The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Treatment effect heterogeneity of cognitive behavioral therapy for insomnia - A meta-analysis

Investigation of the heterogeneity of the treatment effect (HTE) might guide the optimization of cognitive behavioral therapy for insomnia (CBT-I). This study examined HTE in CBT-I thereby analyzing if treatment setting, control group, different CBT-I components, and patient characteristics drive HTE. Randomized controlled trials investigating CBT-I were included. Bayesian random effect meta-regressions were specified to examine variances between the intervention and control groups regarding post-treatment symptom severity. Subgroup analyses analyzing treatment setting and control groups and covariate analysis analyzing treatment components and patient characteristics were specified. No significant HTE in CBT-I was found for the overall data set, settings and control groups. The covariate analyses yielded significant results for baseline severity and the treatment component relaxation therapy. Thus, this study identified potential causes for HTE in CBT-I for the first time, showing that it might be worthwhile to further examine possibilities for precision medicine in CBT-I.

Daridorexant in Japanese patients with insomnia disorder: A phase 3, randomized, double-blind, placebo-controlled study

OBJECTIVE

This Phase 3 double-blind, placebo-controlled study evaluated the efficacy and safety of daridorexant in Japanese patients with insomnia disorder.

PATIENTS/METHODS

490 patients with insomnia disorder from 95 sites in Japan were randomized to daridorexant 50 mg (n = 163), 25 mg (n = 163) or placebo (n = 164) for 4 weeks, followed by a 7-day placebo run-out and a 30-day safety follow-up. The primary efficacy endpoints, in hierarchical order, were change from baseline at Week 4 in subjective total sleep time (sTST) and subjective latency to sleep onset (sLSO), for daridorexant 50 mg vs placebo. sTST and sLSO were also evaluated (secondary endpoints) for daridorexant 25 mg vs placebo. Safety endpoints included adverse events and next-morning sleepiness (Visual Analog Scale, VAS).

RESULTS

Daridorexant 50 mg significantly increased sTST and decreased sLSO versus placebo at Week 4 (least-squares mean difference [LSMD]: sTST 20.3 min [95 % CI 11.4, 29.2] p < 0.001; sLSO -10.7 min [-15.8, -5.5] p < 0.001). Daridorexant 25 mg also significantly improved both endpoints versus placebo (LSMD: sTST 9.2 min [0.3, 18.1] p = 0.042; sLSO -7.2 min [-12.3, -2.0] p = 0.006). Overall incidence of adverse events was similar across groups (50 mg: 22 %; 25 mg: 18 %; placebo 23 %); somnolence, the most common event, increased with increasing dose (50 mg: 6.8 %; 25 mg: 3.7 %; placebo 1.8 %). However, daridorexant did not increase VAS next-morning sleepiness. No rebound or withdrawal-related symptoms were observed after treatment discontinuation.

CONCLUSIONS

In Japanese patients with insomnia disorder, daridorexant (25 and 50 mg) was well tolerated and significantly improved subjective sleep outcomes, with no evidence of residual effects.

Sleep Disorders

AbstractThere are more than 90 recognized sleep disorders, many of which impair sleep and daytime function and adversely impact heath, well-being, and chronic disease risk. Unfortunately, many sleep disorders are undiagnosed or not managed effectively. This review describes how to identify, evaluate, and treat common sleep disorders.

Long-term safety and efficacy of daridorexant in Japanese patients with insomnia disorder

OBJECTIVE/BACKGROUND

The short-term efficacy and safety of daridorexant, a dual orexin receptor antagonist, has been demonstrated in Japanese patients with insomnia disorder. The objective of this study was to evaluate, in a non-overlapping patient population to the short-term study, the long-term safety and efficacy of daridorexant in Japanese patients with insomnia disorder.

PATIENTS/METHODS

In this Phase 3 open-label study conducted in Japan, 154 patients with insomnia disorder were randomized to daridorexant 50 mg (n = 102) or 25 mg (n = 52) for 52 weeks. The primary objective was to assess the safety and tolerability of daridorexant for up to 1 year. Secondary exploratory objectives were to evaluate the long-term efficacy of daridorexant on subjective sleep parameters (total sleep time, latency to sleep onset and wake after sleep onset) and daytime functioning (Insomnia Daytime Symptoms and Impacts Questionnaire).

RESULTS

The incidence of treatment-emergent adverse events (TEAEs) was 74 % and 58 % in the 50 mg and 25 mg groups respectively. No serious drug-related TEAEs were reported. Both doses improved next-morning sleepiness (Visual Analog Scale) throughout the study. Five adjudicated adverse events of special interest were reported; excessive daytime sleepiness (n = 1, 25 mg; n = 2, 50 mg), sleep paralysis (n = 1, 50 mg) and nightmare (n = 1, 25 mg). Improvements in sleep and daytime functioning were maintained from Week 2 (first assessment) through to Week 52 in both dose groups.

CONCLUSIONS

Up to 52-weeks, daridorexant was well tolerated with sustained improvement in sleep onset, sleep maintenance and daytime functioning, supporting its long-term use in Japanese patients with insomnia disorder.

Multi-level exploration of auricular acupuncture: from traditional Chinese medicine theory to modern medical application

As medical research advances and technology rapidly develops, auricular acupuncture has emerged as a point of growing interest. This paper delves into the intricate anatomy of auricular points, their significance and therapeutic principles in traditional Chinese medicine (TCM), and the underlying mechanisms of auricular acupuncture in contemporary medicine. The aim is to delve deeply into this ancient and mysterious medical tradition, unveiling its multi-layered mysteries in the field of neurostimulation. The anatomical structure of auricular points is complex and delicate, and their unique neurovascular network grants them a special status in neurostimulation therapy. Through exploration of these anatomical features, we not only comprehend the position of auricular points in TCM theory but also provide a profound foundation for their modern medical applications. Through systematic review, we synthesize insights from traditional Chinese medical theory for modern medical research. Building upon anatomical and classical theoretical foundations, we focus on the mechanisms of auricular acupuncture as a unique neurostimulation therapy. This field encompasses neuroregulation, pain management, psychological wellbeing, metabolic disorders, and immune modulation. The latest clinical research not only confirms the efficacy of auricular stimulation in alleviating pain symptoms and modulating metabolic diseases at the endocrine level but also underscores its potential role in regulating patients' psychological wellbeing. This article aims to promote a comprehensive understanding of auricular acupuncture by demonstrating its diverse applications and providing substantial evidence to support its broader adoption in clinical practice.

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.

From guidelines to bedside - insomnia treatment practices in South Korea: a nationwide cohort study

Background

Insomnia is a prevalent disorder that impacts quality of life and leads to significant economic costs. Treatment includes both non-medication and pharmacological interventions, with international guidelines recommending cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment.

