

A multicenter randomized clinical trial with 1-year follow-up was conducted between April 10, 2018, and April 30, 2022. Data and statistical analysis were performed between May 1, 2022, and April 24, 2023. Patients with nCSP and insomnia were evaluated using self-report and at-home polysomnography, to exclude underlying sleep pathologic factors. Participants were treated at the University Hospital Brussels or University Hospital Ghent, Belgium. Intention-to-treat analysis was performed.

Interventions

Participants were randomized to either CBTi-BEPM or BEPM only. Both groups received 18 treatment sessions over 14 weeks. The CBTi-BEPM treatment included 6 CBTi sessions and 12 BEPM sessions. The BEPM treatment included pain neuroscience education (3 sessions) and exercise therapy (9 sessions in the CBTi-BEPM group, 15 sessions in the BEPM-only group).

Main Outcomes and Measures

The primary outcome was change in mean pain intensity (assessed with Brief Pain Inventory [BPI]) at 12 months after the intervention. Exploratory secondary outcomes included several pain- and sleep-related outcomes. Blinded outcome assessment took place at baseline, posttreatment, and at 3-, 6-, and 12-month follow-up.

Results

A total of 123 patients (mean [SD] age, 40.2 [11.18] years; 84 women [68.3%]) were included in the trial. In 99 participants (80.5%) with 12-month BPI data, the mean pain intensity at 12 months decreased by 1.976 points (reduction of 40%) in the CBTi-BEPM group and 1.006 points (reduction of 24%) points in the BEPM-only group. At 12 months, there was no significant difference in pain intensity change between groups (mean group difference, 0.970 points; 95% CI, -0.051 to 1.992; Cohen d, 2.665). Treatment with CBTi-BEPM resulted in a response for BPI average pain with a number needed to treat (NNT) of 4 observed during 12 months. On a preliminary basis, CBTi-BEPM was, consistently over time and analyses, more effective than BEPM only for improving insomnia severity (Cohen d, 4.319-8.961; NNT for response ranging from 2 to 4, and NNT for remission ranging from 5 to 12), sleep quality (Cohen d, 3.654-6.066), beliefs about sleep (Cohen d, 5.324-6.657), depressive symptoms (Cohen d, 2.935-3.361), and physical fatigue (Cohen d, 2.818-3.770). No serious adverse effects were reported.

Conclusions and Relevance

In this randomized clinical trial, adding CBTi to BEPM did not further improve pain intensity reduction for patients with nCSP and comorbid insomnia more than BEPM alone. Yet, as CBTi-BEPM led to significant and clinically important changes in insomnia severity and sleep quality, CBTi integrated in BEPM should be considered in the treatment of patients with nCSP and comorbid insomnia. Further research can investigate the patient characteristics that moderate the response to CBTi-BEPM in terms of pain-related outcomes, as understanding of these moderators may be of utmost clinical importance.

Trial Registration

Clinical Trials.gov Identifier: NCT03482856.

Neuroscience in pictures: 2. Sleep, wakefulness, and mental state biology

Sleep is a vital restorative process that has occupied our curiosity for millennia. Despite our longstanding research efforts, the biology of sleep and its connection to mental states remains enigmatic. Unsurprisingly, sleep and wakefulness, the fundamental processes between which our mental states oscillate, are inseparable from our physical and mental health. Thus, clinical consideration of sleep impairments warrants a transdiagnostic approach whilst appropriately acknowledging that certain individual disorders (e.g. depression, schizophrenia) may have somewhat distinct sleep disturbances. Moreover, our knowledge of the anatomy and physiology of sleep regulation-albeit limited-forms the foundation for current treatments for sleep difficulties. This pictorial article overviews the core concepts and future of sleep neuroscience and mental state biology for trainees and practitioners in psychiatry and related professions.

Effect of fezolinetant on sleep disturbance and impairment during treatment of vasomotor symptoms due to menopause

OBJECTIVES

To analyse the effect of fezolinetant on patient-reported sleep disturbance and impairment in individuals with vasomotor symptoms (VMS) using pooled data from the SKYLIGHT 1 and 2 studies.

