The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

Integrating sleep, neuroimaging, and computational approaches for precision psychiatry

In advancing precision psychiatry, we focus on what imaging technology and computational approaches offer for the future of diagnostic subtyping and personalized tailoring of interventions for sleep impairment in mood and anxiety disorders. Current diagnostic criteria for mood and anxiety tend to lump different forms of sleep disturbance together. Parsing the biological features of sleep impairment and brain circuit dysfunction is one approach to identifying subtypes within these disorders that are mechanistically coherent and offer targets for intervention. We focus on two large-scale neural circuits implicated in sleep impairment and in mood and anxiety disorders: the default mode network and negative affective network. Through a synthesis of existing knowledge about these networks, we pose a testable framework for understanding how hyper- versus hypo-engagement of these networks may underlie distinct features of mood and sleep impairment. Within this framework we consider whether poor sleep quality may have an explanatory role in previously observed associations between network dysfunction and mood symptoms. We expand this framework to future directions including the potential for connecting circuit-defined subtypes to more distal features derived from digital phenotyping and wearable technologies, and how new discovery may be advanced through machine learning approaches.

Prevalence and impact of insomnia in children and adolescents with body dysmorphic disorder undergoing multimodal specialist treatment

Pediatric body dysmorphic disorder (BDD) is challenging to treat. This study aimed to establish the prevalence of insomnia in youth with BDD and explore its impact on clinical outcomes. Sixty-six children and adolescents with BDD consecutively referred to a specialist clinic completed a range of clinical measures, including the Yale-Brown Obsessive-Compulsive Scale Modified for BDD-Adolescent Version (BDD-YBOCS-A), and the Insomnia Severity Index (ISI). Patients with clinical insomnia (ISI score ≥ 9) were compared to the rest of the sample on socio-demographic and clinical features. Fifty-six patients who received multimodal treatment were re-assessed post-treatment. A mixed-model ANOVA was performed to compare treatment outcomes between the insomnia vs. no insomnia groups, and Chi-squared tests were used to compare response and remission rates. According to the ISI, 48% of the sample qualified as having insomnia at baseline. These participants showed significantly higher self-reported BDD symptom severity, more depressive symptoms, and more functional impairment in daily activities. Patients with insomnia improved less on the BDD-YBOCS-A than those without insomnia, although the difference did not reach statistical significance. The rates of responders and remitters were lower in the insomnia group, compared to the non-insomnia group. Insomnia is prevalent in pediatric BDD, and is associated with more severe psychopathology and worse functioning in daily activities. Furthermore, youth experiencing BDD and insomnia may benefit from multimodal treatment to a lesser extent than those without insomnia. If these results are replicated in larger samples, treatment refinements for pediatric BDD could include specific modules to directly target insomnia.

Sleep Problems and Social Impairment in Psychosis: A Transdiagnostic Study Examining Multiple Social Domains

Psychotic disorders are characterized by profound social impairment. An accumulation of research has explored the contribution of symptoms, cognitive functioning, and behavioral skills deficits to this social dysfunction. Recent research indicates that sleep disturbance has significant social implications in nonclinical populations-this research suggests that sleep problems may also be relevant to understanding social impairment in psychosis. This study adopted a symptom-oriented dimensional approach to examine how sleep disturbance and sleep-related impairment are related to multiple social domains within a transdiagnostic sample (N = 90). This sample included individuals with a variety of psychotic disorders (n = 75) along with healthy non-clinical participants (n = 15) to ensure sampling across the full range of sleep problems and social functioning. Social domains spanned self-reported perceptions of social relationships, social functioning in the community, and behavioral assessments of social competence. We hypothesized that greater sleep disturbance and sleep-related impairment would be associated with more negative or problematic perceptions of social relationships (i.e., less social support, less companionship, and greater distress), poorer social functioning in the community, smaller social networks, and poorer behavioral ratings of social competency. Results supported these hypotheses indicating that sleep disturbance and sleep-related impairment have widespread deleterious impacts on perceptions of social relationships, social functioning, and competence. Sleep disturbance retained associations with perceptions of social relationships, social functioning, and social competence even after controlling for total symptoms or cognitive functioning. These findings indicate that sleep problems may have important implications for fully understanding the causes of social impairment in psychosis.