Objective

To describe current insomnia treatment practices in South Korea, focusing on pharmacological and non-medication treatments, and to identify gaps in guideline implementation.

Methods

This cohort study used data from the Korea National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002 to 2019 and identified 18,003 patients newly diagnosed with insomnia between 2015 and 2019. This study analyzed treatment patterns and utilization rates.

Results

Of the 18,003 patients, 16,181 (89.9%) received pharmacological treatment, resulting in 35,638 prescriptions. Zolpidem (60%) and benzodiazepines (30-40%) were the most prescribed medications. Most patients were treated in clinics, with consistent dosages and increasing treatment lengths. Psychotherapy claims rose from 3.20% in 2015 to 9.14% in 2019, particularly in general hospitals (22.06% to 48.37%), but remained low in clinics (1.26% to 2.08%).

Conclusion

Pharmacological treatments dominate insomnia management in South Korea, with CBT-I being underutilized. Future efforts should focus on integrating non-pharmacological treatment into routine practice and exploring treatment risks and effectiveness based on patient demographics.

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.

Melatonin Bioavailability After Oral Administration of a New Delayed-Release Form in Healthy Male Volunteers

BACKGROUND

Two main types of galenic formulation, immediate release and prolonged release, have been developed to optimize melatonin bioavailability. We recently described the kinetic profile of a prolonged-release form generating a peak of plasma melatonin 1 h (Tmax) after intake, followed by a prolonged decay over time. We have developed a new oral form of melatonin with the aim of producing a melatonin peak several hours after intake.

OBJECTIVE

The objective is to investigate melatonin bioavailability after administration of this new delayed-release form (DR form).

METHODS

In this single-centre open-label study, 12 healthy male volunteers received one tablet of the DR form containing 1.9 mg melatonin, 10 mg zinc and 200 mg lemon balm extract (Melissa officinalis L aerial parts). Blood samples were collected for 12 h, beginning at 8:00 am. Plasma concentrations of melatonin and 6-sulfatoxymelatonin (6-SMT), the main hepatic melatonin metabolite, were determined by radioimmunoassay.

RESULTS

A progressive increase in plasma melatonin concentrations was observed from 20 min and a peak about 3 h after intake (Cmax 740 ± 824 pg/mL; Tmax 179 ± 60 min). Concentrations remained high between 140 and 220 min, the concentration remaining physiologically significant (over 100 pg/mL) up to 7 h after intake. The DR form was well tolerated.

CONCLUSIONS

The melatonin release profile was consistent with what was anticipated for the DR form. The DR form generated a 2 h delayed Tmax compared with a prolonged-release form previously evaluated. This suggests that the DR form is suitable for the treatment of certain sleep disorders such as short sleep duration or early awakening.

TRIAL REGISTRY

Registration number: NCT05419466.

Vividness of visual imagery is associated with the effect of relaxation response meditation training in elderly people with nonorganic insomnia: A randomized, double-blind, multi-center clinical trial

BACKGROUND

This study aims to explore the efficacy of Relaxation Response Meditation Training (RRMT) on elderly individuals with different levels of vividness of visual imagery.

METHODS

In this randomized controlled, double-blind, multi-center clinical trial, we recruited a total of 136 elderly individuals who were over 60 years with nonorganic sleep disorders to participate in a 4-week RRMT intervention from October 2020 to October 2022. The intervention occurred twice a week, totaling eight times. These individuals were divided into high and low groups based on the vividness of visual imagery, and then randomly assigned to either the control or intervention groups, as follows: low-visualizers intervention group (LI group); low-visualizers control group (LC group); high-visualizers intervention group (HI group); high-visualizers control group (HC group). Their social and psychological parameters were assessed before and after the intervention by the Pittsburgh Sleep Quality Index (PSQI), the Revised Piper's fatigue scale (RPFS), General well-being scale (GWB), and Satisfaction rating. The alpha waves of patients were also collected through electroencephalogram to assess their level of relaxation.

RESULTS

Compared to the LI group, the HI group had a greater reduction rate in the PSQI score [25.2 % (18.8 % to 31.7 %), P < 0∙001], shorter sleep latency (P = 0.001), lower frequency of sleep medication (P < 0.001), lower PSQI scores (P < 0.001), and higher GWB scores (P < 0.001). There were significant differences in all indicators in the HI group vs. HC group and in the LI group vs. LC group. In the first five relaxation training sessions, there was no statistically significant difference in the proportion of α waves between the LI group and the LC group; however, from the sixth session onward, we observed a statistically significant difference (t = 2.86, P = 0.019)，while The HI group and HC group showing significant differences in the first relaxation training session (t = 4.464, P < 0.001). There was a statistically significant difference in subjective satisfaction between the intervention group and the control group (x2 = 49.605, P < 0.001).

CONCLUSION

In this study, we found that most elderly people benefitted from RRMT regardless of their vividness of visual imagery. However, low-visualizers experienced slower and less effective results, so these patients may benefit more from alternative approaches.

A Comprehensive Assessment of Bedtime Routines and Strategies to Aid Sleep Onset in College Students: A Web-Based Survey

College students often experience sleep-wake alterations. Different factors can contribute to insomnia symptoms in this population. The present study aims at investigating pre-sleep behaviours and strategies used to aid sleep onset in young college students and their association with insomnia symptoms. A total of 548 Italian college students (mean age = 23.48 years, range = 19-30 years, 80.5% female) completed a web-based survey on pre-sleep behaviours and sleep-onset facilitators, insomnia symptoms and sleep hygiene, anxiety and depression, and coping strategies. The use of electronic devices at bedtime and as a sleep-onset facilitator was predominant. Students using specific behaviours as sleep-onset facilitators were characterised by more psychological difficulties and poorer sleep. In multivariable linear regression analysis, the frequency of using medications and melatonin, regardless of motivations, was associated with higher insomnia symptoms. The use of specific sleep-onset facilitators positively correlated with the severity of insomnia symptoms. Many students engage in behaviours that are considered sleep-interfering and that are often employed in an attempt to facilitate sleep onset without benefits. Overall, the motivational factors behind pre-sleep behaviours need to be addressed in preventive programs targeting young college students.

One-week inpatient cognitive behavioral therapy for insomnia: a retrospective study

Objective

To examine the effectiveness of one-week inpatient cognitive behavioral therapy for insomnia (CBT-I) in patients without severe mental disorders in the real-world setting to answer the research question "Can inpatient CBT-I be abbreviated?".

Methods

In this retrospective, single-group, pretest-posttest study, the clinical outcome data of 94 patients who underwent one-week inpatient CBT-I were collected. Self-report scale scores and hypnotic medication use were obtained at baseline and at the 3-month follow-up after therapy.

