A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression

Depression and Anxiety Mediate the Association between Sleep Quality and Self-Rated Health in Healthcare Students

OBJECTIVES

This study aimed to investigate factors associated with sleep quality in healthcare students and to determine whether depressive and anxiety symptoms may explain some of the associations between sleep quality and self-rated health.

STUDY DESIGN

This is a cross-sectional study at wave one.

METHODS

A total of 637 healthcare students were recruited via a stratified random sampling method in Hangzhou, China. The Sleep Quality Questionnaire (SQQ) and the four-item Patient Health Questionnaire (PHQ-4) were used to assess sleep quality and depressive and anxiety symptoms, respectively. Self-rated health was assessed via a self-developed questionnaire of both physical and psychological health. Structural equation modeling was used to examine the direct and indirect effects of sleep quality on self-rated health through depressive and anxiety symptoms.

RESULTS

Students engaged in part-time employment (p = 0.022), with poor perceived employment prospects (p = 0.009), and who did not participate in recreational sports (p = 0.008) had worse sleep quality. Structural equation modeling revealed a significant total effect of sleep quality on self-rated health (b = 0.592, p < 0.001), a significant direct effect of both sleep quality and depressive and anxiety symptoms on self-rated health (b = 0.277, 95% CI: 0.032-0.522), and a significant indirect effect of sleep quality on self-rated health through depressive and anxiety symptoms (b = 0.315, 95% CI: 0.174-0.457).

CONCLUSIONS

Depressive and anxiety symptoms partially explain the association between sleep quality and self-rated health. Intervening upon sleep quality, depressive, and anxiety symptoms may bolster the self-rated health of healthcare students.

Poor Sleep Quality in Aging: The Association with Mental Health

Sleep disturbances are common in the elderly. A primary sleep disorder can result from the physiological decline of aging; however, secondary sleep problems result from various causes involving physical and mental health. Since little is known about the relationships between sleep quality and mental health in aging, the present study aims to understand how different aspects generally associated with sleep (e.g., psychological and physiological factors, and sleep medication) may predict poor sleep quality in different stages of the lifespan. Therefore, we conducted several analyses (ANOVAs, Pearson correlations, and linear regressions) to test the hypotheses of the study. Accordingly, from a pool of 180 participants (elderly, middle-aged, and young adults), 143 individuals with poor sleep quality were selected. Different predictive patterns in the three groups emerged. Specifically, the use of sleep medication associated with worse sleep conditions is predicted by poor sleep quality in the elderly and by depression in young adults. In contrast, worsening sleep quality is predicted by depression in middle-aged adults. Previous studies focused on the transitions from good to poor sleep quality, while this is the first study to have examined the features of poor sleep quality in aging, highlighting different sleep patterns across the lifespan. This evidence should be considered from a preventive perspective.

Lifestyle management in polycystic ovary syndrome - beyond diet and physical activity

Polycystic ovary syndrome (PCOS) is a common condition affecting reproductive-aged women with reproductive, metabolic and psychological consequences. Weight and lifestyle (diet, physical activity and behavioural) management are first-line therapy in international evidence-based guidelines for PCOS. While these recommend following population-level diet and physical activity guidelines, there is ongoing interest and research in the potential benefit of including psychological and sleep interventions, as well as a range of traditional, complimentary and integrative medicine (TCIM) approaches, for optimal management of PCOS. There is limited evidence to recommend a specific diet composition for PCOS with approaches including modifying protein, carbohydrate or fat quality or quantity generally having similar effects on the presentations of PCOS. With regards to physical activity, promising evidence supports the provision of vigorous aerobic exercise, which has been shown to improve body composition, cardiorespiratory fitness and insulin resistance. Psychological and sleep interventions are also important considerations, with women displaying poor emotional wellbeing and higher rates of clinical and subclinical sleep disturbance, potentially limiting their ability to make positive lifestyle change. While optimising sleep and emotional wellbeing may aid symptom management in PCOS, research exploring the efficacy of clinical interventions is lacking. Uptake of TCIM approaches, in particular supplement and herbal medicine use, by women with PCOS is growing. However, there is currently insufficient evidence to support integration into routine clinical practice. Research investigating inositol supplementation have produced the most promising findings, showing improved metabolic profiles and reduced hyperandrogenism. Findings for other supplements, herbal medicines, acupuncture and yoga is so far inconsistent, and to reduce heterogeneity more research in specific PCOS populations, (e.g. defined age and BMI ranges) and consistent approaches to intervention delivery, duration and comparators are needed. While there are a range of lifestyle components in addition to population-recommendations for diet and physical activity of potential benefit in PCOS, robust clinical trials are warranted to expand the relatively limited evidence-base regarding holistic lifestyle management. With consumer interest in holistic healthcare rising, healthcare providers will be required to broaden their knowledge pertaining to how these therapies can be safely and appropriately utilised as adjuncts to conventional medical management.

Teleworking Is Significantly Associated with Anxiety Symptoms and Sleep Disturbances among Paid Workers in the COVID-19 Era

Due to social distancing during COVID-19, teleworking has spread in Korea. Accordingly, the effects of teleworking on physical and mental health have emerged. We aim to determine the association between teleworking and mental health, including anxiety symptoms and sleep disturbance, in paid workers. The data of paid workers from the Sixth Korean Working Conditions Survey, collected between October 2020 and April 2021, were analyzed. Gender stratification analysis and propensity score matching were performed for variables relevant to sociodemographic and occupational characteristics. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for each sex were analyzed using multivariable logistic regression, adjusting for sociodemographic and occupational characteristics. Among 28,633 participants, analyses were performed for anxiety symptoms (teleworkers vs. non-teleworkers; men: 12.1% vs. 4.9%; women: 13.5% vs. 5.3%) and sleep disturbance (men: 33.6% vs. 21.3%; women: 39.7% vs. 25.3%). In male teleworkers, the AORs for anxiety symptoms and sleep disturbance were 1.86 (95% CI: 1.14-3.04) and 1.52 (95% CI: 1.10-2.11), respectively. In female teleworkers, the AORs for anxiety symptoms and sleep disturbance were 1.66 (95% CI: 1.13-2.43) and 1.65 (95% CI: 1.28-2.14), respectively. Our results emphasize the importance of mental health and the need for continuous education and care for teleworkers, given the rapid increase in teleworking.

The top 100 most cited papers in insomnia: A bibliometric analysis

Objective

The number of citations to a paper represents the weight of that work in a particular area of interest. Several highly cited papers are listed in the bibliometric analysis. This study aimed to identify and analyze the 100 most cited papers in insomnia research that might appeal to researchers and clinicians.

Methods

We reviewed the Web of Science (WOS) Core Collection database to identify articles from 1985 to 24 March 2022. The R bibliometric package was used to further analyze citation counts, authors, year of publication, source journal, geographical origin, subject, article type, and level of evidence. Word co-occurrence in 100 articles was visualized using VOS viewer software.

Results

A total of 44,654 manuscripts were searched on the Web of Science. Between 2001 and 2021, the top 100 influential manuscripts were published, with a total citation frequency of 38,463. The top countries and institutions contributing to the field were the U.S. and Duke University. Morin C.M. was the most productive author, ranking first in citations. Sleep had the highest number of manuscripts published in the top 100 (n = 31), followed by Sleep Medicine Reviews (n = 9). The most cited manuscript (Bastien et al., Sleep Medicine, 2001; 3,384 citations) reported clinical validation of the Insomnia Severity Index (ISI) as a brief screening indicator for insomnia and as an outcome indicator for treatment studies. Co-occurrence analyses suggest that psychiatric disorders combined with insomnia and cognitive behavioral therapy remain future research trends.

Conclusion

This study provides a detailed list of the most cited articles on insomnia. The analysis provides researchers and clinicians with a detailed overview of the most cited papers on insomnia over the past two decades. Notably, COVID-19, anxiety, depression, CBT, and sleep microstructure are potential areas of focus for future research.

An online tiered screening procedure to identify mental health problems among refugees

BACKGROUND

Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure.

METHODS

Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers.

RESULTS

The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%).

DISCUSSION

This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation.