Sleep Predicts Collegiate Academic Performance: Implications for Equity in Student Retention and Success

College students show high levels of insufficient sleep, excessive daytime sleepiness, sleep schedule irregularity, poor sleep quality, and inadequate sleep hygiene. This article describes the evidence linking poor sleep with impaired academic performance; discusses mediating environmental, behavioral, and demographic factors that correlate with sleep; and highlights examples of successful health promotion initiatives on college campuses. Given that students who are traditionally minoritized on college campuses tend to have worse sleep, improving sleep health emerges as an important issue for retention, equity, and inclusion.

The association between excessive screen-time behaviors and insufficient sleep among adolescents: Findings from the 2017 youth risk behavior surveillance system

Although studies have examined the association between television viewing and poor sleep quality, few studies have considered the association between excessive screen-time behaviors and insufficient sleep among adolescents drawing on a large nationally representative sample. The objective of this study was to examine the association between excessive screen-time behaviors and insufficient sleep among adolescents. Data for this study came from the 2017 Youth Risk Behavior Survey. A sample of 14,603 adolescents aged 14-18 years (51.5% female) was analyzed using logistic regression with insufficient sleep as the outcome variable and excessive screen-time behaviors as the main explanatory variable. Of the 14,603 adolescents, almost three out of four (74.8%) had less than 8 h of sleep on an average school night, and about 43% engaged in excessive screen-time behaviors on an average school day. Controlling for all other predictors, odds were 1.34 times higher for adolescents who engaged in excessive screen-time behaviors to have insufficient sleep when compared to adolescents who did not engage in excessive screen-time behaviors (AOR = 1.34, p < .001, 95% CI = 1.22-1.48). School-based behavior interventions that focus on reduction in excessive screen-time and sedentary behaviors might be beneficial in reducing excessive screen-time behaviors and consequently improve sleep quality among adolescents.

Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial

STUDY OBJECTIVES

Insomnia is a common precursor to depression; yet, the potential for insomnia treatment to prevent depression has not been demonstrated. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces concurrent symptoms of insomnia and depression and can be delivered digitally (dCBT-I); however, it remains unclear whether treating insomnia leads to sustained reduction and prevention of depression. This randomized controlled trial examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up period.

METHODS

Patients with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) insomnia disorder were randomly assigned to receive dCBT-I or an attentional control. The follow-up sample included 358 patients in the dCBT-I condition and 300 patients in the online sleep education condition. The primary outcome measure was relative rate ratios for depression at 1-year follow-up. Insomnia responses to treatment were also tested as predictors of incident depression at the 1-year follow-up.

RESULTS

At 1-year follow-up, depression severity continued to be significantly lower in the dCBT-I condition relative to control. In addition, the number of individuals who reported no depression at 1-year follow-up was 51% higher in the dCBT-I condition relative to control. In those with minimal to no depression at baseline, the incident rate of moderate-to-severe depression at 1-year follow-up was reduced by half in the dCBT-I condition relative to the control condition.

CONCLUSION

dCBT-I showed robust effects as an intervention that prevents depression. Future research should examine dose-response requirements and further characterize mechanisms of action of dCBT-I for depression prevention.

CLINICAL TRIAL

Sleep to Prevent Evolving Affective Disorders; NCT02988375.

Online Social anxiety Cognitive therapy for Adolescents (OSCA): protocol for a randomised controlled trial

BACKGROUND

Adolescent social anxiety disorder (SAD) is common, impairing and persistent. There is a need to intervene early to avert its long-term consequences. Cognitive Therapy for SAD is the leading treatment for adults and shows promise for adolescents. However, given the scale of the problem of adolescent SAD and the limited availability of psychological therapists in child and adolescent mental health services, there is a substantial gap in service provision. Delivering therapy via the Internet may provide part of the solution to this problem. An Internet version of adult Cognitive Therapy for SAD has been developed, with outcomes similar to face-to-face therapy. We have recently adapted this treatment for use with adolescents with SAD. Here, we describe a randomised controlled trial designed to test the efficacy of Internet Cognitive Therapy for adolescent SAD compared to waitlist.