Results

CBT-I significantly improved insomnia severity (Z = -7.65, P < 0.001, Cohen's d = 1.34), anxiety (Z = -6.23, P < 0.001, Cohen's d = 1.02), depression (Z = -6.42, P < 0.001, Cohen's d = 1.06), daytime sleepiness (Z = -2.40, P = 0.016, Cohen's d = 0.35), and fatigue severity (Z = -5.54, P < 0.001, Cohen's d = 0.88) and reduced hypnotic medication use (χ2 = 33.62, P < 0.001). At the follow-up assessment, 58 patients (67.4%) had clinically meaningful changes in insomnia, and 51 patients (59.3%) met the criteria for insomnia remission.

Conclusion

The results of this preliminary study imply that one-week inpatient CBT-I may be an effective intervention for the treatment of insomnia in patients without severe mental disorders.

Melatonin targets the paraventricular thalamus to promote non-rapid eye movement sleep in C3H/HeJ mice

Melatonin (MLT) is an important circadian signal for sleep regulation, but the neural circuitries underlying the sleep-promoting effects of MLT are poorly understood. The paraventricular thalamus (PVT) is a critical thalamic area for wakefulness control and expresses MLT receptors, raising a possibility that PVT neurons may mediate the sleep-promoting effects of MLT. Here, we found that MLT receptors were densely expressed on PVT neurons and exhibited circadian-dependent variations in C3H/HeJ mice. Application of exogenous MLT decreased the excitability of PVT neurons, resulting in hyperpolarization of membrane potential and reduction of action potential firing. MLT also inhibited the spontaneous activity of PVT neurons at both population and single-neuron levels in freely behaving mice. Furthermore, pharmacological manipulations revealed that local infusion of exogeneous MLT into the PVT promoted non-rapid eye movement (NREM) sleep and increased NREM sleep duration, whereas MLT receptor antagonists decreased NREM sleep. Moreover, we found that selectively knocking down endogenous MLT receptors in the PVT decreased NREM sleep and correspondingly increased wakefulness, with particular changes shortly after the onset of the dark or light phase. Taken together, these results demonstrate that PVT is an important target of MLT for promoting NREM sleep.

Investigation of screening questions to identify insomnia in cancer patients

The high prevalence of insomnia in cancer patients leads to a significant reduction in the quality of life of those affected. A detailed record of symptoms therefore plays an essential role for further course of treatment. Which screening instruments enable identification of cancer patients with insomnia is the subject of this single-arm nonrandomized study. During the data collection period, cancer patients meeting the following criteria: self-reported tiredness and/or trouble falling or staying asleep or sleeping too much in an electronic patient-reported outcome measurement were enrolled. For further analysis, focus was placed on the Patient Health Questionnaire Depression Scale (PHQ-8), the Minimal Documentation System (MIDOS2) and the Insomnia Severity Index (ISI). Frequency, correlation, and variance analyses were conducted to identify likely predictors of insomnia. Our findings indicate a closer correlation between the screening question pertaining to sleep disorders and the ISI, compared to the question on tiredness and the ISI. The initial recording of sleep-related parameters plays an essential role for cancer patients in order to identify and treat modifiable factors as promptly as possible. For an initial assessment, we recommend asking about trouble falling or staying asleep or sleeping too much.

Data mining and safety analysis of dual orexin receptor antagonists (DORAs): a real-world pharmacovigilance study based on the FAERS database

Objective

Using the Food and Drug Administration Adverse Event Reporting System (FAERS) database, four signal detection methods were applied to mine adverse drug events (ADEs) related to use of dual orexin receptor antagonists (DORAs) to provide reference for safe clinical use.

Research design and Methods

Data collected from Q3rd 2014 to Q4th 2023 were obtained from the FAERS database. According to the preferred terminology (PT) and systematic organ classification (SOC) of MedDRA v.26.0, the reporting odds ratio (ROR), proportional reporting ratio (PRR), multi-item gamma Poisson shrinker (MGPS), and Bayesian confidence propagation neural network (BCPNN) were used to detect ADE signals.

Results

A total of 11,857 DORAs-related adverse reactions were detected, reported with suvorexant, lemborexant, and daridorexant as the main suspected drugs was 8717584, and 2556, respectively. A higher proportion of females than males were reported (57.27% vs. 33.04%). The top 20 positive PT signals from three DORAs showed that "sleep paralysis" ranked first. "Brain fog" was stronger following daridorexant but was not detected for the other two drugs, and "sleep sex" and "dyssomnia" were stronger in suvorexant but not in the other two drugs. Additionally, some PTs occurred that were not included in drug instructions, such as "hangover" and "hypnagogic hallucination."

Conclusion

In this study, four algorithms (ROR, PRR, BCPNN, and MGPS) were used to mine the safety signals of DORAs. We identified some potential ADE signals that can promote the rational use of DORAs and improve their safety.

Sleep Disorders in Adults with Intellectual Disability: Current Status and Future Directions

Purpose of Review

We performed a narrative review of the current knowledge in epidemiology, mechanisms, clinical presentation, and treatment of sleep disorders in adults with intellectual disability.

Recent Findings

Adults with Intellectual disability face significant mental and physical health disparities, including in sleep medicine. Despite sleep disorders having been identified as adversely affecting the health and quality of life of both adults with intellectual disabilities and their caregivers, the evidence base for assessment, diagnosis and treatment in this population remains under developed when compared to that of the general population. This review summarises the existing literature on insomnia, sleep disordered breathing, and other common sleep disorders in adults with intellectual disability. Emphasising the existing gaps in our understanding of sleep disorders in adults with intellectual disabilities, we propose strategies to address and mitigate these gaps.

Summary

Sleep disorders are common, yet frequently ignored in adults with intellectual disabilities. To address sleep health inequality gaps, future research should adopt tailored approaches, considering the heterogeneity within the intellectual disability population, including stratification by aetiology and health comorbidities. This is essential to improve the diagnostic accuracy and treatment of sleep disorders in adults with intellectual disability.

Chinese herbal medicine and acupuncture for insomnia in stroke patients: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Insomnia is highly prevalent in stroke patients; however, there is no ideal intervention. This systematic review examined the effect and safety of Chinese herbal medicine (CHM) and acupuncture on sleep in adults with stroke.

METHODS

Six databases were searched from inception to June 2023 to identify randomised controlled trials (RCTs). The primary outcome was Pittsburgh Sleep Quality Index (PSQI) scores. Risk of bias and evidence quality was assessed. A pairwise random-effect meta-analysis was performed.

RESULTS

A total of 54 RCTs published in 55 articles were finally included in the systematic review, including 35 of CHM and 19 of acupuncture therapies. Compared with placebo/sham procedure, CHM and acupuncture were more effective in improving PSQI scores. The evidence of moderate quality suggested that CHM outperformed benzodiazepine drugs (BZDs) while it presented an effect similar to that of non-BZDs in improving sleep quality. CHM and acupuncture also provided additional benefits to the patients treated with pharmacological agents alone. However, the evidence specific to individual CHM prescriptions lay in various factors and methodological quality, and the evidence on the comparative effectiveness between acupuncture and other therapies was conflicting or limited.