STUDY DESIGN

The SKYLIGHT studies were phase-3, double-blind investigations. Individuals (≥40-≤65 years) who were assigned female at birth and seeking treatment of/relief from moderate-to-severe VMS were enrolled. Participants were randomised to receive placebo, fezolinetant 30 mg, or fezolinetant 45 mg during a 12-week treatment period.

MAIN OUTCOME MEASURES

Sleep assessments: Patient-Reported Outcomes Measurement Information System Sleep Disturbance - Short Form 8b (PROMIS SD SF 8b), PROMIS Sleep-Related Impairment - Short Form 8a (PROMIS SRI SF 8a), and Patient Global Impression of Change/Severity in SD (PGI-C SD and PGI-S SD). Assessments were completed at baseline (except PGI-C SD), weeks 4 and 12.

RESULTS

Overall, 1022 individuals were randomised and took ≥1 dose of study drug. PROMIS SD SF 8b results showed that improvements in sleep disturbance were observed for fezolinetant 30 and 45 mg versus placebo (week 12, least squares [LS] mean differences: -0.6 [95 % confidence interval [CI]: -1.7, 0.4] for 30 mg and -1.5 [-2.5, -0.5] for 45 mg). Similar improvements in sleep impairment were reported using the PROMIS SRI SF 8a (week 12, LS mean differences: -1.1 [95 % CI: -2.1, -0.1] for 30 mg and -1.3 [-2.3, -0.3] for 45 mg). For PGI-C SD at week 12, 33.6 % (98/292 participants) of the placebo group felt much/moderately better versus 40.1 % (110/274) and 51.0 % (154/302) of the fezolinetant 30 mg and 45 mg groups, respectively. For PGI-S SD at week 12, 44.0 % (129/293) of the placebo group had severe/moderate problems versus 41.1 % (113/275) and 36.6 % (111/303) of the fezolinetant 30 mg and 45 mg groups, respectively. The 12-week timeframe for this analysis was limited by the length of the placebo-controlled period.

CONCLUSIONS

Fezolinetant had a beneficial effect on four measures of sleep disturbance and impairment following treatment for VMS.

Sleep-wake behaviors associated with cognitive performance in middle-aged participants of the Hispanic Community Health Study/Study of Latinos

OBJECTIVES

Many sleep-wake behaviors have been associated with cognition. We examined a panel of sleep-wake/activity characteristics to determine which are most robustly related to having low cognitive performance in midlife. Secondarily, we evaluate the predictive utility of sleep-wake measures to screen for low cognitive performance.

METHODS

The outcome was low cognitive performance defined as being >1 standard deviation below average age/sex/education internally normalized composite cognitive performance levels assessed in the Hispanic Community Health Study/Study of Latinos. Analyses included 1006 individuals who had sufficient sleep-wake measurements about 2years later (mean age=54.9, standard deviation= 5.1; 68.82% female). We evaluated associations of 31 sleep-wake variables with low cognitive performance using separate logistic regressions.

RESULTS

In individual models, the strongest sleep-wake correlates of low cognitive performance were measures of weaker and unstable 24-hour rhythms; greater 24-hour fragmentation; longer time-in-bed; and lower rhythm amplitude. One standard deviation worse on these sleep-wake factors was associated with ∼20%-30% greater odds of having low cognitive performance. In an internally cross-validated prediction model, the independent correlates of low cognitive performance were: lower Sleep Regularity Index scores; lower pseudo-F statistics (modellability of 24-hour rhythms); lower activity rhythm amplitude; and greater time in bed. Area under the curve was low/moderate (64%) indicating poor predictive utility.

CONCLUSION

The strongest sleep-wake behavioral correlates of low cognitive performance were measures of longer time-in-bed and irregular/weak rhythms. These sleep-wake assessments were not useful to identify previous low cognitive performance. Given their potential modifiability, experimental trials could test if targeting midlife time-in-bed and/or irregular rhythms influences cognition.

Ecological momentary assessment and cue-elicited drug craving as primary endpoints: study protocol for a randomized, double-blind, placebo-controlled clinical trial testing the efficacy of a GLP-1 receptor agonist in opioid use disorder

BACKGROUND

Despite continuing advancements in treatments for opioid use disorder (OUD), continued high rates of relapse indicate the need for more effective approaches, including novel pharmacological interventions. Glucagon-like peptide 1 receptor agonists (GLP-1RA) provide a promising avenue as a non-opioid medication for the treatment of OUD. Whereas GLP-1RAs have shown promise as a treatment for alcohol and nicotine use disorders, to date, no controlled clinical trials have been conducted to determine if a GLP-1RA can reduce craving in individuals with OUD. The purpose of the current protocol was to evaluate the potential for a GLP-1RA, liraglutide, to safely and effectively reduce craving in an OUD population in residential treatment.