[Insomnia in the context of affective disorders]

The article analyzes the current literature on the relationship of insomnia with affective disorders, in particular with depression and anxiety. Research shows that there is a strong multi-channel relationship between insomnia, depression, and anxiety, with insomnia being considered a risk factor for mood disorders more often than vice versa. The so-called insomnia paradox of bipolar disorder is described, the essence of which is that in manic episodes the frequency of insomnia is higher than in depressive episodes. The data of a network meta-analysis, which found an evidence base for the use of a variety of drugs used for the pharmacological treatment of insomnia in adults, are presented. Efficiency and convenience in taking the drug Valocordin-Doxylamine are noted.

Electroencephalographic Changes in Sleep During Acute and Subacute Phases After Sports-Related Concussion

Purpose

Little is known about sleep after a concussion, a form of mild traumatic brain injury. Given the importance of sleep for both maintaining brain health and recovery from injury, we sought to examine sleep acutely and subacutely after concussion.

Methods

Athletes who experienced a sports-related concussion were invited to participate. Participants underwent overnight sleep studies within 7 days of the concussion (acute phase), and again eight-weeks after the concussion (subacute phase). Changes in sleep from both the acute and subacute phases were compared to population normative values. Additionally, changes in sleep from acute to subacute phase were analysed.

Results

When compared to normative data, the acute and subacute phases of concussion showed longer total sleep time (p < 0.005) and fewer arousals (p < 0.005). The acute phase showed longer rapid eye movement sleep latency (p = 0.014). The subacute phase showed greater total sleep spent in Stage N3% (p = 0.046), increased sleep efficiency (p < 0.001), shorter sleep onset latency (p = 0.013), and reduced wake after sleep onset (p = 0.013). Compared to the acute phase, the subacute phase experienced improved sleep efficiency (p = 0.003), reduced wake after sleep onset (p = 0.02), and reduced latencies for both stage N3 sleep (p = 0.014) and rapid eye movement sleep (p = 0.006).

Conclusion

This study indicated sleep during both the acute and subacute phases of SRC was characterised by longer and less disrupted sleep, along with improvements in sleep from the acute to subacute phases of SRC.

Process model of emotion regulation-based digital intervention for emotional problems

Background

To address the lack of mental health practitioners in developing countries, the current study explored the feasibility of a newly developed self-guided digital intervention program TEA (training for emotional adaptation) in alleviating depressive and anxiety symptoms, as one of a few studies which adapted from theoretical models with effective intervention techniques.

Methods

The first part of this study involved 11 professional mental health practitioners giving feedback on the feasibility of the TEA; while the second part involved a mixed-method single-arm study with 32 participants recruited online, who went through the seven intervention sessions within 14 days. The questionnaires were collected before, after, 14 days after, and 30 days after intervention. Additionally, 10 participants were invited to semi-structured interviews regarding their suggestions.

Results

Practitioners thought that the TEA showed high professionalism (8.91/10) and is suitable for treating emotional symptoms (8.09/10). The generalized estimating equation model showed that the TEA significantly reduced participants' depressive and anxiety symptoms, while the effects of the intervention remained 30 days post intervention (Cohen's d > 1). Thematic analysis revealed three main themes about future improvement, including content improvement, interaction improvement, and bug-fixing.

Conclusions

To address the current needs for digital mental health intervention programs to account for the insufficient availability of mental health services in China, the current study provides preliminary evidence of the effectiveness of TEA, with the potential to address the urgent need for remote mental health services.

Trial registration

The study was registered at the Chinese Clinical Trial Register (ChiCTR), with number [ChiCTR2200065944].

Examining the Impact of Different Components of Sleep Quality on Anxiety Among Family Carers of People with Dementia

Existing interventions for family carers of people with dementia tend to be less effective for anxiety than for depression. Therefore, identifying factors affecting carer anxiety is important to inform future interventions. This study conducted 2 multiple regression analyses using a sample of 91 family carers. The first regression model (∆R² = .24), exploring the impact of demographic variables and carer stressors, demonstrated that hours of caring (β = .33) and overall sleep quality (β = .28) were significant predictors of anxiety. To further investigate the impact of sleep quality, the second model (∆R² = .24) focussed on exploring the differential impact of various components of sleep quality on anxiety. Findings demonstrated that subjective sleep quality (β = .33) and sleep disturbances (β = .22) were significant predictors. Hours of caring per week, subjective sleep quality and sleep disturbances seem to be critical for treating anxiety in family carers. Future studies should investigate whether targeting these variables could improve carer anxiety.

Effect of mindfulness on anxiety and depression in insomnia patients: A systematic review and meta-analysis

Background

As a common clinical symptom, insomnia has a high incidence of combined mental illness and it is also a risk factor for the development of depression, anxiety and suicide. As a new concept in the field of health in recent years, mindfulness therapy can improve insomnia, anxiety and depression, which is a new way to solve such diseases.

Objective

This study aims to systematically evaluate the effects of mindfulness compared with conventional treatment on scores of the Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) in people with insomnia and anxiety-depressive symptoms.

Methods

Articles published before October 2022 were searched from seven databases and included in randomized controlled trials (RCTs) to evaluate mindfulness therapy. The assessment tool of Cochrane bias risk was used to evaluate the methodological quality of the literature. The main outcome indicators were HAMD and HAMA scores, and the secondary outcome indicators were SDS and SAS scores.

Results

Ten randomized controlled trials including 1,058 subjects were systematically evaluated and meta-analyzed in this study. In the main outcome indicators, there was a significant difference between mindfulness therapy and conventional treatment in reducing HAMD score (MD: -3.67, 95% CI: -5.22-2.11, p < 0.01) and HAMA score (MD: -3.23, 95% CI: -3.90-2.57, p < 0.01). In the secondary outcome indicators, mindfulness therapy also showed a significant difference in reducing SDS scores (MD: -6.49, 95% CI: -6.86-6.11, p < 0.01) and SAS scores (MD: -7.97, 95% CI: -9.68-6.27, p < 0.01) compared with conventional treatment.

Conclusion

For the people with insomnia, anxiety and depression, the use of conventional treatment with the addition of 4-12 weeks of mindfulness treatment can significantly improve anxiety and depression symptoms of patients. This is a new diagnosis and treatment idea recommended for insomniacs with or without anxiety and depression symptoms. Due to the methodological defects in the included study and the limited sample size of this paper, more well-designed randomized controlled trials are needed for verification.

Embedding digital sleep health into primary care practice: A triangulation of perspectives from general practitioners, nurses, and pharmacists

Introduction

While digital health interventions (DHIs) can potentially address the unmet needs for sleep health services, little is known about their implementation in practice. The current study aimed to explore primary care health providers' attitudes and beliefs towards DHIs for sleep and implementation into practice.

Methods

A cross-sectional online survey was administered to Australian primary care health professionals: general practitioners (GPs), community nurses, and community pharmacists. Semi-structured interviews were conducted within a sub-sample of participants exploring their experiences with DHIs and perceived barriers/facilitators for embedding DHIs into primary care. Semi-structured interviews were thematically analysed using the framework approach to contextualise survey findings.

Results

Ninety-six surveys were returned (GPs  =  36, nurses = 30, and pharmacists = 30) and 45 interviews conducted (GPs  =  17, nurses = 14, and pharmacists  =  14). From the survey, GPs were more likely to endorse familiarity (p  =  0.009) and use (p < 0.001) of sleep DHIs in clinical practice than pharmacists and nurses. GPs were more interested in utilising the diagnostic features within a sleep DHI (p  =  0.009) compared to other professionals. Thematic analysis of the interviews revealed three major themes, contextualised by profession: (1) Scope for DHIs in Current Practice, (2) Practice Gaps and Training Needs, and (3) Envisioning a Model of Care Using Sleep DHIs. While DHIs can potentially improve care, greater clarity of care pathways and reimbursement structures are needed for integration into practice.

Conclusion

Primary care health professionals highlighted the training, care pathway and financial models required to realise the potential for translating findings from efficacy studies for DHIs into primary care to optimise sleep health.

COVID-19-related social isolation and symptoms of depression and anxiety in young men in Poland: Does insomnia mediate the relationship?