CONCLUSIONS

Overall, CHM and acupuncture used alone or in combination with pharmacotherapy can safely improve sleep in stroke patients with insomnia. In the future, RCTs on outstanding CHM prescriptions and the comparative effectiveness research between acupuncture and other therapies are needed.

REGISTRATION

PROSPERO No. CRD42020194029 and No. CRD42020194030.

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.

Exploring the relationship between response time sequence in scale answering process and severity of insomnia: A machine learning approach

Utilizing computer-based scales for cognitive and psychological evaluations allows for the collection of objective data, such as response time. This cross-sectional study investigates the significance of response time data in cognitive and psychological measures, with a specific focus on its role in evaluating sleep quality through the Insomnia Severity Index (ISI) scale. A mobile application was designed to administer scale tests and collect response time data from 2729 participants. We explored the relationship between symptom severity and response time. A machine learning model was developed to predict the presence of insomnia symptoms in participants using response time data. The result revealed a statistically significant difference (p < 0.01) in the total response time between participants with or without insomnia symptom. Furthermore, a strong correlation was observed between the severity of specific insomnia aspects and the response times at the individual questions level. The machine learning model demonstrated a high predictive Area Under the ROC Curve (AUROC) of 0.824 in predicting insomnia symptoms based on response time data. These findings highlight the potential utility of response time data to evaluate cognitive and psychological measures.

Establishing causal relationships between insomnia and gestational diabetes mellitus using Mendelian randomization

Background

Gestational diabetes mellitus (GDM) is a common condition observed globally, and previous studies have suggested a link between GDM and insomnia. The objective of this study was to elucidate the causative relationship between insomnia and GDM, and to investigate the influence of factors related to insomnia on GDM.

Methods

We performed bidirectional Mendelian randomization (MR) analyses using single nucleotide polymorphisms (SNPs) as genetic instruments for exposure and mediators, thereby minimizing bias due to confounding and reverse causation. The Cochran Q test was utilized for heterogeneity analysis, MR-Egger regression for pleiotropy assessment, and the leave-one-out method for evaluating the robustness of the results. Additionally, we determined the causal relationships between GDM and other factors such as coffee consumption, alcohol intake, and household income.

Results

Insomnia was positively associated with GDM, as indicated by 39 SNPs (OR = 1.27, 95 % CI 1.12-1.439, P-value = 0.008). Conversely, the MR analysis did not reveal any causal relationship between GDM and insomnia (OR = 1.032, 95 % CI 0.994-1.071, P-value = 0.99). Additionally, no causal relationship was observed between coffee consumption, alcohol intake, household income, and GDM (all P-values >0.05).

Conclusion

Our study indicates that insomnia elevates the risk of GDM, thereby establishing a causal link with GDM, independent of coffee consumption, alcohol intake, and household income.

Arginine vasopressin: Critical regulator of circadian homeostasis

Circadian rhythms optimally regulate numerous physiological processes in an organism and synchronize them with the external environment. The suprachiasmatic nucleus (SCN), the center of the circadian clock in mammals, is composed of multiple cell types that form a network that provides the basis for the remarkable stability of the circadian clock. Among the neuropeptides expressed in the SCN, arginine vasopressin (AVP) has attracted much attention because of its deep involvement in the function of circadian rhythms, as elucidated in particular by studies using genetically engineered mice. This review briefly summarizes the current knowledge on the peptidergic distribution and topographic neuronal organization in the SCN, the molecular mechanisms of the clock genes, and the relationship between the SCN and peripheral clocks. With respect to the physiological roles of AVP and AVP-expressing neurons, in addition to a sex-dependent action of AVP in the SCN, studies using AVP receptor knockout mice and mice genetically manipulated to alter the clock properties of AVP neurons are summarized here, highlighting its importance in maintaining circadian homeostasis and its potential as a target for therapeutic interventions.

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.

[Pharmacological treatment of posttraumatic stress disorder]

In addition to trauma-focussed psychotherapy, pharmacological treatment is often unavoidable, especially in patients with severe posttraumatic stress disorder (PTSD). As long as comorbid disorders do not dictate the pharmacotherapy approach, sertraline and paroxetine, along with other off-label prescribable substances approved in Germany, can be used for the treatment of PTSD. Venlafaxine, in particular, has shown good effectiveness in studies, whereas risperidone has shown lower effectiveness in augmentation. Overall, only a small to medium effect size is to be expected for all substances. Psychopharmacotherapy plays an important role in addressing sleep disorders, which are highly prevalent in PTSD. Treatment of trauma-related nightmares can be attempted with doxazosin or clonidine. In contrast, there are limited empirical data available for sleep disorders associated with PTSD, but the pharmacological treatment of insomnia can provide some guidance.

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.

Advancements in the physiopathological study of acupuncture treatment for insomnia: A review

Insomnia is a common sleep disorder that significantly impacts an individual's psychological and physical health, characterized by persistent difficulties in falling asleep, decreased sleep quality, and impaired daytime functioning. Traditional treatment approaches primarily rely on pharmacotherapy and behavioral therapy, yet not all patients benefit from these methods, and they often come with certain side effects. Thus, identifying safe and effective alternative or adjunctive treatments is of paramount importance. The purpose of this paper is to review the research progress on acupuncture in the treatment of insomnia and to explore the mechanisms by which acupuncture may treat insomnia through regulating neurotransmitters and nervous system, anti-inflammatory actions, and improving neuroplasticity, providing evidence to support the broad application of acupuncture in clinical practice.

An online behavioral self-help intervention rapidly improves acute insomnia severity and subjective mood during the coronavirus disease-2019 pandemic: a stratified randomized controlled trial

STUDY OBJECTIVES

Stressful life events, such as the coronavirus disease-2019 (COVID-19) pandemic, can cause acute insomnia. Cognitive behavioral therapy for acute insomnia is effective but is both time and resource-intensive. This study investigated if an online behavioral self-help intervention, which has been successfully used alongside sleep restriction for acute insomnia, reduced insomnia severity and improved mood in acute insomnia. This study also assessed good sleepers to explore if a "sleep vaccination" approach was feasible.

METHODS

In this online stratified randomized controlled trial, 344 participants (103 good sleepers and 241 participants with DSM-5 acute insomnia) were randomized to receive the intervention/no intervention (good sleepers) or intervention/intervention after 28 days (poor sleepers). Insomnia severity was assessed using the ISI (primary outcome), and anxiety and depression using the GAD-7/PHQ-9 (secondary outcomes) at baseline, 1 week, 1 month, and 3-month follow-up.