METHOD

This preliminary study was a randomized, double-blinded, placebo-controlled clinical trial designed to test the safety and efficacy of the GLP-1RA, liraglutide, in 40 participants in residential treatment for OUD. Along with taking a range of safety measures, efficacy for cue-induced craving was evaluated prior to (Day 1) and following (Day 19) treatment using a Visual Analogue Scale (VAS) in response to a cue reactivity task during functional near-infrared spectroscopy (fNIRS) and for craving. Efficacy of treatment for ambient craving was assessed using Ecological Momentary Assessment (EMA) prior to (Study Day 1), across (Study Days 2-19), and following (Study Days 20-21) residential treatment.

DISCUSSION

This manuscript describes a protocol to collect clinical data on the safety and efficacy of a GLP-1RA, liraglutide, during residential treatment of persons with OUD, laying the groundwork for further evaluation in a larger, outpatient OUD population. Improved understanding of innovative, non-opioid based treatments for OUD will have the potential to inform community-based interventions and health policy, assist physicians and health care professionals in the treatment of persons with OUD, and to support individuals with OUD in their effort to live a healthy life.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04199728. Registered 16 December 2019, https://clinicaltrials.gov/study/NCT04199728?term=NCT04199728 .

PROTOCOL VERSION

10 May 2023.

Efficacy of Mobile App-Based Cognitive Behavioral Therapy for Insomnia: Multicenter, Single-Blind Randomized Clinical Trial

BACKGROUND

Cognitive behavioral therapy for insomnia (CBTi) is the first-line therapy for chronic insomnia. Mobile app-based CBTi (MCBTi) can enhance the accessibility of CBTi treatment; however, few studies have evaluated the effectiveness of MCBTi using a multicenter, randomized controlled trial design.

OBJECTIVE

We aimed to assess the efficacy of Somzz, an MCBTi that provides real-time and tailored feedback to users, through comparison with an active comparator app.

METHODS

In our multicenter, single-blind randomized controlled trial study, participants were recruited from 3 university hospitals and randomized into a Somzz group and a sleep hygiene education (SHE) group at a 1:1 ratio. The intervention included 6 sessions for 6 weeks, with follow-up visits over a 4-month period. The Somzz group received audiovisual sleep education, guidance on relaxation therapy, and real-time feedback on sleep behavior. The primary outcome was the Insomnia Severity Index score, and secondary outcomes included sleep diary measures and mental health self-reports. We analyzed the outcomes based on the intention-to-treat principle.

RESULTS

A total of 98 participants were randomized into the Somzz (n=49, 50%) and SHE (n=49, 50%) groups. Insomnia Severity Index scores for the Somzz group were significantly lower at the postintervention time point (9.0 vs 12.8; t95=3.85; F2,95=22.76; ηp2=0.13; P<.001) and at the 3-month follow-up visit (11.3 vs 14.7; t68=2.61; F2,68=5.85; ηp2=0.03; P=.01) compared to those of the SHE group. The Somzz group maintained their treatment effect at the postintervention time point and follow-ups, with a moderate to large effect size (Cohen d=-0.62 to -1.35; P<.01 in all cases). Furthermore, the Somzz group showed better sleep efficiency (t95=-3.32; F2,91=69.87; ηp2=0.41; P=.001), wake after sleep onset (t95=2.55; F2,91=51.81; ηp2=0.36; P=.01), satisfaction (t95=-2.05; F2,91=26.63; ηp2=0.20; P=.04) related to sleep, and mental health outcomes, including depression (t95=2.11; F2,94=29.64; ηp2=0.21; P=.04) and quality of life (t95=-3.13; F2,94=54.20; ηp2=0.33; P=.002), compared to the SHE group after the intervention. The attrition rate in the Somzz group was 12% (6/49).