METHODS/DESIGN

Forty adolescents aged 14-18 years with a diagnosis of SAD will be recruited via schools. Participants will be randomly allocated to Internet Cognitive Therapy or to waitlist. All participants will be assessed three times during the study-at baseline (pretreatment/wait), midtreatment/wait (week 8) and posttreatment/wait (week 15). Participants in the experimental arm will also complete weekly measures as part of the online program and they will be assessed at 3 and 6 months. Postwait, participants in the waitlist arm will be offered Internet Cognitive Therapy, and weekly and posttreatment data will also be collected for them. The trial aims to test whether Internet Cognitive Therapy is superior to waitlist in reducing social anxiety symptoms and in reducing the proportion of adolescents meeting criteria for SAD. Other outcomes of interest include depression and general anxiety symptoms. Acceptability of the online treatment will also be evaluated.

DISCUSSION

This randomised controlled trial will provide preliminary evidence on whether this intervention, requiring relatively low levels of therapist input, is safe and clinically effective. If this is shown to be the case, Internet Cognitive Therapy for adolescents has the potential to provide a service to the large population of adolescents with untreated SAD.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN15079139 . Version 1 registered on 06/02/2019.

Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial

OBJECTIVE

Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions.

METHOD

This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs).

RESULTS

All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1).

CONCLUSIONS

CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.

A cluster randomized controlled trial of a theory-based sleep hygiene intervention for adolescents

Study Objectives

To use theory to design and evaluate an intervention to promote sleep hygiene and health among adolescents.

Methods

The Theory of Planned Behavior (TPB) and the Health Action Process Approach (HAPA) were used to develop an intervention, which was then evaluated in a cluster randomized trial. Participants were high school students (N = 2,841, M age = 15.12, SD = 1.50). Adolescents in the intervention group received four face-to-face sessions providing behavior change techniques targeting the theoretical determinants of sleep hygiene. Adolescents in the control group only received educational material at the end of the study. The primary outcome was sleep hygiene measured at 1 and 6 months postintervention. A number of secondary outcomes were also measured, including beliefs about sleep, self-regulatory processes, and outcomes related to health and wellbeing.

Results

Sleep hygiene was improved in the intervention group when compared with the control group at both follow-up points (coefficients = 0.16 and 0.19, 95% CIs = 0.12-0.20 and 0.15-0.23 at 1 and 6 months, respectively, for scores on the Adolescent Sleep Hygiene Scale), as were psychosocial and general aspects of health. Mediation analyses suggested that beliefs about sleep hygiene as specified by the TPB, along with self-regulatory processes from HAPA, both mediated the effect of the intervention on outcomes. In turn, the effects of the intervention on sleep hygiene mediated its impact on general health.

Conclusions

Healthcare practitioners might consider intervention programs based on the TPB and the HAPA to improve sleep among adolescents.

Clinical Trial Registration

Clinicaltrials.gov (NCT02551913) https://clinicaltrials.gov/ct2/show/NCT02551913.

The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors

BACKGROUND

The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding.

AIMS

To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors - identified from a cognitive model - before delusion onset.

METHOD

A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed.

RESULTS

Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types.

CONCLUSIONS

Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality.

DECLARATION OF INTEREST

None.

Capturing behavioral indicators of persecutory ideation using mobile technology

Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (M_kilometers = -1.20, SD = 18.88), time spent in a vehicle (M_minutes = -4.15, SD = 49.59), length of outgoing phone calls (M_minutes = -0.79, SD = 13.13), time spent proximal to human speech (M_minutes = -6.26, SD = 153.03), and an increase in time sitting still (M_minutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI.