RESULTS

In people with acute insomnia, relative to baseline, there were significant reductions in ISI (dz = 1.17), GAD-7 (dz = 0.70), and PHQ-9 (dz = 0.60) scores at 1-week follow-up. ISI, GAD-7, and PHQ-9 scores were significantly lower at all follow-up time points, relative to baseline. Subjective diary-derived sleep continuity was unaffected. No beneficial effects on sleep or mood were observed in good sleepers.

CONCLUSIONS

An online behavioral self-help intervention rapidly reduces acute insomnia severity (within 1 week), and benefits mood in people with acute insomnia. These beneficial effects are maintained up to 3 months later. Although the use of the intervention is feasible in good sleepers, their subjective sleep was unaffected.

CLINICAL TRIAL REGISTRATION

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic; prospectively registered at ISRCTN on 8 April 2020 (identifier: ISRCTN43900695).

Promoting sleep health during pregnancy for enhancing women's health: a longitudinal randomized controlled trial combining biological, physiological and psychological measures, Maternal Outcome after THERapy for Sleep (MOTHERS)

BACKGROUND

Sleep is vital for maintaining individuals' physical and mental health and is particularly challenged during pregnancy. More than 70% of women during the gestational period report insomnia symptoms. Sleep dysfunction in the peripartum increases the risk for a cascade of negative health outcomes during late pregnancy, birth, and postpartum. While psychological interventions are considered the first line treatment for sleep difficulties, they are still scarcely offered during pregnancy and there is a lack of longitudinal research combining psychological and physiological indices.

METHODS

The present protocol outlines a randomized controlled trial aimed at testing the long-term effectiveness of an automatized digitalized psychoeducational intervention for insomnia for expectant mothers complaining insomnia symptoms without comorbidity. Outcomes include physiological, hormonal, and subjective indices of maternal psychopathology, stress, and emotional processes, and sleep and wellbeing of the family system. The trial is part of a longitudinal study evaluating expectant mothers from early pregnancy (within the 15th gestational week) to 6-months postpartum through 6 observational phases: baseline (BSL), 6- and 12-weeks from BSL (FU1-FU2), 2-to-4 weeks after delivery (FU3), and 3- and 6-months after delivery (FU4-5). We plan to recruit 38 women without sleep difficulties (Group A) and 76 women with sleep difficulties (Group B). Group B will be randomly assigned to digital psychological control intervention (B1) or experimental psychoeducational intervention targeting insomnia (B2). At 3 time points, an ecological-momentary-assessment (EMA) design will be used to collect data on sleep and emotions (diaries), sleep-wake parameters (actigraphy) and stress reactivity (salivary cortisol). We will also test the DNA methylation of genes involved in the stress response as biomarkers of prenatal poor sleep. Information on partner's insomnia symptoms and new-borns' sleep will be collected at each stage.

DISCUSSION

The proposed protocol aims at testing an easily accessible evidence-based psychoeducational intervention for expectant mothers to help them improving sleep, health, and wellbeing in the peripartum. The results could improve the understanding and management of sleep difficulties and peripartum depression.

TRIAL REGISTRATION

The study protocol has been registered on 22 April 2024 with ClinicalTrials.gov Protocol Registration and Results System (PRS), ID: NCT06379074.

PROTOCOL VERSION

April 23, 2024.

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.

The influence of sleep disorders on perioperative neurocognitive disorders among the elderly: A narrative review

This review comprehensively assesses the epidemiology, interaction, and impact on patient outcomes of perioperative sleep disorders (SD) and perioperative neurocognitive disorders (PND) in the elderly. The incidence of SD and PND during the perioperative period in older adults is alarmingly high, with SD significantly contributing to the occurrence of postoperative delirium. However, the clinical evidence linking SD to PND remains insufficient, despite substantial preclinical data. Therefore, this study focuses on the underlying mechanisms between SD and PND, underscoring that potential mechanisms driving SD-induced PND include uncontrolled central nervous inflammation, blood-brain barrier disruption, circadian rhythm disturbances, glial cell dysfunction, neuronal and synaptic abnormalities, impaired central metabolic waste clearance, gut microbiome dysbiosis, hippocampal oxidative stress, and altered brain network connectivity. Additionally, the review also evaluates the effectiveness of various sleep interventions, both pharmacological and nonpharmacological, in mitigating PND. Strategies such as earplugs, eye masks, restoring circadian rhythms, physical exercise, noninvasive brain stimulation, dexmedetomidine, and melatonin receptor agonists have shown efficacy in reducing PND incidence. The impact of other sleep-improvement drugs (e.g., orexin receptor antagonists) and methods (e.g., cognitive-behavioral therapy for insomnia) on PND is still unclear. However, certain drugs used for treating SD (e.g., antidepressants and first-generation antihistamines) may potentially aggravate PND. By providing valuable insights and references, this review aimed to enhance the understanding and management of PND in older adults based on SD.

Therapeutic potential of hypnotic herbal medicines: A comprehensive review

Insomnia affects millions of people worldwide, prompting considerable interest in herbal remedies for its treatment. This review aims to assess the therapeutic potential of such remedies for insomnia by analyzing current scientific evidence. The analysis identified several herbs, including Rosmarinus officinalis, Crocus sativus, Rosa damascena, Curcuma longa, Valeriana officinalis, Lactuca sativa, Portulaca oleracea, Citrus aurantium, Lippia citriodora, and Melissa officinalis, which show promise in improving overall sleep time, reducing sleep latency, and enhancing sleep quality. These plants act on the central nervous system, particularly the serotonergic and gamma-aminobutyric acid (GABA)ergic systems, promoting sedation and relaxation. However, further research is necessary to fully understand their mechanisms of action, optimal dosages, and treatment protocols. Combining herbal medicines with conventional treatments may offer an effective natural alternative for those seeking medication. Nevertheless, individuals should consult their healthcare provider before using herbal remedies for insomnia. While this review provides evidence supporting their use, additional high-quality studies are needed to firmly establish their clinical efficacy.

Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives

BACKGROUND

Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects.

METHODS

We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences.

RESULTS

The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

CONCLUSION

The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

Does valerian work for insomnia? An umbrella review of the evidence

Valerian is one of the most used herbal agents (phytotherapeutics) to manage sleep disturbances, in particular, sleep-onset difficulties in young adults. However, the evidence based on primary studies and systematic reviews that supports its use in this domain is weak or inconclusive. In the current study, an umbrella review was performed on the efficacy of valerian for sleep disturbances with a focus on insomnia. As such, only systematic reviews (with or without meta-analysis) were considered for this study. Systematic searches in PubMed, Web of Science, Scopus, Cochrane Database of Systematic Reviews, PROSPERO and CNKI databases retrieved 70 records. Only 8 articles were considered eligible for qualitative analysis. Overall, data suggested that valerian has a good safety profile, however, the results showed no evidence of efficacy for the treatment of insomnia. Moreover, valerian appears to be effective concerning subjective improvement of sleep quality, although its effectiveness has not been demonstrated with quantitative or objective measurements. Despite its widespread use and prescription by general practitioners, psychiatrists and other professionals, valerian does not have empirical support for insomnia. Further studies, in particular high quality randomized controlled trials, are highly recommended since there are scarce studies and the existing ones are quite heterogeneous and with low methodological quality. The implications of our findings for clinical practice are critically discussed.