CONCLUSIONS

Somzz outperformed SHE in improving insomnia, mental health, and quality of life. The MCBTi can be a highly accessible, time-efficient, and effective treatment option for chronic insomnia, with high compliance.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS) KCT0007292; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=22214&search_page=L.

How is cognitive behavioural therapy for insomnia delivered to adults with comorbid persistent musculoskeletal pain and disordered sleep? A scoping review

BACKGROUND

Disordered sleep and persistent musculoskeletal pain are highly comorbid. Behavioural interventions such as Cognitive Behavioural Therapy for Insomnia (CBT-I) have shown promise in the management of both disordered sleep and persistent musculoskeletal pain. The aim of this review was to examine how CBT-I is delivered in randomised controlled trials involving people with comorbid disordered sleep and persistent musculoskeletal pain.

METHODS

The protocol for this scoping review was registered with the Open Science Framework. Electronic searches of ten database and three clinical trials registries were performed up to 25 October 2023. The methodological quality of each study was evaluated by two independent reviewers using the PEDro tool. The reporting of CBT-I interventions was evaluated using the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Twelve studies met the eligibility criteria. TIDieR scores ranged from 7-11/12, with a mean score of 8.8/12. CBT-I always involved two core components-sleep restriction and stimulus control. Furthermore, an additional five components were usually involved-a cognitive component, sleep hygiene, sleep education, relaxation/deactivation procedures and relapse planning. There was also considerable consistency in the frequency (weekly) and duration (5-9 weeks) of CBT-I programmes. Aspects inconsistently reported included who delivered the intervention; what modifications were made, if any; and the session content and duration. PEDro scores ranged from 5-8/10, with a mean score of 6.7/10.

CONCLUSIONS

These findings demonstrate considerable consistency in the components of CBT-I delivered in clinical trials along with the number of sessions. The frequency of sessions was also consistent where almost all studies held weekly session. However, some aspects were either not reported (e.g., precise content of components) or inconsistent (e.g., use of terminology). CBT-I was delivered both individually and in groups. Greater consistency, and more detailed reporting regarding who delivered the intervention, the training provided, and the specific content of CBT-I components would add clarity, and may enhance CBT-I efficacy and allow better replication.

Efficacy and safety of electroacupuncture for insomnia: A systematic review and meta-analysis

BACKGROUND

Electroacupuncture is often used to treat insomnia.

OBJECTIVE

To evaluate the efficacy and safety of electroacupuncture for insomnia.

SEARCH STRATEGY

Databases including PubMed, Cochrane Library, Embase, Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wanfang Data and VIP Full-text e-Journals Database were searched up to January 15, 2023.

INCLUSION CRITERIA

Randomized clinical trials were included if they compared the clinical efficacy and safety of electroacupuncture with sham acupuncture, no treatment or usual care (UC) and general acupuncture.

DATA EXTRACTION AND ANALYSIS

The full texts of the studies were reviewed to remove ineligible literature. The extracted data included authors, publication year, diagnostic criteria, sample size, population characteristics, interventions and outcomes. The above steps were performed independently by two reviewers and the data were cross-checked. Stata15.0 software was used to analyze the extracted outcome data. For continuous data (Pittsburgh Sleep Quality Index [PSQI] score and Insomnia Severity Index score), weighted mean difference (WMD) was calculated and 95% confidence interval (CI) was reported when the same scale was applied. For dichotomous variables (clinical response rate and adverse events), a meta-analysis was performed using risk ratio (RR) as the effect indicator.

RESULTS

Thirty-one trials with 2226 subjects were included. The meta-analysis suggested that electroacupuncture was more effective in improving insomnia compared with the control group (sham acupuncture, no treatment, UC and general acupuncture) (RR = 1.21; 95% CI: [1.16, 1.27]), significantly reducing the PSQI score in insomnia patients after treatment and at follow-up (WMD = -3.23; 95% CI: [-4.29, -2.17]; P < 0.001). There was no significant difference in the incidence of adverse events between the EA and control groups (sham acupuncture and no treatment or UC. RR = 1.48; 95% CI: [0.91, 2.40]; P = 0.117). In addition, the regression results revealed that receiving electroacupuncture for seven to nine weeks provided the best efficacy (P < 0.05).