Individual Correlates of Sleep Among Childbearing Age Women in Canada

Objective/Background: Women of childbearing age (WOCBA) may be at high risk for short or poor sleep. Yet few studies have focused on this population. The study objective was to identify individual correlates of sleep duration and quality among WOCBA. Participants: The sample consisted of 9,749 WOCBA aged 18-44 years from the Canadian Community Health Survey 2011-2014. Methods: All variables were self-reported. Sleep duration was dichotomized as insufficient (< 7 hr/night) or adequate (≥ 7 hr/night). A composite score of sleep quality was dichotomized as having sleeping problems none/little or some/most/all the time. Age, ethnicity, level of education, household income, mood disorders, parity, geographical location, fruit and vegetable (FV) intake, physical activity, smoking and alcohol consumption were tested as correlates of sleep duration or quality using hierarchical logistic regression. Results: Ethnicity, parity, geographical location and smoking were correlates of sleep duration; this model discriminated 56.9% of WOCBA. Ethnic minorities, WOCBA with many children, living in urban areas and smoking were associated with lower odds of having adequate sleep duration. Ethnicity, level of education, mood disorders, geographical location, FV intake, and alcohol consumption were correlates of sleep quality; this model discriminated 59.0% of WOCBA. Ethnic minorities, lower level of education, mood disorders, living in urban areas, low FV intake, and alcohol consumption were associated with lower odds of having quality sleep. Conclusions: Some WOCBA may be more at risk for short or poor sleep based on their demographics and health behaviors. This can be used to identify which WOCBA are most in need of sleep interventions.

Treatable clinical intervention targets for patients with schizophrenia

BACKGROUND

Treatment approaches for patients with psychosis need major improvement. Our approach to improvement is twofold: target putative causal mechanisms for psychotic experiences that are treatable and also that patients wish treated. This leads to greater treatment engagement and clinical benefit. To inform mental health service provision we assessed the presence of treatable causal mechanisms and patient treatment preferences.

METHODS

Patients with non-affective psychosis attending NHS mental health services completed assessments of paranoia, hallucinations, anxious avoidance, worry, self-esteem, insomnia, analytic reasoning, psychological well-being, and treatment preferences.

RESULTS

1809 patients participated. Severe paranoia was present in 53.4% and frequent voices in 48.2%. Of the causal mechanisms, severe worry was present in 67.7%, avoidance at agoraphobic levels in 64.5%, analytic reasoning difficulties in 55.9%, insomnia in 50.1%, poor psychological well-being in 44.3%, strongly negative self-beliefs in 36.6%, and weak positive self-beliefs in 19.2%. Treatment target preferences were: feeling happier (63.2%), worrying less (63.1%), increasing self-confidence (62.1%), increasing activities (59.6%), improving decision-making (56.5%), feeling safer (53.0%), sleeping better (52.3%), and coping with voices (45.3%). Patients with current paranoia and/or hallucinations had higher levels of the causal factors and of wanting these difficulties treated.

CONCLUSIONS

Patients with non-affective psychosis have high levels of treatable problems such as agoraphobic avoidance, worry, low self-esteem, and insomnia and they would like these difficulties treated. Successful treatment of these difficulties is also likely to decrease psychotic experiences such as paranoia.

Adolescent Paranoia: Prevalence, Structure, and Causal Mechanisms

BACKGROUND

Adolescence can be a challenging time, characterized by self-consciousness, heightened regard for peer acceptance, and fear of rejection. Interpersonal concerns are amplified by unpredictable social interactions, both online and offline. This developmental and social context is potentially conducive to the emergence of paranoia. However, research on paranoia during adolescence is scarce.

METHOD

Our aim was to examine the prevalence, structure, and probabilistic causal mechanisms of adolescent paranoia. A representative school cohort of 801 adolescents (11-15 y) completed measures of paranoia and a range of affective, cognitive, and social factors. A Bayesian approach with Directed Acyclic Graphs (DAGs) was used to assess the causal interactions with paranoia.

RESULTS

Paranoid thoughts were very common, followed a continuous distribution, and were hierarchically structured. There was an overall paranoia factor, with sub-factors of social fears, physical threat fears, and conspiracy concerns. With all other variables controlled, DAG analysis identified paranoia had dependent relationships with negative affect, peer difficulties, bullying, and cognitive-affective responses to social media. The causal directions could not be fully determined, but it was more likely that negative affect contributed to paranoia and paranoia impacted peer relationships. Problematic social media use did not causally influence paranoia.