Dimdazenil: First Approval

Dimdazenil (Junoenil®) is a small-molecule, oral, partial positive allosteric modulator of the gamma-aminobutyric acid (GABA)A receptor that is being developed by Zhejiang Jingxin Pharmaceutical in collaboration with Evotec for the treatment of insomnia. Dimdazenil is designed to overcome issues associated with full GABAA receptor agonists, such as tolerance, withdrawal symptoms and associated adverse effects. On 29 November 2023, dimdazenil oral capsules received approval in China for the short-term treatment of insomnia. This article summarizes the milestones in the development of dimdazenil leading to this first approval for insomnia.

Antipsychotic medications and sleep problems in patients with schizophrenia

BACKGROUND

Sleep problems are common and related to a worse quality of life in patients with schizophrenia. Almost all patients with schizophrenia use antipsychotic medications, which usually increase sleep. Still, the differences in subjective sleep outcomes between different antipsychotic medications are not entirely clear.

METHODS

This study assessed 5466 patients with schizophrenia and is part of the nationwide Finnish SUPER study. We examined how the five most common antipsychotic medications (clozapine, olanzapine, quetiapine, aripiprazole, and risperidone) associate with questionnaire-based sleep problems in logistic regression analyses, including head-to-head analyses between different antipsychotic medications. The sleep problems were difficulties initiating sleep, early morning awakenings, fatigue, poor sleep quality, short (≤6 h) and long sleep duration (≥10 h).

RESULTS

The average number of antipsychotic medications was 1.59 per patient. Clozapine was associated with long sleep duration (49.0 % of clozapine users vs 30.2 % of other patients, OR = 2.05, 95 % CI 1.83-2.30, p < .001). Olanzapine and risperidone were in head-to-head analyses associated with less sleep problems than patients using aripiprazole, quetiapine, or no antipsychotic medication. Aripiprazole and quetiapine were associated with more insomnia symptoms and poorer sleep quality. Patients without antipsychotic medications (N = 159) had poorer sleep quality than patients with antipsychotic use, and short sleep duration was common (21.5 % of patients not using antipsychotics vs 7.8 % of patients using antipsychotics, OR = 2.97, 95 % CI 1.98-4.44, p < .001).

CONCLUSIONS

Prevalence of sleep problems is markedly related to the antipsychotic medication the patient uses. These findings underline the importance of considering and assessing sleep problems when treating schizophrenia patients with antipsychotics.

Assessment and management of chronic insomnia disorder: an algorithm for primary care physicians

BACKGROUND

Primary care physicians often lack resources and training to correctly diagnose and manage chronic insomnia disorder. Tools supporting chronic insomnia diagnosis and management could fill this critical gap. A survey was conducted to understand insomnia disorder diagnosis and treatment practices among primary care physicians, and to evaluate a diagnosis and treatment algorithm on its use, to identify ways to optimize it specifically for these providers.

METHODS

A panel of experts developed an algorithm for diagnosing and treating chronic insomnia disorder, based on current guidelines and experience in clinical practice. An online survey was conducted with primary care physicians from France, Germany, Italy, Spain, and the United Kingdom, who treat chronic insomnia patients, between January and February 2023. A sub-sample of participants provided open-ended feedback on the algorithm and gave suggestions for improvements.

RESULTS

Overall, 106 primary care physicians completed the survey. Half (52%, 55/106) reported they did not regularly screen for insomnia and half (51%, 54/106) felt they did not have enough time to address patients' needs in relation to insomnia or trouble sleeping. The majority (87%,92/106) agreed the algorithm would help diagnose chronic insomnia patients and 82% (87/106) agreed the algorithm would help improve their clinical practice in relation to managing chronic insomnia. Suggestions for improvements were making the algorithm easier to read and use.

CONCLUSION

The algorithm developed for, and tested by, primary care physicians to diagnose and treat chronic insomnia disorder may offer significant benefits to providers and their patients through ensuring standardization of insomnia diagnosis and management.

Relationship Between Insomnia and Continued Outpatient Treatment in Psychiatric Patients

Purpose

Sleep plays an essential role in maintaining both physical and mental well-being. Many patients in psychiatric outpatient settings complain of insomnia. However, the causal relationship between insomnia and depressive symptoms in all mental illnesses remains unclear. Moreover, research on insomnia and the continuation of outpatient treatment is lacking. We hypothesize a high correlation between depression and insomnia among patients with diverse mental illnesses. Additionally, we posit that insomnia significantly influences the continuity of outpatient visits. To this end, we evaluated insomnia and depression symptoms in psychiatric patients both at their initial visit and one year later. We also examined factors related to insomnia at the outset and factors associated with the ongoing utilization of outpatient treatment.

Patients and Methods

The participants of the study consisted of patients who made their first visit to the outpatient department of psychiatry and neurology at Showa University East Hospital between June 1, 2021, and March 31, 2023, and who continued attending the outpatient clinic for one year. Clinical characteristics were assessed using the Self-rating Depression Scale (SDS) and the Athens Insomnia Scale (AIS).

Results

The study's findings were collected from a cohort of 1106 patients and revealed that more than 70% experienced insomnia at the time of their initial visit. In total 137 patients continued to receive outpatient treatment for one year, and their AIS scores improved from 9 points to 5 points. A multivariate analysis revealed that the SDS items of depressed mood and insomnia were confounding factors influencing AIS improvement.

Conclusion

Given that 70% of patients complained of insomnia at the time of their first visit and that sleep improved in many of the 12.4% of patients who continued to receive outpatient treatment for at least one year, the results suggest that sleep status is an important determinant of whether a patient continues to attend outpatient clinics.