CONCLUSION

Electroacupuncture can significantly promote better sleep quality in insomnia patients and is suitable for the treatment of various types of insomnia. However, the articles included were single-center trials with small sample sizes, and some articles were of poor quality. Therefore, further research is still needed to confirm these findings. Please cite this article as: Xu HY, Wu LN, Zhang Y, Ba T, Zhao XF. Efficacy and safety of electroacupuncture for insomnia: A systematic review and meta-analysis. J Integr Med. 2024; 22(4): 460-473.

Daytime sleepiness in insomnia: Are we focusing on what truly matters?

Insomnia, the most prevalent sleep disorder, is commonly associated with other mental and somatic disorders, making it a significant health concern. It is characterized by nighttime symptoms and daytime dysfunction, with sleepiness being a potential criterion for the latter. Sleepiness is a normal physiological state that is typically experienced near usual bedtime, in normal circumstances. In insomnia, it seems somewhat logical the idea that there is significant daytime sleepiness. However, the topic has been the subject of various discussions in sleep medicine, with studies yielding contradictory and inconsistent results. In this article, we aim to critically examine daytime sleepiness in individuals with insomnia disorder and propose an alternative approach to addressing it, both in clinical practice and research settings. It is crucial to further investigate the role of daytime sleepiness in insomnia, particularly by focusing on sleepiness perception as a more relevant dimension to explore in majority of patients. It is plausible that certain insomnia phenotypes are objectively sleepy during the day, but more studies are necessary, particularly with well-defined clinical samples. The implications of assessing sleepiness perception in insomnia for clinical practice are discussed, and new avenues for research are suggested.

Knowledge, attitude and practice towards insomnia and sleep hygiene among patients with chronic insomnia in Northwest China in 2023: a cross-sectional survey

OBJECTIVES

To investigate the knowledge, attitude and practice (KAP) towards insomnia and sleep hygiene among patients with chronic insomnia.

DESIGN

Web-based cross-sectional survey.

SETTING

Shaanxi Provincial People's Hospital (northwest China) between January 2023 and May 2023.

PARTICIPANTS

Patients with chronic insomnia.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic characteristics and KAP towards insomnia and sleep hygiene were collected by distributing a questionnaire developed by the authors.

RESULTS

A total of 613 people participated in this study, with a Mean Knowledge Score of 7.63±2.56 (total score of 12), a Mean Attitude Score of 48.39±6.643 (total score of 70) and a Mean Practice Score of 42.37±8.592 (total score of 70). Knowledge was significantly correlated with attitude (r=0.447, p<0.001) and practice (r=0.327, p<0.001), and attitude was significantly correlated with practice (r=0.486, p<0.001). Multivariable logistic regression showed that higher knowledge (OR=1.181 (1.062-1.314), p=0.002) and better attitude (OR=1.171 (1.124-1.221), p<0.001) were independently associated with good practice. According to the structural equation modelling analysis, knowledge directly influenced practice (β=0.457, p=<0.001) and attitude (β=1.160, p=<0.001), while attitude influenced practice (β=0.550, p=<0.001).

CONCLUSION

The KAP towards insomnia and sleep hygiene among patients with chronic insomnia in Northwest China in 2023 was moderate, with better practice showing signs of being influenced by better knowledge and more positive attitudes.

Treatment strategies for insomnia in Japanese primary care physicians' practice: A Web-based questionnaire survey

BACKGROUND

It is unclear how primary care physicians manage insomnia after the introduction of novel hypnotics such as orexin receptor antagonists and melatonin receptor agonists. This Web-based questionnaire survey aimed to examine treatment strategies for insomnia in Japanese primary care practice.

METHODS

One-hundred-and-seventeen primary care physicians were surveyed on the familiarity of each management option for insomnia on a binary response scale (0 = "unfamiliar"; 1 = "familiar") and how they managed insomnia using a nine-point Likert scale (1 = "I never prescribe/perform it"; 9 = "I often prescribe/perform it"). Physicians who were unfamiliar with a management option were deemed to have never prescribed or performed it.