The need for physical distancing due to COVID-19 mitigation efforts forced prolonged social isolation, which may affect sleep and lead to mental health problems. Previous research has shown that young adults are particularly vulnerable to psychological stress caused by social isolation, the negative psychological impact of the pandemic, and greater frequency and severity of sleep problems. Therefore, the main goal of the present study was to examine whether insomnia could constitute a mediation mechanism that explains the relationship between social isolation experienced during the COVID-19 pandemic and mental health outcomes (depression and anxiety) reported up to 1.5 years later. The study was conducted among young (M±SD; 24.08±3.75) men (N = 1025) in Poland. Data were collected by means of self-report questionnaires, including The Social Isolation Index, The Athens Insomnia Scale, The State-Trait Anxiety Inventory (STAI-S) and Beck's Depression Inventory (BDI-II). The results show that insomnia mediates the relationships between social isolation and both anxiety and depression. The current findings emphasize the role of insomnia in the relationships between social isolation experienced during COVID-19 and negative emotional states. From a clinical perspective, the results suggest that implementing therapeutic components that address social isolation in insomnia treatment programs may prevent the development of depression and anxiety symptoms among young men.

The Case for the Patient-Centric Development of Novel Digital Sleep Assessment Tools in Major Depressive Disorder

Background

Depression imposes a major burden on public health as the leading cause of disability worldwide. Sleep disturbance is a core symptom of depression that affects the vast majority of patients. Nonetheless, it is frequently not resolved by depression treatment and may even be worsened through some pharmaceutical interventions. Disturbed sleep negatively impact patients' quality of life, and persistent sleep disturbance increases the risk of recurrence, relapse, and even suicide. However, the development of novel treatments that might improve sleep problems is hindered by the lack of reliable low-burden objective measures that can adequately assess disturbed sleep in this population.

Summary

Developing improved digital measurement tools that are fit for use in clinical trials for major depressive disorder could promote the inclusion of sleep as a focus for treatment, clinical drug development, and research. This perspective piece explores the path toward the development of novel digital measures, reviews the existing evidence on the meaningfulness of sleep in depression, and summarizes existing methods of sleep assessments, including the use of digital health technologies.

Key Messages

Our objective was to make a clear call to action and path forward for the qualification of new digital outcome measures which would enable assessment of sleep disturbance as an aspect of health that truly matters to patients, promoting sleep as an important outcome for clinical development, and ultimately ensure that disturbed sleep will not remain the forgotten symptom of depression.

Recent advances in sleep and depression

PURPOSE OF REVIEW

There is increasing interest in the connection between sleep disturbances and mood disorders. The purpose of this review is to summarize and evaluate current research on the role of sleep disturbance in the development of depression, as well as to describe recent advances in treatments that improve both sleep and depression symptoms.

RECENT FINDINGS

Relevant publications included in this review cover a wide range of topics related to sleep and depression. Data from large longitudinal studies suggest that insomnia and evening circadian preference are unique risk factors for depression. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances. A few recent trials of cognitive behavioral therapy for insomnia and triple chronotherapy in unipolar depression have shown promising results.

SUMMARY

Sleep disturbance is a modifiable risk factor in the development and maintenance of depression. In the context of current depression, although the data is mixed, some evidence suggests treating sleep disturbance can improve overall outcomes. Recent evidence also suggests that treating sleep disturbance may prevent the future depressive episodes.

Short sleep duration is associated with a wide variety of medical conditions among United States military service members

OBJECTIVES

This cross-sectional study investigated self-reported sleep duration and its association with a comprehensive range of clinically-diagnosed medical condition categories (CDMCs), as well as the relationship between short sleep duration (≤6 h) and demographic/lifestyle factors, among United States military service members (SMs).

METHODS

A stratified random sample of SMs (n = 20,819) completed an online questionnaire on usual daily hours of sleep and demographic/lifestyle characteristics. CDMCs for a six-month period prior to questionnaire completion were obtained from a comprehensive military electronic medical surveillance system and grouped into 33 CDMCs covering both broad and specific medical conditions. Prevalence of CDMCs was compared among three sleep duration categories (≤4, 5-6 and ≥7 h).

RESULTS

SMs reported a mean ± standard deviation of 6.3 ± 1.4 h of sleep per day. After adjustment for demographic/lifestyle characteristics, shorter sleep duration was associated with higher odds of a medical condition in 25 of 33 CDMCs, with most (n = 20) demonstrating a dose-response relationship. The five CDMCs with the largest differences between ≤4 vs ≥ 7 h sleep were: diseases of the nervous system (odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 2.4-3.4), mental/behavioral diseases (OR = 2.7, 95%CI = 2.3-3.2), diseases of the musculoskeletal system (OR = 1.9, 95%CI = 1.6-2.1), diseases of the circulatory system (OR = 1.7, 95%CI = 1.3-2.2), and diseases of the digestive system (OR = 1.6, 95%CI = 1.2-2.0). Six hours of sleep or less was independently associated with older age, less formal education, race, Hispanic ethnicity, higher body mass index, smoking, and military service branch.

CONCLUSIONS

In this young, physically active population, reporting shorter sleep duration was associated with a higher risk of multiple CDMCs.

The economic costs of insomnia comorbid with depression and anxiety disorders: an observational study at a sleep clinic in Mexico

Significant advances documenting the costs associated with insomnia have been achieved. However, those related to insomnia associated with mood disorders remain understudied, even though insomnia is more severe in the presence of comorbid conditions such as depression and anxiety. The aim of this study was to determine the direct and indirect costs of insomnia associated with depression and anxiety disorders (DAD) from the perspective of the patient in a private healthcare system. This was an observational study of chronic insomnia associated with DAD at a private Sleep Disorders Clinic in Mexico City between 2019 and 2020. Patients were followed for up to one year. Healthcare resource utilization data were collected through clinical records. Direct and indirect costs associated with insomnia treatment were estimated through micro-costing. The estimated economic burden was projected to 5 years adjusting for inflation and discounting future costs. A deterministic sensitivity analysis was performed. The median cost of the first year of insomnia treatment associated with DAD was US$3537.57 per patient. The work productivity loss represented the highest economic burden (63.84%) followed by direct medical costs (28.32%), and the direct non-medical costs (7.85%). The estimated annual economic burden for patients treated in the private healthcare system in Mexico was US$293 million. The costs of insomnia associated with DAD at a private clinic in México were found to be high. The burden of the costs faced by these patients is substantial relative to the median income of the population. The economic costs at an individual and societal levels are substantial.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-022-00412-6.

Changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown: A systematic review and meta-analysis

Introduction

This systematic review and meta-analysis aims to explore changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown.

Methods

The protocol was registered in PROSPERO (CRD42021256378) and the PRISMA guidelines were followed. The major databases and gray literature were systematically searched from inception to 28/05/2021 to identify observational studies evaluating sleep changes in the general population during the lockdown with respect to the pre-lockdown period. A random effects meta-analysis was undertaken for studies reporting (a) the means of the Pittsburgh Sleep Quality Index (PSQI) global scores or the means of the sleep onset latency (SOL) times (minutes - min) before and during the lockdown, (b) the percentages of poor sleep quality before and during the lockdown, or (c) the percentages of changes in sleep quality. Subgroup analysis by risk of bias and measurement tool utilized was carried out. A narrative synthesis on sleep efficiency, sleep disturbances, insomnia and sleep medication consumption was also performed.

Results

Sixty-three studies were included. A decline in sleep quality, reflected in a pooled increase in the PSQI global scores (standardized mean difference (SMD) = 0.26; 95% CI 0.17-0.34) and in SOL (SMD = 0.38 min; 95% CI 0.30-0.45) were found. The percentage of individuals with poor sleep quality increased during the lockdown (pooled relative risk 1.4; 95% CI 1.24-1.61). Moreover, 57.3% (95% CI 50.01-61.55) of the individuals reported a change in sleep quality; in 37.3% (95% CI 34.27-40.39) of these, it was a worsening. The studies included in the systematic review reported a decrease in sleep efficiency and an increase in sleep disturbances, insomnia, and in sleep medication consumption.

Discussion

Timely interventions are warranted in view of the decline in sleep quality and the increase in sleep disturbances uncovered and their potentially negative impact on health. Further research and in particular longitudinal studies using validated instruments examining the long-term impact of the lockdown on sleep variables is needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256378, identifier CRD42021256378.

Insomnia in primary care: Considerations for screening, assessment, and management

Insomnia, including insomnia disorder, is a common but often overlooked complaint in primary care settings. It is a risk factor for various medical and psychiatric diagnoses and is associated with substantial health care costs. While cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia disorder, access to CBT-I is limited. This article provides a pragmatic approach to screening, assessment, and treatment of insomnia in the primary care setting, promoting a population health approach. The authors review the role of CBT-I, treatment of comorbid conditions, and pharmacologic recommendations in working with primary care patients with insomnia. In addition, the authors highlight the potential utility of technology in improving access to insomnia care.