Comparative Analysis of the Sedative and Hypnotic Effects among Various Parts of Zizyphus spinosus Hu and Their Chemical Analysis

Zizyphus spinosus Hu (ZS), as a "medicinal and food-homologous" plant, has been used for a long history. The study was to assess the sedative and hypnotic effects among various parts of ZS. The model, diazepam (DZP), ZS kernel (ZSS), ZS flesh (ZSF), and ZS husk (ZSKS) group occurred subsequent to the successful establishment of the para-chlorophenylalanine induced insomnia model via intraperitoneal injection. The latency and duration of sleep in mice in each group were recorded. The substance basis of various parts of ZS was analyzed by the UPLC-QTOF-MS technique. The results showed that relative to the model group, DZP, ZSS, ZSF, and ZSKS groups demonstrated shortened sleep latency (p < 0.05) and extended sleep duration (p < 0.01). The GABA, 5-HT, and BDNF levels were significantly upregulated in the brain tissues of the mice in the DZP, ZSF, and ZSS groups (p < 0.01). However, the improvement in ZSKS was non-significant. Additionally, the mRNA and protein expression levels of 5-HT1AR, GABAARα1, and BDNF in mice in the DZP, ZSS, and ZSF groups were significantly enhanced (p < 0.01). However, the improvement in the ZSKS group was insignificant (p < 0.05). The examination of the substance composition across different parts revealed that the shared chemical basis contributing to the sedative and hypnotic potency of different parts of ZS may involve the presence of compounds such as (1) magnoflorine, (8) betulinic acid, (9) ceanothic acid, and (10) alphitolic acid. It provides a basis for further elucidation of the substance basis responsible for the functional and medicinal effects of ZS.

The Role of Anxiety and Depression in Shaping the Sleep-Pain Connection in Patients with Nonspecific Chronic Spinal Pain and Comorbid Insomnia: A Cross-Sectional Analysis

(1) Background: This exploratory study aims to explore the relationship between nonspecific chronic spinal pain (nCSP) and insomnia symptoms, by examining the interconnections, strengths, and directional dependence of the symptoms. In addition, we aim to identify the key symptoms of the nCSP-insomnia relationship and shed light on the bidirectional nature of this relationship. (2) Methods: This study is a secondary analysis of the baseline data (cross-sectional) from a randomized controlled trial, which examined the added value of Cognitive Behavioral Therapy for Insomnia (CBT-I) combined with cognition-targeted exercise therapy, conducted in collaboration with the Universiteit Gent and Vrije Universiteit Brussel (Belgium). One hundred and twenty-three nCSP patients with comorbid insomnia were recruited through the participating hospitals, advertisements, announcements in local newspapers, pharmacies, publications from support groups, and primary care. To explore the interconnections and directionality between symptoms and the strengths of the relationships, we estimated a regularized Gaussian graphical model and a directed acyclic graph. (3) Results: We found only one direct, but weak, link between sleep and pain, namely, between average pain and difficulties maintaining sleep. (4) Conclusions: Despite the lack of strong direct links between sleep and pain, pain and sleep seem to be indirectly linked via anxiety and depression symptoms, acting as presumable mediators in the network of nCSP and comorbid insomnia. Furthermore, feeling slowed down and fatigue emerged as terminal nodes, implying their role as consequences of the network.

The effects of exercise on insomnia disorders: An umbrella review and network meta-analysis

OBJECTIVE

To summarize the evidence of various exercise modalities on population with insomnia disorders.

METHOD

PubMed, Embase, Cochrane Library, and Web of Science were searched for eligible studies published from inception to October 2022 and updated on September 2023. Systematic reviews with meta-analyses and randomized controlled trials designed to investigate the effect of various exercise modalities on population with insomnia were eligible.

RESULTS

A total of 4 SRs with (very) low methodological quality and 1034 participants in 10 network meta-analyses explored the association between different types and intensity exercise modalities with insomnia disorders. Various exercise modalities could significantly improve total sleep time and sleep quality and alleviate insomnia severity. Compared to passive control, moderate aerobic exercise, moderate aerobic exercise combined with light intensity strength and mind-body exercise can improve sleep efficiency and reduce wake after sleep onset by objectively measured. Moderate intensity strength, light intensity strength and mind-body exercise can improve sleep efficiency subjectively measured; mind-body exercise can reduce sleep onset latency and wake time after sleep onset, and increase total sleep time; moderate aerobic exercise can reduce sleep onset latency. Moderate intensity strength, light intensity strength, mind body exercise and moderate aerobic exercise combined with light intensity strength can the severity of insomnia and improv sleep quality.

CONCLUSION

Exercise had a positive effect on relief insomnia and improve sleep quality. Moderate aerobic exercise, mind-body exercise and moderate aerobic exercise combined with light intensity strength play an important role in improving the sleep quality in people with insomnia disorders.

Acceptance and Commitment Therapy, Combined with Bedtime Restriction, versus Cognitive Behavioral Therapy for Insomnia: A Randomized Controlled Pilot Trial

INTRODUCTION

Cognitive behavioral therapy for insomnia (CBT-I) is the current first-line treatment for insomnia. However, rates of nonresponse and nonremission are high and effects on quality of life are only small to moderate, indicating a need for novel treatment developments. We propose that Acceptance and Commitment Therapy (ACT) addresses core pathophysiological pathways of insomnia. ACT therefore has the potential to improve treatment efficacy when combined with bedtime restriction, the most effective component of CBT-I. The aim of this study was to compare the efficacy of ACT for insomnia combined with bedtime restriction (ACT-I) and CBT-I in improving insomnia severity and sleep-related quality of life.

METHODS

Sixty-three patients with insomnia disorder (mean age 52 years, 65% female, 35% male) were randomly assigned to receive either ACT-I or CBT-I in a group format. The primary outcomes were insomnia severity (Insomnia Severity Index) and sleep-related quality of life (Glasgow Sleep Impact Index). Outcomes were assessed before randomization (T0), directly after treatment (T1), and at 6-month follow-up (T2).

RESULTS

The results indicated significant, large pre-to-post improvements in both groups, for both primary and secondary outcomes. Improvements were maintained at the 6-month follow-up. However, there was no significant group by time interactions in linear mixed models, indicating an absence of differential efficacy. On a subjective treatment satisfaction scale, patients in the ACT-I group indicated significantly greater satisfaction with their improvement of several aspects of health including their energy level and work productivity.

CONCLUSIONS

The results suggest that ACT-I is feasible and effective, but not more effective than CBT-I for the improvement of insomnia severity and sleep-related quality of life. Future studies are needed to assess whether ACT-I is noninferior to CBT-I and to shed light on mechanisms of change in both treatments.

How patients with insomnia interpret and respond to the consensus sleep diary: a cognitive interview study

OBJECTIVE/BACKGROUND

The Consensus Sleep Diary (CSD) is widely used to assess subjective sleep. Psychometric evaluations and focus-groups support its validity and clinical usefulness, but further research into its validity is needed. The aim of the study was to evaluate a Swedish translation of the CSD regarding test content and response processes in patients with insomnia.

PATIENTS/METHODS

In connection with translating the CSD into Swedish, we used cognitive interviewing to evaluate test content and the response process, that is, how people make decisions when responding to survey items. Cognitive interviews were conducted with 13 primary health care patients with insomnia disorder (mean age, 49 years; SD 15.5). Iterative, reparative analysis was used to investigate test content. Descriptive deductive analysis was used to investigate interview transcripts for the themes of the cognitive model: comprehension, retrieval, decision process, and judgement. Together, the themes explain the response process when responding to a patient-reported outcome measure.