RESULTS

Regarding medication, most physicians were familiar with novel hypnotics. Suvorexant was the most used hypnotic, followed by lemborexant and ramelteon. These novel hypnotics averaged 4.8-5.4 points and 4.0-4.7 points for sleep onset and sleep maintenance insomnia, respectively. By contrast, most benzodiazepines were seldom used below two points. Regarding psychotherapy, only approximately 40% of the physicians were familiar with cognitive behavioral therapy for insomnia (CBT-I) and they rarely implemented it, at an average of 1.5-1.6 points. More physicians were familiar with single-component psychotherapies (i.e., relaxation, sleep restriction therapy, and stimulus control) compared to CBT-I, and 48-74% of them implemented it slightly more often, with scores ranging from 2.6 to 3.4 points.

CONCLUSION

This study suggests that Japanese primary care physicians seldom use CBT-I to treat insomnia. In addition, they use novel sleep medications more frequently than benzodiazepines in terms of pharmacotherapy. The use and availability of CBT-I in Japanese primary care might be facilitated by: educating primary care physicians, implementing brief or digital CBT-I, and/or developing collaborations between primary care physicians and CBT-I specialists.

Association between sleep state misperception and bedtime behavior in patients with chronic insomnia

Previous studies on sleep state misperception have objectively evaluated sleep status in special environments using polysomnography. There is a paucity of data from studies that evaluated habitual sleep status in home environments. The present study aimed to investigate sleep state misperception in the home environment of patients with chronic insomnia using a lumbar-worn actigraphy to identify sleep habits associated with sleep state misperception severity. Thirty-one patients and 42 healthy volunteers were included in the insomnia and non-insomnia group, respectively. Participants recorded subjective assessments in sleep diaries, objective assessments with an actigraphy worn for 14 days, and self-assessments using questionnaires. Both groups had similar objective sleep ratings; however, insomnia group had significantly worse subjective ratings (total sleep time, wake after sleep onset, and sleep onset latency). A significant correlation was found between subjective and objective total sleep time scores in non-insomnia group but not in insomnia group. Insomnia group had earlier bedtimes, significantly longer bedtimes, and impaired daytime functioning (Sheehan Disability Scale score); additionally, they underestimated their total sleep time, particularly with earlier bedtimes and longer laying durations. Monitoring the sleep status and habits of individuals in home environments could be instrumental in identifying key points for targeted interventions on sleep hygiene and cognitive behavioral therapy for insomnia.

Investigating non-inferiority of internet-delivered versus face-to-face cognitive behavioural therapy for insomnia (CBT-I): a randomised controlled trial (iSleep well)

BACKGROUND

Insomnia is a highly prevalent disorder associated with numerous adverse health outcomes. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment by clinical guidelines but is accessible to only a minority of patients suffering from insomnia. Internet-delivered CBT-I (iCBT-I) could contribute to the widespread dissemination of this first-line treatment. As there is insufficient evidence regarding non-inferiority, this study directly aims to compare therapist-guided internet-delivered versus face-to-face CBT-I in terms of insomnia severity post-treatment. Furthermore, a health-economic evaluation will be conducted, and potential benefits and disadvantages of therapist-guided iCBT-I will be examined.

METHODS

This study protocol describes a randomised controlled two-arm parallel-group non-inferiority trial comparing therapist-guided iCBT-I with face-to-face CBT-I in routine clinical care. A total of 422 patients with insomnia disorder will be randomised and treated at 16 study centres throughout Germany. Outcomes will be assessed at baseline, 10 weeks after randomisation (post), and 6 months after randomisation (follow-up). The primary outcome is insomnia severity measured using the Insomnia Severity Index. Secondary outcomes include depression-related symptoms, quality of life, fatigue, physical activity, daylight exposure, adverse events related to treatment, and a health-economic evaluation. Finally, potential moderator variables and several descriptive and exploratory outcomes will be assessed (e.g. benefits and disadvantages of internet-delivered treatment).

DISCUSSION

The widespread implementation of CBT-I is a significant healthcare challenge. The non-inferiority of therapist-guided iCBT-I versus face-to-face CBT-I will be investigated in an adequately powered sample in routine clinical care, with the same therapeutic content and same level of therapist qualifications provided with both interventions. If this trial demonstrates the non-inferiority of therapist-guided iCBT-I, healthcare providers may be more confident recommending this treatment to their patients, contributing to the wider dissemination of CBT-I.

TRIAL REGISTRATION

Trial registration number in the German Clinical Trials Register: DRKS00028153 ( https://drks.de/search/de/trial/DRKS00028153 ). Registered on 16th May 2023.