CONCLUSIONS

There is a continuum of paranoia in adolescence and occasional suspicions are common at this age. Anxiety and depression are closely connected with paranoia and may causally contribute to its development. Paranoia may negatively impact adolescent peer relationships. The clinical significance of paranoia in adolescents accessing mental health services must now be established.

The relationship between insomnia and complex diseases-insights from genetic data

Insomnia is a common condition whose pathophysiology is poorly understood. Large genetic studies have provided insights into the etiology of insomnia, highlighting biological pathways that are shared with other complex disorders. Increased focus on treating sleep problems in the clinic and through public health interventions may reduce the overall burden of disease in human populations.

Schizophrenia liability shares common molecular genetic risk factors with sleep duration and nightmares in childhood

Background: Sleep abnormalities are common in schizophrenia, often appearing before psychosis onset; however, the mechanisms behind this are uncertain. We investigated whether genetic risk for schizophrenia is associated with sleep phenotypes. Methods: We used data from 6,058 children and 2,302 mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC). We examined associations between a polygenic risk score for schizophrenia and sleep duration in both children and mothers, and nightmares in children, along with genetic covariances between these traits. Results: Polygenic risk for schizophrenia was associated with increased risk of nightmares (OR=1.07, 95% CI: 1.01, 1.14, p=0.02) in children, and also with less sleep (β=-44.52, 95% CI: -88.98, -0.07; p=0.05). We observed a similar relationship with sleep duration in mothers, although evidence was much weaker (p=0.38). Finally, we found evidence of genetic covariance between schizophrenia risk and reduced sleep duration in children and mothers, and between schizophrenia risk and nightmares in children. Conclusions: These molecular genetic results support recent findings from twin analysis that show genetic overlap between sleep disturbances and psychotic-like experiences. They also show, to our knowledge for the first time, a genetic correlation between schizophrenia liability and risk of nightmares in childhood.

Internet-Delivered Cognitive Behavioral Therapy for Insomnia: Tailoring Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Insomnia

Chronic insomnia is preferably treated with cognitive behavioral therapy for insomnia (CBTI), but many insomnia sufferers receive medication instead, likely because of high costs, lack of knowledge about optimal insomnia treatment among physicians, and lack of CBTI-trained professionals in mental health care. A possible solution is to offer CBTI through the Internet: I-CBTI. I-CBTI is generally acceptable to patients and greatly improves insomnia symptoms. We review the state of knowledge around I-CBTI and its effects. CBTI's effectiveness is influenced by treatment characteristics and patient-specific factors. We review potential factors that help identify which patients may benefit from I-CBTI.

Poor sleep quality predicts psychotic-like symptoms: an experience sampling study in young adults with schizotypal traits

OBJECTIVE

Psychotic-like experiences (PLEs) are unusual experiences such as perceptual abnormalities and delusional-like thoughts that resemble the symptoms of psychosis at the sub-clinical level. PLEs are associated with sleep complaints in healthy and clinical samples; however, evidence for day-to-day associations between poor sleep and subsequent PLEs under naturalistic conditions is scarce. We hypothesized that poor sleep quality would predict next days' PLEs, and vice versa, daytime PLEs would be associated with worse subsequent sleep quality.

METHOD

Seventy-three university students with moderate to high levels of positive schizotypy participated in an experience sampling study. Participants rated their sleep each morning, as well as PLEs and affective states during the day over 3 weeks.

RESULTS

Multilevel regression models indicated that poor sleep quality predicted increased PLEs the following day. Poor sleep was linked to negative daytime mood that partially mediated the associations between sleep quality and next days' PLEs. Furthermore, PLEs were enhanced in the evening as compared to daytime reports. The prediction of poor sleep quality by previous days' PLEs was negligible.

CONCLUSIONS

The results are consistent with the position that sleep-related interventions might reduce the risk of psychosis, especially in individuals that tend to experience psychotic-like phenomena and negative affect.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): a pragmatic within-group pilot evaluation

BACKGROUND

Sleep disturbances, including insomnia, are common in adult Attention Deficit Hyperactivity Disorder (ADHD). Treatment of choice for insomnia is cognitive behavioral therapy (CBT-i), but evidence is lacking for CBT-i in patients with ADHD. The purpose of this study was to investigate if patients with insomnia and other sleep problems, at a specialist clinic for ADHD, benefit from a group delivered behavioral treatment based on CBT-i; whether insomnia severity improves following this treatment.