Daily dynamics and mechanisms of anxious symptomatology in the general population: A network study during the COVID-19 pandemic

To understand the interplay between anxiety symptoms and their maintaining psychological processes in the population, an analysis of longitudinal within-person relationships is required. A sample of 1706 individuals completed daily measures during a 40-day period with strict mitigation protocols. Data of 1368 individuals who completed at least 30 assessments were analyzed with the multilevel vector autoregressive (mlVAR) model. This model estimates a temporal, a contemporaneous, and a between-person network. Uncontrollability of worry, generalized worry, fear of being infected, fear of significant others being infected, and threat monitoring had the highest outstrength within the temporal network, indicating that daily fluctuations in these components were the most predictive of next-day fluctuations in other components. Of specific connections, both fear of self and fear of close others being infected predicted generalized worry and threat monitoring. In turn, generalized worry and threat monitoring engaged in several positive feedback loops with other anxiety symptoms and processes. Also, intolerance of uncertainty was predictive of other components. The findings align with the mechanisms both in the metacognitive therapy (MCT) model and in the intolerance of uncertainty model of generalized anxiety disorder (GAD).

More time awake after sleep onset is linked to reduced ventral striatum response to rewards in youth with anxiety

BACKGROUND

Poor sleep and anxiety disorders are highly comorbid in youth, and each predicts altered ventral striatum (VS) response to rewards, which may impact mental health risk. Contrasting evidence suggests previously reported negative associations between sleep health and VS response may be stronger or weaker in youth with anxiety, indicating sensitivity to win/loss information or blunted reward processing, respectively. We cross-sectionally examined the role of sleep in VS response to rewards among youth with anxiety versus a no-psychiatric-diagnosis comparison (ND) group. We expected a group*sleep interaction on VS response to rewards but did not hypothesize directionality.

METHODS

As part of the pretreatment battery for a randomized clinical trial, 74 youth with anxiety and 31 ND youth (ages 9-14 years; n = 55 female) completed a monetary reward task during fMRI. During the same pretreatment window, actigraphy and diary-estimated sleep were collected over 5 days, and participants and their parents each reported participants' total sleep problems. We examined group*sleep interactions on VS response to monetary rewards versus losses via three mixed linear models corresponding to actigraphy, diary, and questionnaires, respectively.

RESULTS

Each model indicated group*sleep interactions on VS response to rewards. Actigraphy and diary-estimated time awake after sleep onset predicted reduced VS response in youth with anxiety but not ND youth. Parent-reported sleep problems similarly interacted with group, but simple slopes were nonsignificant.

CONCLUSIONS

Wake after sleep onset was associated with blunted reward response in youth with anxiety. These data suggest a potential pathway through which sleep could contribute to perturbed reward function and reward-related psychopathology (e.g., depression) in youth with anxiety.

Improving perinatal sleep via a scalable cognitive behavioural intervention: findings from a randomised controlled trial from pregnancy to 2 years postpartum

BACKGROUND

Sleep disturbance is common in gestational parents during pregnancy and postpartum periods. This study evaluated the feasibility and efficacy of a scalable cognitive behavioural therapy (CBT) sleep intervention tailored for these periods.

METHODS

This is a two-arm, parallel-group, single-blind, superiority randomised controlled trial. Nulliparous females without severe medical/psychiatric conditions were randomised 1:1 to CBT or attention- and time-matched control. All participants received a 1 h telephone session and automated multimedia emails from the third trimester until 6 months postpartum. Outcomes were assessed with validated instruments at gestation weeks 30 (baseline) and 35 (pregnancy endpoint), and postpartum months 1.5, 3, 6 (postpartum endpoint), 12 and 24.

RESULTS

In total, 163 eligible participants (age M ± s.d. = 33.35 ± 3.42) were randomised. The CBT intervention was well accepted, with no reported adverse effect. Intention-to-treat analyses showed that compared to control, receiving CBT was associated with lower insomnia severity and sleep disturbance (two primary outcomes), and lower sleep-related impairment at the pregnancy endpoint (p values ⩽ 0.001), as well as at 24 months postpartum (p ranges 0.012-0.052). Group differences across the first postpartum year were non-significant. Participants with elevated insomnia symptoms at baseline benefitted substantially more from CBT (v. control), including having significantly lower insomnia symptoms throughout the first postpartum year. Group differences in symptoms of depression or anxiety were non-significant.

CONCLUSIONS

A scalable CBT sleep intervention is efficacious in buffering against sleep disturbance during pregnancy and benefitted sleep at 2-year postpartum, especially for individuals with insomnia symptoms during pregnancy. The intervention holds promise for implementation into routine perinatal care.

Describing 24-hour movement behaviours among preconception and recently pregnant Canadian parents: who do we need to target?

This study aimed to describe adherence to 24-hour movement guidelines and determine factors associated with meeting guidelines in pregnancy planning and recently postpartum parents. A survey of preconception care attitudes and beliefs was conducted in Canadian adults who were pregnancy planning or ≤5 years postpartum. The Global Physical Activity Questionnaire was used to evaluate physical activity and sedentary time. Respondents reported the number of hours spent sleeping and using a screen per day. Multiple logistic regressions were run to determine factors (sociodemographic and health related) associated with meeting each individual movement guideline and number of guidelines met. 1080 females and 224 males provided survey data. 54.0% (n = 654) of the sample met the physical activity guideline, with no difference between females and males. More than 78.4% (n = 909) met the sedentary behavior guideline, 56.4% (n = 679) met the sleep guideline, and 15.4% (n = 187) met the screen time guideline. Only 5.0% (n = 60) of the sample met all four guidelines. Higher odds of meeting more guidelines were associated with parity and perceived health. Lower odds of meeting more guidelines were associated with obesity and overweight; and with depression. Most parents and parents-to-be are not meeting 24-hour movement guidelines. Interventions should focus on optimizing movement behaviors in the peri-partum period, while focusing on mental health, obesity, and general wellbeing.

Prevalence and associated factors of poor sleep quality among Chinese retirees: A multicenter cross-sectional study

BACKGROUND

Sleep problems are common among older adults worldwide. The present study aims to determine the prevalence of poor sleep quality and its independent factors among retired people in health check-ups population in China.

METHOD

In this multicenter, cross-sectional survey in 2017, a group of retired people was invited to participate in an online survey of health status, and their data, including socio-demographic information, lifestyle, and medical characteristics, were recorded. Binary logistic regression was used to analyze the independent factors responsible for poor sleep quality.

RESULTS

Data from 17,408 responders who met the inclusion criteria were analyzed; among them, 53.04 % (95 % CI = 52 %-54 %) reported poor sleep quality. Binary logistic regression showed that poor sleep quality was associated with a number of factors, including being female (OR = 1.42, 95 % CI = 1.32-1.53), being single (OR = 1.35, 95 % CI = 1.18-1.54), non-smoker (OR = 1.12, 95 % CI = 1.03-1.22), physical inactivity (OR = 1.14, 95 % CI = 1.05-1.23), poor self-rated health status (OR = 1.69, 95 % CI = 1.43-2.00), long-term medication use (OR = 1.05, 95 % CI = 1.07-1.23), chronic pain (OR = 1.33, 95 % CI = 1.22-1.45), comorbidity (OR = 1.16, 95 % CI = 1.07-1.25), and depressive symptoms (mild depression: OR = 2.14, 95 % CI = 1.96-2.34; moderate depression: OR = 4.00, 95 % CI = 3.49-4.58, moderately severe depression: OR = 4.15, 95 % CI = 3.47-4.97, severe depression: OR = 4.27, 95 % CI = 2.93-6.22); while age (OR = 0.99, 95 % CI = 0.99-1.00) was negatively related to poor sleep quality.

CONCLUSION

The prevalence of poor sleep quality in the studied population is relatively high (53.04 %). Sleep problems are common among Chinese retirees, especially older females, and have a great impact on their quality of life. People living with depression, chronic diseases, and chronic pain were at a higher risk of developing sleep disorders. Therefore, it is critical to formulate effective management strategies for Chinese retirees with poor sleep quality in the context of healthy aging.

Stress, mental ill-health and functional somatic syndromes in incident and chronic sleep disturbance in a general adult population

Objective

Sleep disturbance may constitute health problems for the afflicted individual, but documentation of its chronicity is sparse. The objective was to investigate the extent to which incident and chronic sleep disturbance are associated with stress, mental ill-health and functional somatic syndromes.