RESULTS

The overall comprehension of the CSD could be affected by poor adherence to the instructions (comprehension). Patients had difficulty with recall if they did not complete the diary immediately in the morning and just before bedtime (retrieval). They could have problems deciding how to respond to certain items because they imbued sleep-related concepts with extra meaning (decision process), and had trouble finding response alternatives nuanced enough to describe their experience of sleep and tiredness (judgement).

CONCLUSIONS

This study contributes knowledge on how the instrument is perceived and used by care-seeking patients with insomnia. In this context, the CSD exhibits known flaws such as memory lapses if the diary is not filled in directly in the morning. To increase the accuracy of patients' responses, therapists should support patients in reading the instructions.

Analysis of the correlation between immune cell characteristics and insomnia: a Mendelian randomization study

Insomnia, recognized as a prevalent sleep disorder, has garnered extensive attention within the realm of public health. Recent studies indicate a close interaction between the immune system and sleep; however, the specific mechanism remains not yet fully understood. Based on the publicly available Genome-Wide Association Study (GWAS) data, we used two-sample Mendelian randomization (MR) analyses to investigate the associations between 731 immune cell traits and insomnia risk. Five MR analysis methods and a comprehensive sensitivity analysis were used to evaluate the reliability of the results. In this study, we identified that 14 immune characteristics among four immune profiles [median fluorescence intensity (MFI), relative cell count (RC), absolute cell count (AC), and morphological parameters (MP)] demonstrated a significant causal association with insomnia. Specifically, eight immune cell characteristics were associated with an increased risk of insomnia, including CD11c+ monocyte% (P < 0.001), CD11c+ HLA DR++ monocyte% (P = 0.004), CD86+ plasmoid dendritic cell (DC) AC (P < 0.001), CD33br HLA DR+ CD14dim AC (P < 0.001), CD8dim AC (P = 0.002), CCR2 on CD14+ CD16- monocyte (P < 0.001), CD39 on monocyte (P < 0.001), and SSC-A on myeloid DC (P < 0.001). Six immune cell characteristics demonstrated protective effects against insomnia, including PB/PC %B cell (P < 0.001), CM CD4+% CD4+ (P < 0.001), T-cell AC (P < 0.001), BAFF-R on IgD- CD38br (P < 0.001), CD16-CD56 on HLA DR+ NK cells (P < 0.001), and CD14 on CD33br HLA DR+ CD14dim (P < 0.001). Our study established the correlation between immune cell characteristics and insomnia, offering a novel theoretical foundation for the concept of sleep-immune cross talk.NEW & NOTEWORTHY This study investigated the association between 731 immune cell characteristics and insomnia using Mendelian randomization, revealing that 14 immune cell characteristics across four groups of immune traits (MFI, RC, AC, and MP) have a significant and causal association with insomnia risk. Our results contribute to the understanding of the sleep-immune cross talk doctrine and offer a new theoretical basis for immune modulation in treating insomnia.

Neurophysiological Parameters Influencing Sleep-Wake Discrepancy in Insomnia Disorder: A Preliminary Analysis on Alpha Rhythm during Sleep Onset

Sleep state misperception (SSM) is a common issue in insomnia disorder (ID), causing a discrepancy between objective and subjective sleep/wake time estimation and increased daytime impairments. In this context, the hyperarousal theory assumes that sustained central nervous system activation contributes to the SSM. This study investigates factors influencing SSM during sleep latency (SL) and total sleep time (TST). Objective polysomnographic sleep variables (the alpha density index, latency-to-sleep stages and the first K-complex, and Rapid Eye Movement (REM) arousal density) and subjective sleep indices, taken from sleep diaries, were analyzed in 16 ID patients. Correlation analyses revealed a positive association between the degree of SL misperception (SLm) and the percentage of epochs that contained a visually scored stereotyped alpha rhythm during objective SL. A regression analysis showed that the REM arousal density and alpha density index significantly predicted TST misperception (TSTm). Furthermore, the degree of SLm was associated with an increased probability of transitioning from stage 1 of non-REM sleep to wakefulness during subjective SL. These findings support the role of hyperarousal in SSM and highlight the importance of alpha activity in unravelling the heterogeneous underpinnings of SSM.

[Management of patients with insomnia and polymorbidity. A draft of the clinical guidelines]

Insomnia is a serious and widespread public health problem, but is often undetected and patients do not receive needed treatment. Insomnia is often comorbid with other diseases and conditions, such as arterial hypertension, type 2 diabetes mellitus, pain syndromes, anxiety and depressive disorders, etc. A separate problem is drug-induced insomnia, when patients develop symptoms due to other diseases treatments. Insomnia has a negative effect on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and decreased quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so clinical guidelines draft for the evaluation and treatment of insomnia in multimorbid patients is proposed. Diagnostic methods are reviewed and recommendations are given for the treatment of acute and chronic insomnia and features of the treatment of insomnia in multimorbid patients. A clinical algorithm has been proposed to determine treatment tactics in multimorbid patients.

Epidemiology and burden of chronic insomnia disorder in Europe: an analysis of the 2020 National Health and Wellness Survey

INTRODUCTION

Chronic insomnia disorder (CID) is considered a significant worldwide public health concern; however, its exact burden is unknown. We estimate its prevalence across France, Germany, Italy, Spain, and the United Kingdom, and assess the economic and humanistic burden for a broader insomnia population.

METHODS

This retrospective, cross-sectional, observational study used 2020 National Health and Wellness Survey (NHWS) data. Patients reporting insomnia were characterized to define CID. Health-related quality of life (HRQoL), work productivity, and healthcare resource use (HCRU) outcomes were assessed in four cohorts according to insomnia diagnosis and treatment status and examined using multivariable analyses according to Insomnia Severity Index categories.

RESULTS

Among 62,319 respondents, 9,035 (21.2%) reported experiencing insomnia over the previous 12 months. CID prevalence rates were 5.5% to 6.7% across the five countries and 6.0% overall. HRQoL outcomes were persistently poorer in cohorts of patients diagnosed with insomnia than those with undiagnosed insomnia. Undiagnosed and treated insomnia patients reported the highest work presenteeism and total work productivity impairment and the highest number of emergency room and hospitalization visits than patients with insomnia (either treated or untreated). After adjusting for covariates, patients with severe insomnia reported significantly worse EQ-5D-5L utility scores, higher absenteeism and presenteeism rates, and more healthcare provider visits over the past 6 months than patients without insomnia (all p < 0.01).

CONCLUSIONS

Our prevalence rates for CID align with published literature. A diagnosis of insomnia, use of sleep medications, and severity of insomnia are associated with poor quality of life, loss of work productivity, and higher HCRU, confirming the high unmet need and substantial humanistic and economic burden of CID.