METHODS

This pragmatic within-group pilot study with a pre to post and three-month follow-up design was set at a specialist psychiatric out-patient clinic for adult ADHD. As an adjunct to care-as-usual at the clinic, a CBT-i-based group treatment targeting several sleep problems prevalent in the ADHD-population, was offered as 10 weekly 90-min group sessions and scheduled telephone support. All outcome measures were subjectively reported by participants. Data analyzed with dependent t-tests according to intent-to-treat.

RESULTS

Nineteen patients (37 [SD 13.7] years; 68% female) with ADHD and subjectively reported sleep problems provided informed consent and pre-treatment measures. Patients had suffered from sleep problems for 15.3 [SD 13.4] years, 42% used sleep medications, 79% used stimulant medication(s). At post-treatment, insomnia severity (Insomnia Severity Index; score range 0-28) had improved with 4.5 points (95% CI, 2.06-6.99, p = .002), at 3 months with 6.8 points (95% CI, 4.71-8.91, p < .0001) from pre-treatment.

CONCLUSIONS

CBT-i adjusted for ADHD is promising for improving insomnia severity in adult patients at specialist psychiatric out-patient clinics, who suffer from ADHD and sleep disturbances.

TRIAL REGISTRATION

Study registered with the Regional ethical review board in Stockholm, January 13th 2016, Study id: 2015/2078-31/1. Study registered retrospectively with Clinicaltrials.org, February 21st 2019, ID: NCT03852966.

Adolescent-Sleep-Intervention Research: Current State and Future Directions

Emerging evidence suggests that cognitive-behavioral interventions should be considered as a first-line treatment for adolescent sleep problems and can also address associated mental health concerns. This article’s aim is to prioritize future directions for this research. Studies are needed that (a) leverage innovative technology, which may allow for a more personalized-medicine approach to care; (b) use alternative research designs, such as treatment-optimization strategies; (c) evaluate mechanisms of therapeutic improvements, including mediators and moderators of change, predictors of treatment adherence, dose–response relationships, and specificity of effects of different treatment components; (d) “scale up” the interventions so that a large proportion of adolescents can access them; and (e) develop flexible approaches to delivery (e.g., online platforms) and stepped-care guidelines. National and international standards of secondary school start times of 8:30 a.m. or later are also needed. The field is now mature enough to take these next steps, which will enhance the effectiveness and public health impact of these interventions.

Insomnia, sleep duration and academic performance: a national survey of Norwegian college and university students

Objective

The aim of this study was to evaluate the associations between insomnia, sleep duration and self-reported academic performance/failure in a large sample of Norwegian college and university students.

Methods

This cross-sectional survey comprised 50,054 full-time students (69% women) aged 18-35 years (mean age 23.2, standard deviation (SD) = 3.3), with a response rate of 31%. Binary logistic regression analyses were conducted to examine the associations between the independent variables, an approximation of the insomnia disorder and sleep duration, and the dependent variables, failed examinations and delayed study progress.

Results

The results showed that insomnia was associated with a higher risk of failed examinations (adjusted for background variables, odds ratio (OR_adjusted) = 1.31, 95% confidence interval (CI) 1.25-1.37, p < 0.001) and delayed study progress (OR_adjusted = 1.32, 95% CI: 1.22-1.42, p < 0.001). A curvilinear relationship between sleep duration and risk of academic failure was demonstrated, where both sleeping less than 5 h, and 10 h or more, were associated with higher odds of failed study examinations, compared to with sleeping 7-9 h (OR_adjusted = 1.46, 95% CI: 1.33-1.63, p < 0.001 and OR_adjusted = 1.53, 95% CI: 1.33-1.75, p < 0.001, respectively). Insomnia and deviations from an optimal sleep duration may have notable consequences for academic success in higher education.