Design

This was a prospective, longitudinal study with 3-year interval between two assessments (T1 and T2), with a population-based sample forming groups with incident sleep disturbance (disturbance only at T2; n = 303), chronic sleep disturbance (disturbance at T1 and T2; n = 343) and without sleep disturbance (neither at T1 nor T2; n = 1421). Questionnaire data were used at T2 of physician-based diagnosis of anxiety disorder, depression, exhaustion syndrome, and functional somatic syndrome as well as of degree of stress, burnout, anxiety and depression.

Results

Significant associations were found between chronic sleep disturbance and all four diagnoses (odds ratios = 1.74-2.19), whereas incident sleep disturbance was associated only with exhaustion syndrome and depression (odds ratios = 2.18-2.37). Degree of stress, burnout, anxiety and depression increased significantly from the referents to incident and chronic sleep disturbance, in that order (eta² = 0.083-0.166), except for the two latter groups not differing in depression.

Conclusion

The findings imply that healthcare professionals should be observant regarding various conditions of, apart from stress, mental ill-health and functional somatic syndromes in patients who present themselves with sleep disturbance, and in particular chronic disturbance.

A bibliometric analysis of sleep in older adults

Background

Sleep problems severely affect the quality of life in the elderly and have gradually gained attention among scholars. As a major hot spot of current research, sleep in older adults is highly exploratory and of great significance for human health.

Objective

Therefore, in this study, the current state of the art of sleep research in older adults was analyzed through the visual mapping function of CiteSpace software. Using this software, we analyzed popular research questions and directions and revealed the development trends and research frontiers of this field.

Methods

In this paper, we searched the Web of Science database for sleep-related studies focusing on older adults and analyzed the number of publications, journals, authors, institutions, country regions, and keywords by using CiteSpace software.

Results

Our results revealed that the number of publications concerning sleep in older adults has gradually increased; after 2017, this field underwent rapid development. The journal Sleep has published the majority of the articles on sleep in older adults and has the highest citation frequency. The Journal of the American Geriatrics Society has the highest impact factor and CiteScore among the top 10 journals in terms of the number of published articles. The United States has the highest number of publications and most of the leading institutions in this field are located in the United States, with the University of California, Los Angeles, and the University of Pittsburgh having the highest number of publications. Dzierzewski JM is the most published author and has played an important role in guiding the development of this field. Research in this area is focused on insomnia, sleep quality, depression, and sleep duration.

Conclusion

The rapid development of sleep research in older adults, which shows a yearly growth trend, indicates that this field is receiving increasing attention from researchers. Insomnia in older adults is the most concerning problem in this field. At the same time, future research should continue to focus on the impact of sleep disorders on older adults to improve sleep and quality of life in older adults.

Digital media use and sleep in late adolescence and young adulthood: A systematic review

Despite much attention on digital media use and young peoples' sleep, the literature on digital media and its impact on sleep in older adolescents and young adults remains to be synthesized. We conducted a systematic review of studies including young people aged 16-25 years. We searched Medline, Web of Science, and CINAHL for observational studies, identifying 60 studies. These studies were assessed for methodological quality. Only studies rated as moderate or high-quality studies were included (n = 42). A narrative synthesis summarized the impact of digital media use on eight sleep outcomes: Bedtime; Sleep onset latency or problems falling asleep; Sleep duration; Early awakening; Sleep disturbance; Daytime tiredness and function; Sleep deficits; Sleep quality. In summary, digital media use was associated to shorter sleep duration and poorer sleep quality. These associations were found for general screen use and use of mobile phone, computer, internet, and social media, but not for television, game console, and tablet use. Most studies investigating bedtime or nighttime use found associations to poor sleep outcomes. Later bedtime and daytime tiredness were associated with mobile phone use at night. Additional research is warranted to draw solid conclusions about the causal direction and to understand the underlying mechanisms.

Sleep quality and the evolution of the COVID-19 pandemic in five European countries

The COVID-19 pandemic has led to lifestyle changes across Europe with a likely impact on sleep quality. This investigation considers sleep quality in relation to the evolution of the COVID-19 pandemic in five European countries. Using panel regressions and keeping policy responses to COVID-19 constant, we show that an increase in the four-week average daily COVID-19 deaths/100,000 inhabitants (our proxy for the evolution of the pandemic) significantly reduced sleep quality in France, Germany, Italy, Spain, and Sweden between April 2020 and June 2021. Our results are robust to a battery of sensitivity tests and are larger for women, parents and young adults. Additionally, we show that about half of the reduction in sleep quality caused by the evolution of the pandemic can be attributed to changes in lifestyles, worsened mental health and negative attitudes toward COVID-19 and its management (lower degree of confidence in government, greater fear of being infected). In contrast, changes in one's own infection-status from the SARS-CoV-2 virus or sleep duration are not significant mediators of the relationship between COVID-19-related deaths and sleep quality.

A two-mediator serial mediation chain of the association between social isolation and impaired sleep in old age

Poor sleep is a long-term public health issue that has become increasingly prevalent among socially isolated older adults. However, research on the mechanisms explaining the link between social isolation and impaired sleep (IS) remains limited, particularly in low- and middle-income countries. This study explored the serial mediating effects of loneliness and mental distress on the association of social isolation with IS among Ghanaian older adults. We analyzed data from 1201 adults aged ≥ 50 from Ghana's AgeHeaPsyWel-HeaSeeB study (mean age = 66.14, SD = 11.85, age range = 50-111; women = 63.28%). Measures included the UCLA 3-item Loneliness Scale, modified Berkman-Syme Social Network Index, Sleep Quality Scale, and Mental Distress Questionnaire. We used bootstrapping techniques from Hayes' PROCESS macro program to estimate the hypothesized serial mediation. Social isolation was significantly associated with IS (β = 0.242, p < 0.001). Crucially, social isolation indirectly predicted IS via three significant mediating pathways. Loneliness accounted for 17.6% (β = 0.054, CI = 0.096, 0.016), mental distress accounted for 6.5% (β = 0.020, 95% CI = 0.004, 0.040), and loneliness and mental distress accounted for 32.2% (β = 0.099, 95% CI = 0.065, 0.138) of the overall effect. The total mediating effect was 56.4%. These findings suggest that the social isolation-sleep link is respectively and serially explained by loneliness and mental distress. Social integrative interventions for sleep quality in old age should target mental and emotional well-being.

Association between Family Support, Stress, and Sleep Quality among College Students during the COVID-19 Online Learning Period

(1) Background: During the past 3 years, the COVID-19 pandemic has severely affected the normal school schedule of college students, jeopardizing their mental health, sleep quality, and interpersonal relationships. However, previous studies have focused on the dimension of social support received, and few studies have measured in depth the association of support received from family on adolescents’ physical and mental health. Therefore, this study explored the associations between family support received by Chinese college students during COVID-19 pandemic online classes, stress and sleep quality, and the mediating role of stress. (2) Methods: A cross-sectional study conducted at Chongqing Medical University recruited 712 college students through a university-wide incidental random sample using the Questionnaire Star platform. Statistical description and correlation analysis was conducted using SPSS 25.0, and structural equation modeling was constructed using AMOS 22.0 to test for mediating effects; (3) Results: The family support score of college students during the COVID-19 pandemic online course was 19.41 ± 4.62. Correlation analysis showed that sleep quality was negatively correlated with family support (r = −0.224, p < 0.01), positively correlated with stress (r = 0.324, p < 0.01), and family support was negatively correlated with stress (r = −0.159, p < 0.01). The results of structural equation modeling showed that stress partially mediated the relationship between family support and sleep quality among college students (indirect effect = −0.150, p < 0.01, SE = 0.013,95% CI = [−0.208, −0.064]). The model R2 was 36.4%. (4) Conclusions: Schools should consider implementing sleep education, and stress relief curriculum measures to improve the quality of students’ sleep, and should focus on the role that family plays during online classes. This will help students overcome the negative emotional effects of stress in the COVID-19 pandemic and improve their learning efficiency and physical and mental health.