Digital Delivery of Cognitive Behavioral Therapy for Insomnia

PURPOSE OF REVIEW

Digital cognitive behavioral therapy (dCBT) has been available for over a decade. We reviewed the evidence that accumulated over the past 5 years and discuss the implications for introducing dCBT into standard healthcare.

RECENT FINDINGS

Studies have consistently supported the use of dCBT to treat insomnia. Evidence is now demonstrating large short-term effects and smaller long-term effects up to 1.5 years after treatment across populations with various co-occurring health problems. The effects also extend into a range of psychological well-being factors. Mediators and moderators have been studied to understand mechanisms and create new opportunities to enhance effectiveness and reduce dropout. Incorporating personalized guidance in dCBT may further enhance effectiveness. The evidence for dCBT for insomnia is strong and suggests that dCBT is ready for application in standard healthcare. Further research, digital innovation, and development of effective implementation methods are required to ensure dCBT fulfills its potential.

Internet interventions for mental health in university students: A systematic review and meta-analysis

OBJECTIVES

Mental health disorders are highly prevalent among university students. Universities could be an optimal setting to provide evidence-based care through the Internet. As part of the World Mental Health International College Student initiative, this systematic review and meta-analysis synthesizes data on the efficacy of Internet-based interventions for university students' mental health.

METHOD

A systematic literature search of bibliographical databases (CENTRAL, MEDLINE, and PsycINFO) for randomized trials examining psychological interventions for the mental health (depression, anxiety, stress, sleep problems, and eating disorder symptoms), well-being, and functioning of university students was performed through April 30, 2018.

RESULTS

Forty-eight studies were included. Twenty-three studies (48%) were rated to have low risk of bias. Small intervention effects were found on depression (g = 0.18, 95% confidence interval [CI; 0.08, 0.27]), anxiety (g = 0.27, 95% CI [0.13, 0.40]), and stress (g = 0.20, 95% CI [0.02, 0.38]). Moderate effects were found on eating disorder symptoms (g = 0.52, 95% CI [0.22-0.83]) and role functioning (g = 0.41, 95% CI [0.26, 0.56]). Effects on well-being were non-significant (g = 0.15, 95% CI [-0.20, 0.50]). Heterogeneity was moderate to substantial in many analyses. After adjusting for publication bias, effects on anxiety were not significant anymore.

DISCUSSION

Internet interventions for university students' mental health can have significant small-to-moderate effects on a range of conditions. However, more research is needed to determine student subsets for which Internet-based interventions are most effective and to explore ways to increase treatment effectiveness.

Impact of adult attention deficit hyperactivity disorder and medication status on sleep/wake behavior and molecular circadian rhythms

Attention deficit hyperactivity disorder (ADHD) is a common neuropsychiatric condition that has been strongly associated with changes in sleep and circadian rhythms. Circadian rhythms are near 24-h cycles that are primarily generated by an endogenous circadian timekeeping system, encoded at the molecular level by a panel of clock genes. Stimulant and non-stimulant medication used in the management of ADHD has been shown to potentially impact on circadian processes and their behavioral outputs. In the current study, we have analyzed circadian rhythms in daily activity and sleep, and the circadian gene expression in a cohort of healthy controls (N = 22), ADHD participants not using ADHD-medication (N = 17), and participants with ADHD and current use of ADHD medication (N = 17). Rhythms of sleep/wake behavior were assessed via wrist-worn actigraphy, whilst rhythms of circadian gene expression were assessed ex-vivo in primary human-derived dermal fibroblast cultures. Behavioral data indicate that patients with ADHD using ADHD-medication have lower relative amplitudes of diurnal activity rhythms, lower sleep efficiency, more nocturnal activity but not more nocturnal wakenings than both controls and ADHD participants without medication. At the molecular level, there were alterations in the expression of PER2 and CRY1 between ADHD individuals with no medication compared to medicated ADHD patients or controls, whilst CLOCK expression was altered in patients with ADHD and current medication. Analysis of fibroblasts transfected with a BMAL1:luc reporter showed changes in the timing of the peak expression across the three groups. Taken together, these data support the contention that both ADHD and medication status impact on circadian processes.