The Mediating Role of Sleep Quality in the Relationship between Negative Emotional States and Health-Related Quality of Life among Italian Medical Students

Sleep problems have been shown to be related to adverse outcomes concerning physical and mental well-being. Furthermore, mental health issues and sleep problems were reported to be highly prevalent among medical students and physicians, and were found to be associated with worse academic and clinical performance in these populations. This study aims to investigate the prevalence of poor sleep to examine the associations between sleep quality and health-related quality of life (HRQoL), and to explore the possible mediating role of sleep in the relationship between psychological distress and HRQoL itself in a sample of medical and dental students attending a large Italian university. Participants (n = 407, mean age: 24.2 ± 2.4) answered an online questionnaire comprising the 21-item Depression Anxiety Stress Scale, the Pittsburgh Sleep Quality Index, and the Short Form-12 health survey. Up to 62% of the participants reported poor sleep quality. Controlling for psychological distress, sleep quality components were found to be associated with physical and mental HRQoL. Mediation analysis showed that overall sleep quality mediated all the single associations between anxiety, depression, and stress and HRQoL. These preliminary findings suggest that the quality of sleep is important for the well-being of medical students and that targeting sleep issues in this academic population may be beneficial.

Sleep quality among inpatients of Spanish public hospitals

Sleep is a complex process and is needed both in health and illness. Deprivation of sleep is known to have multiple negative physiological effects on people's bodies and minds. Despite the awareness of these harmful effects, previous studies have shown that sleep is poor among hospitalised patients. We utilized an observational design with 343 patients recruited from medical and surgical units in 12 hospitals located in nine Spanish regions. Sociodemographic and clinical characteristics of patients were collected. Sleep quality at admission and during hospitalisation was measured by the Pittsburgh Sleep Quality Index. Sleep quantity was self-reported by patients in hours and minutes. Mean PSQI score before and during hospitalisation were respectively 8.62 ± 4.49 and 11.31 ± 4.04. Also, inpatients slept about an hour less during their hospital stay. Lower educational level, sedative medication intake, and multi-morbidity was shown to be associated with poorer sleep quality during hospitalisation. A higher level of habitual physical activity has shown to correlate positively with sleep quality in hospital. Our study showed poor sleep quality and quantity of inpatients and a drastic deterioration of sleep in hospital versus at home. These results may be helpful in drawing attention to patients' sleep in hospitals and encouraging interventions to improve sleep.

Sleep disturbances, depressive symptoms, and cognitive efficiency as determinants of mistakes at work in shift and non-shift workers

Introduction

Shift work is known to reduce productivity and safety at work. Previous studies have suggested that a variety of interrelated factors, such as mood, cognition, and sleep, can affect the performance of shift workers. This study aimed to identify potential pathways from depression, sleep, and cognition to work performance in shift and non-shift workers.

Material and methods

Online survey including the Center for Epidemiologic Studies Depression Scale (CES-D), Cognitive Failure Questionnaire (CFQ), and Pittsburgh Sleep Quality Index (PSQI), as well as two items representing work mistakes were administered to 4,561 shift workers and 2,093 non-shift workers. A multi-group structural equation model (SEM) was used to explore differences in the paths to work mistakes between shift and non-shift workers.

Results

Shift workers had higher PSQI, CES-D, and CFQ scores, and made more mistakes at work than non-shift workers. The SEM revealed that PSQI, CES-D, and CFQ scores were significantly related to mistakes at work, with the CFQ being a mediating variable. There were significant differences in the path coefficients of the PSQI and CES-D between shift and non-shift workers. The direct effects of sleep disturbances on mistakes at work were greater in shift workers, while direct effects of depressive symptoms were found only in non-shift workers.

Discussion

The present study found that shift workers made more mistakes at work than non-shift workers, probably because of depressed mood, poor sleep quality, and cognitive inefficiency. Sleep influences work performance in shift workers more directly compared to non-shift workers.

Clinical staging and the differential risks for clinical and functional outcomes in young people presenting for youth mental health care

BACKGROUND

Clinical staging proposes that youth-onset mental disorders develop progressively, and that active treatment of earlier stages should prevent progression to more severe disorders. This retrospective cohort study examined the longitudinal relationships between clinical stages and multiple clinical and functional outcomes within the first 12 months of care.

METHODS

Demographic and clinical information of 2901 young people who accessed mental health care at age 12-25 years was collected at predetermined timepoints (baseline, 3 months, 6 months, 12 months). Initial clinical stage was used to define three fixed groups for analyses (stage 1a: 'non-specific anxious or depressive symptoms', 1b: 'attenuated mood or psychotic syndromes', 2+: 'full-threshold mood or psychotic syndromes'). Logistic regression models, which controlled for age and follow-up time, were used to compare clinical and functional outcomes (role and social function, suicidal ideation, alcohol and substance misuse, physical health comorbidity, circadian disturbances) between staging groups within the initial 12 months of care.

RESULTS

Of the entire cohort, 2093 young people aged 12-25 years were followed up at least once over the first 12 months of care, with 60.4% female and a baseline mean age of 18.16 years. Longitudinally, young people at stage 2+ were more likely to develop circadian disturbances (odds ratio [OR]=2.58; CI 1.60-4.17), compared with individuals at stage 1b. Additionally, stage 1b individuals were more likely to become disengaged from education/employment (OR=2.11, CI 1.36-3.28), develop suicidal ideations (OR=1.92; CI 1.30-2.84) and circadian disturbances (OR=1.94, CI 1.31-2.86), compared to stage 1a. By contrast, we found no relationship between clinical stage and the emergence of alcohol or substance misuse and physical comorbidity.

CONCLUSIONS

The differential rates of emergence of poor clinical and functional outcomes between early versus late clinical stages support the clinical staging model's assumptions about illness trajectories for mood and psychotic syndromes. The greater risk of progression to poor outcomes in those who present with more severe syndromes may be used to guide specific intervention packages.

Examining the Indirect Effect of Online Gaming on Depression via Sleep Inequality and Anxiety-A Serial and Parallel Mediation Analysis

Stress-related disorders are highly prevalent among first-year college students. Gaming disorder (GD) is an emerging disorder linked to physical and psychological consequences. We aimed to investigate the mechanism linking GD with anxiety, depression, and sleep disorders among first-year undergraduate students. Four hundred fifty-seven participants were recruited, and the survey included the Internet Gaming Disorder Scale Short-Form (IGDS9-SF), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Pittsburgh Sleep Quality Index (PSQI). Our results showed that female students scored significantly higher than males in anxiety and depression. Furthermore, we found that depression is positively and strongly correlated to anxiety, and both are moderately associated with sleep quality. Gaming is positively related to depression, anxiety, and sleep quality. Interestingly, the health sciences tracks showed lower sleep quality than undergraduates from other tracks. There was a 64% variance in depression explained by many predictors, including anxiety, sleep quality, gaming, painkiller use, and gender. In addition, the mediation models showed that the association between gaming and depression is mediated indirectly by sleep quality, and sleep quality may be mediated directly by anxiety. The first year in college occurs at a critical developmental and professional stage, and our results highlight the need to establish support programs and conduct mental health educational workshops.

Digital cognitive behavior therapy for insomnia improving sleep quality: a real-world study

BACKGROUND

Digital cognitive behavior therapy for insomnia (dCBT-I) is an effective treatment in alleviating insomnia. This study examined the effect of dCBT-I for improving sleep quality in patients with insomnia complaints from a clinical population in a real-world setting.

METHODS

The study included 6,002 patients aged 18 years and above with primary complaints of dissatisfying sleep from a sleep clinic in a psychiatric hospital from November 2016 to April 2021. Patients were diagnosed with insomnia, anxiety disorders, or anxiety comorbid with insomnia or depression according to ICD-10. A mobile app was developed for self-reported assessment and delivering dCBT-I interventions and treatment prescriptions to participants. The primary outcome was change in global sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). At 8- and 12-week follow-up, 509 patients were reassessed. Data were analyzed with non-parametric tests for repeated measures.

RESULTS

Patients treated with dCBT-I monotherapy were younger, with a more frequent family history of insomnia compared to those with medication monotherapy and those with combined dCBT-I and medication therapy. Improvements of sleep quality from baseline to 8-week follow-up were significant in each treatment type. Compared to 8-week follow-up, PSQI scores at 12-week were significantly decreased in the depression group receiving combined therapy and in the anxiety group treated with dCBT-I monotherapy and with combined therapy. A time-by-treatment interaction was detected in anxiety patients indicating differential reduction in PSQI scores over time between different treatment options.

CONCLUSION

The current findings suggest dCBT-I is a practical and effective approach for lessening insomnia symptoms, especially for patients with anxiety symptoms suggesting with a more extended intervention period (i.e., 12 weeks).

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR1900022699).

Cross-lagged relationship between anxiety, depression, and sleep disturbance among college students during and after collective isolation

Object

Repeated quarantine policies over the past 3 years have led to poor psychological consequences for the public. Previous studies have proved that the quarantine policy leaves individuals vulnerable to anxiety, depression, and insomnia, especially among college students. This study aims to explore whether psychological problems during isolation continue with the release of isolation.

Methods

Overall, 2,787 college students both answered a web-based survey during and after the closure management was lifted. The Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Youth Self-rating Insomnia Scale were measured. The cross-lagged path model was used to explore the influence of psychological impact during isolation on the individual after the release.

Results

We found that anxiety and sleep disturbance levels alleviated significantly after quarantine, except for depression. As expected, a bidirectional relationship exists between anxiety, depression, and sleep disturbance. Moreover, depression and sleep disturbance can predict post quarantine depression, sleep disturbance, and anxiety, yet anxiety cannot predict sleep disturbance afterward.

Conclusion

Timely and effective intervention for anxiety, depression, and insomnia during isolation is essential for individuals to repair themselves quickly after the release.

The bidirectional relationship between sleep and externalizing behavior: A systematic review

It is well-established that sleep and behavior are interrelated. Although studies have investigated this association, not many have evaluated the bidirectional relationship between the two. To our knowledge this is the first systematic review providing a comprehensive analysis of a reciprocal relationship between sleep and externalizing behavior. Five databases (PsycINFO, PubMed, Web of Science, Scopus, and Google Scholar) were utilized to yield a total of 3,762 studies of which 20 eligible studies, empirical articles examining bidirectionality of sleep and externalizing behavior, were selected for analysis. According to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis, the varying methodological approaches used in these studies were analyzed and synthesized, including examining differences and similarities in outcomes between distinct study designs (longitudinal vs cross-sectional), sleep measures (objective vs subjective vs a combination of both), informants (parents, self-report, teachers), and recruited participants (clinical, subclinical and typical populations). The assessment of risk of bias and quality of studies was guided by the instruments employed in research on sleep and behavior in the past. This review establishes that a bidirectional relationship between sleep problems and externalizing behavior clearly exists, and identifies limitations in the existing literature. Furthermore, the importance of early interventions that target both externalizing behaviors and sleep problems is highlighted as a potentially effective way of breaking the sleep-externalizing behavior relationship. Nonetheless, causality cannot be claimed until more trials that manipulate sleep and evaluate changes in externalizing behavior are conducted.

Discrimination is associated with poor sleep quality in pregnant Black American women

BACKGROUND

Heightened exposure to racial/ethnic discrimination is associated with poorer sleep health among non-pregnant adults. This relationship has received limited research attention among pregnant women, despite the importance of prenatal sleep quality for optimal maternal and child health outcomes.

METHODS

We utilized perinatal data from a sample of Black American women (n = 600) participating in a cohort study who reported their lifetime experiences of racial/ethnic discrimination and gendered racial stress during early pregnancy and reported on their sleep quality and depressive symptoms during early and mid-pregnancy. Hierarchical multiple linear regression models were fit to examine associations between lifetime experiences of racial/ethnic discrimination or gendered racial stress and sleep quality during early and mid-pregnancy. We also adjusted for women's concurrent depressive symptoms and tested whether the discrimination/sleep quality association varied by socioeconomic status.

RESULTS

Greater exposure to racial/ethnic discrimination was associated with poorer sleep quality during early (ΔR2 = 0.04, ΔF = 26.08, p < 0.001) and mid-pregnancy (ΔR2 = 0.02, ΔF = 9.88, p = 0.002). Similarly, greater gendered racial stress was associated with poorer sleep quality during early (ΔR2 = 0.10, ΔF = 65.72, p < 0.001) and mid-pregnancy (ΔR2 = 0.06, ΔF = 40.43, p < 0.001. These findings largely held after adjustment for concurrent prenatal depressive symptoms. Socioeconomic status did not modify the observed relationships.

CONCLUSIONS

Efforts to decrease institutional and interpersonal experiences of racial/ethnic discrimination and gendered racism would benefit the sleep quality of pregnant Black American women, particularly during early pregnancy.

Sex differences in associations between alcohol use and sleep in mid-to-late life

OBJECTIVES

To examine associations between alcohol use and sleep in middled-aged/older adults and to test sex as a moderator of this relationship.

METHODS

Participants were 183 adults (46% female) ages 50 and above who consumed alcohol in the past year. Linear regressions tested sex as a moderator of associations between alcohol use and sleep parameters. Alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT). Overall sleep health and sleep quality were assessed using the Pittsburgh Sleep Quality Index (PSQI), and pre-sleep arousal was assessed using the Pre-Sleep Arousal Scale.

RESULTS

Overall, 11% of participants screened positive for hazardous drinking (AUDIT scores of 7+/8+ for women/men), and 59% reported poor overall sleep health (scores >5 on the PSQI). Alcohol use was not associated with overall sleep health (B = -0.25, p = .08) or pre-sleep arousal (B = 0.15, p = .64). However, contrary to hypotheses, more hazardous drinking was associated with better subjective sleep quality, only among women (B = -0.08, p = .009). Alcohol use was not associated with sleep quality among men (B = 0.01, p = .58). Associations remained significant when controlling for age, symptoms of anxiety and depression, body mass index, use of sleep medication, number of medical conditions, and chronic pain.

CONCLUSIONS

Among middle-aged and older adults, alcohol use is more strongly associated with sleep patterns among women than men, when assessed concurrently (i.e., at the same time point). Findings support the need for further consideration of sex differences in associations between alcohol use and sleep.

Cross-Lagged Analyses of Prolonged Grief and Depression Symptoms with Insomnia Symptoms

Prolonged grief disorder, characterized by severe, persistent and disabling grief, has recently been added to the DSM-5-TR and ICD-11. Treatment for prolonged grief symptoms shows limited effectiveness. It has been suggested that prolonged grief symptoms exacerbate insomnia symptoms, whereas insomnia symptoms, in turn, may fuel prolonged grief symptoms. To help clarify if treating sleep disturbances may be a viable treatment option for prolonged grief disorder, we examined the proposed reciprocal relationship between symptoms of prolonged grief and insomnia. On three time points across 6-month intervals, 343 bereaved adults (88% female) completed questionnaires to assess prolonged grief, depression, and insomnia symptoms. We applied random intercept cross-lagged panel models (RICLPMs) to assess reciprocal within-person effects between prolonged grief and insomnia symptoms and, as a secondary aim, between depression and insomnia symptoms. Changes in insomnia symptoms predicted changes in prolonged grief symptoms but not vice versa. Additionally, changes in depression and insomnia symptoms showed a reciprocal relationship. Our results suggest that targeting insomnia symptoms after bereavement is a viable option for improving current treatments for prolonged grief disorder.

Understanding health anxiety in the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic continues to be one of the greatest public health challenges faced by the UK. Reported rates of psychiatric difficulties have increased and the mechanisms by which the pandemic has affected mental health requires investigation.

AIMS

The aim of the study was to understand the psychological impact of the COVID-19 pandemic on health anxiety in the general population, with a focus on Oxford Health NHS Foundation Trust, which provides specialist mental health care within Oxfordshire and Buckinghamshire.

METHODS

We invited participants aged 18+ across Oxfordshire and Buckinghamshire to complete an online questionnaire consisting of standardised questionnaires measuring psychological wellbeing, non-standardised questions to provide demographic information, and information about social circumstances and behaviour during the COVID-19 pandemic. Participants were then invited via email to complete a 3-month follow-up questionnaire.

RESULTS

About 324 participants completed the baseline survey while 199 completed the follow-up. Our analysis demonstrated that higher scores on a health anxiety inventory were related to reports of depression, anxiety, loneliness, poor quality of life and obsessive-compulsive symptoms and panic. We also identified several predictors of health anxiety such as being female, having a pre-existing physical or mental health condition, and poor tolerance of uncertainty. Lifestyle and demographic factors such as changes in financial situation, changes in employment status, having a close relative or friend with COVID-19, being able to do grocery shopping, being a key worker, and ethnicity were not found to predict health anxiety.

CONCLUSIONS

Awareness of the impact of health anxiety on people needs to be consistently high among healthcare professionals, especially in the continuing fallout from the COVID-19 pandemic. The relationship between health anxiety and fatigue, sleep quality, gender and co-morbid mental and physical health difficulties needs to be investigated further to determine areas of intervention.

Mind-Body Integrative Health (MBIH) Interventions for Sleep among Adolescents: A Scoping Review of Implementation, Participation and Outcomes

Adolescents get insufficient sleep, adversely affecting health. Mind-body integrative health interventions for adolescents have been shown to reduce stress, a barrier to good sleep. This scoping review aimed to synthesize mind-body integrative health interventions for adolescents, how interventions were implemented, who was reached. A systematic search of four online databases was conducted. Randomized, quasi-experimental, and single-group designs with participants ages 10-24 years were included. Twelve studies covering 10 interventions using mindfulness, qigong, aromatherapy, or yoga were identified. Participants were predominantly female; only one study reported participants' race or ethnicity (81% non-Hispanic white). Most (n=6) interventions were delivered in groups, and half reported significant improvements in subjective sleep quality. Mindfulness-based stress reduction and mindfulness-based cognitive therapy were the most commonly used modalities, with reported impact on sleep outcomes measured objectively. The two interventions that found statistically significant, moderate improvements in objectively-measured sleep onset latency and sleep efficiency were of higher intensity and used mindfulness. Four interventions were self-directed; participants in these struggled with adherence; significant impacts on sleep were not found. While findings were mixed, stemming in part from the quality of the underlying studies, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline (rather than a general population of adolescents). The findings suggests that sleep interventions for adolescents may improve psychological well-being as an intermediate effect, as sleep improvements were observed mostly among participants with poor sleep quality or anxiety symptoms at baseline. This review identified several gaps in the literature. Despite documented racial and ethnic disparities in sleep quality among adolescents, published evidence of mind-body integrative health-based sleep interventions among Black and Latinx adolescents is lacking. None of the studies in this review assessed developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. These two gaps in the evidence should be addressed in future intervention research.

Sleep and Circadian Disturbance in Cardiovascular Risk

PURPOSE OF REVIEW

We discuss the relationship between sleep and circadian factors with cardiovascular disease (CVD) risk, including physiologic, behavioral, and psychological mechanisms along this pathway.

RECENT FINDINGS

The relationship between short and long sleep duration, as well as insomnia, with CVD risk is well-established. Recent work has highlighted how other sleep factors, such as sleep regularity (i.e., consistency of sleep timing), multidimensional sleep health, and circadian factors like chronotype and social jetlag, relate to CVD risk. Sleep-focused interventions (e.g., cognitive behavioral therapy for insomnia and sleep extension) may be effective to reduce CVD risk and disease burden. Sleep is increasingly recognized as an integral component of cardiovascular health. This was underscored by the recent inclusion of sleep duration as a health behavior in the American Heart Association's Life's Essential 8 for defining optimal cardiovascular health.

Self-reported changes in sleep patterns and behavior in children and adolescents during COVID-19

The COVID-19 pandemic and lockdowns worldwide forced children and adolescents to change and adapt their lives to an unprecedented situation. Using an online survey, we investigated whether they showed changes in sleep quality and other related factors due to this event. Between February 21st, 2021 and April 19th, 2021, a total of 2,290 Austrian children and adolescents (6-18 years) reported their sleep habits and quality of sleep as well as physical activity, daylight exposure and usage of media devices during and, retrospectively, before the pandemic. Results showed an overall delay of sleep and wake times. Almost twice as many respondents reported having sleeping problems during the pandemic as compared to before, with insomnia, nightmares and daytime sleepiness being the most prevalent problems. Furthermore, sleeping problems and poor quality of sleep correlated positively with COVID-19 related anxiety. Lastly, results showed a change from regular to irregular bedtimes during COVID-19, higher napping rates, a strong to very strong decrease in physical activity and daylight exposure, as well as a high to very high increase in media consumption. We conclude that the increase in sleeping problems in children and adolescent during COVID-19 is concerning. Thus, health promoting measures and programs should be implemented and enforced.

Psychological and sleep disturbances among first-line, second-line, and at home medical staff during the COVID-19 pandemic in Shanghai, China

Objectives

Medical workers are prone to psychological and sleep disturbances during the coronavirus disease 2019 (COVID-19) pandemic. Little is known about the varying degrees of influence among vaccinated medical staff working in different positions. The current study is aimed to evaluate and compare depression, anxiety and sleep disturbances among first-line, second-line and at home vaccinated medical staff during the COVID-19 pandemic in Shanghai, China.

Methods

A cross-sectional online survey was conducted in May 2022. In addition to demographic data, levels of depression, anxiety, sleep quality, and insomnia were measured using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Pittsburgh Sleep Quality Index (PSQI), and Athens Insomnia Scale (AIS).

Results

A total of 236 vaccinated medical workers completed the questionnaires, including 85 first-line medical staff (FMS), 82 second-line medical staff (SMS) and 69 at home medical staff (HMS). The proportions of depressive symptoms, anxiety symptoms, poor sleep quality, and insomnia were 52.1, 44.1, 55.9, and 49.2%, respectively. Compared with HMS, medical staff at work (FMS and SMS) got significantly higher frequency of poor sleep quality (both p < 0.001), insomnia (both p < 0.001), depressive (p < 0.001 and p = 0.003, respectively) and anxiety symptoms (p < 0.001 and p = 0.002, respectively). Compared with SMS, FMS were more likely to have poor sleep quality (p = 0.020). Besides, nurses got significantly higher percentage of poor sleep quality (OR = 1.352, p = 0.016) and insomnia (OR = 1.243, p = 0.041) than doctors. Whereas, the proportion of anxiety symptoms was increased in females than in males (OR = 2.772, p = 0.008).

Conclusions

Psychological and sleep disturbances are common among medical staff at work during the COVID-19 pandemic. More psychological intervention should be administrated for FMS, especially for nurses.

Sleep Disturbance in Chinese College Students with Mental Health Problems: A Moderated Mediation Model

Sleep disturbance has an enormous impact on college students. Poor sleep is associated with low academic achievement, psychological distress and high health risk behaviors. College students with various mental health problems (e.g., anxiety and depression) are particularly at risk for sleep problems. The aim of the present study was to examine the impact of a wide range of internalizing/externalizing psychological problems on sleep disturbance. A total of 2134 Chinese college students (60.2% men) with mental health problems were selected as participants after completing the self-reported Chinese college student mental health screening scale. A web-based survey was used to assess a wide variety of internalizing/externalizing psychological problems and sleep disturbance. The results showed that hostility, somatic symptoms and obsessive-compulsive symptoms (OCS) were significantly associated with sleep disturbance. Somatic symptoms played a mediating role in the relationship between hostility and sleep disturbance. Moreover, the mediating effect was moderated by OCS, and a significant difference in the mediating effects was observed between low OCS and high OCS groups. Overall, our research findings indicate that a high level of OCS exacerbates the adverse effects of somatic symptoms on sleep disturbance, and suggests that assessment and improvement of hostility, somatic symptoms and OCS should be considered in facilitating better sleep among college students with mental health problems.

Wirkmechanismen körperlicher Aktivität auf den Schlaf bei Patienten mit Depression: Ein Narratives Review

Insomnie ist eines der Kardinalsymptome einer unipolaren Depression. Insomnie hat dabei einen negativen Einfluss auf den Krankheitsverlauf, ist eines der häufigsten Residualsymptome und ein Risikofaktor für ein Rezidiv. Im vorliegenden Überblick werden mögliche Wirkmechanismen von körperlichem Training auf den Schlaf bei Patienten mit Depression zusammengefasst. Die vorgestellten Mechanismen beruhen auf Daten aus In-vitro‑, Tier- und Humanstudien, welche die Effekte von Kraft‑, Ausdauer- und Mind-Body-Training untersuchen. Sowohl akutes Training als auch über mehrere Wochen regelmäßig absolviertes Training kann über verschiedene Signalwege positive Effekte auf den Schlaf bei Patienten mit Depression haben. Folgende Mechanismen sind dabei relevant: Zeitgebereffekte, Energiekonservierung, Regeration, Thermoregulation, psychophysiologische Effekte und „tissue–brain crosstalk“. Diese Befunde sind relevant, um die Therapie von nichtorganischen Schlafstörungen im Rahmen einer depressiven Episode besser zu verstehen, weiterzuentwickeln und auf individuelle Patienten anzupassen.