Unravelling the Prospective Associations Between Mixed Anxiety-Depression and Insomnia During the Course of Cognitive Behavioral Therapy

OBJECTIVE

Previous studies have suggested that there is a reciprocal relationship between anxiety/depression and insomnia. However, little is known about the prospective relationships between these constructs across the course of cognitive behavioral therapy (CBT). The aim of the study was to examine these relationships in clients who received short-term CBT in a primary care setting.

METHODS

A total of 653 clients (mean [SD] age = 37.8 [12.9], 26.4% men) with mild to moderate levels of anxiety and depression and a treatment duration of at least 7 weeks were included for analyses. The clients completed questionnaires measuring mixed anxiety-depression (MAD - Patient Health Questionnaire Anxiety and Depression Scale) and insomnia (3 items derived from the Karolinska Sleep Questionnaire representing core DSM-V criteria) on a session-to-session basis. The data were analyzed using latent growth curve models and random intercept cross-lagged panel models.

RESULTS

The results of the latent growth curve models showed that there was a significant decrease in both MAD (cubic slope; B = .002, p < .001, quadratic slope; B = .036, p < .001, linear slope; B = -.205, p < .001) and insomnia (linear slope; B = -.080, p < .001) across treatment. A strong correlation (r = .838, p < .001) between the linear slopes indicated co-occurring change processes. The cross-lagged panel model showed that insomnia significantly predicted MAD at the subsequent measurements (B = .190, p < .001), but not vice versa (B = .252, p = .343).

CONCLUSIONS

Changes in MAD and insomnia are co-occurring processes during the course of CBT. Changes in insomnia predicted prospectively changes in MAD, but not vice versa. Targeting insomnia in the context of brief CBT in clients with mild to moderate anxiety and depression may therefore further reduce not only symptoms of insomnia but also symptoms of anxiety and depression.

Sleep disturbances in schizophrenia spectrum and bipolar disorders - a transdiagnostic perspective

BACKGROUND

Sleep disturbances are prevalent in severe mental disorders but their type and frequency across diagnostic categories has not been investigated in large scale studies.

METHODS

Participants with Schizophrenia spectrum disorders (SCZ, (N = 617)), Bipolar disorders (BD, (N = 440)), and Healthy Controls (HC, (N = 173)) were included in the study. Sleep disturbances (insomnia, hypersomnia and delayed sleep phase) were identified based on items from the Inventory of Depressive Symptoms - Clinician rated scale. Clinical symptoms were assessed with the Positive and Negative Syndrome scale and level of functioning with the Global assessment of Functioning scale.

RESULTS

The rate of any sleep disturbance was 78% in SZ, 69% in BD and 39% in HC. Insomnia was the most frequently reported sleep disturbance across all groups. Both diagnostic groups reported significantly more of any sleep disturbances than HC (P < 0.001). Having a sleep disturbance was associated with more severe negative and depressive symptoms and with lower functioning across diagnostic groups (P < 0.001, η² = 0.0071). Hypersomnia was the only sleep disturbance associated with previous treatment history.

CONCLUSION

Sleep disturbances, including insomnia, hypersomnia and delayed sleep phase, are frequent in SCZ and BD, and associated with more severe clinical symptomatology across diagnostic groups. This suggests that sleep disturbance is a clinically relevant transdiagnostic phenomenon.

Interventions for sleep difficulties in adults with an intellectual disability: a systematic review

BACKGROUND

Current literature highlights higher prevalence rates of sleep difficulties amongst adults with an intellectual disability. However, no synthesis has been conducted to assess the effectiveness of existing interventions in this population. Thus, the aim of this review was to assess the effectiveness of sleep interventions in adults with an intellectual disability (ID).

METHOD

Eight databases were searched to identify interventions for sleep difficulties amongst adults with an ID. The study quality was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions. Nine studies (n = 97) were eligible for inclusion in the review.

RESULTS

There was a notable study on heterogeneity in terms of the population, study design, intervention studied, sleep assessment and outcome assessments used. Eight of the nine studies reported improvement in sleep following intervention. However, these findings need additional support as only 97 participants involving a variety of interventions and measurement systems were used across all studies. Furthermore, eight of the nine studies had serious to critical risk of bias. The only study identified as having low risk of bias was a placebo-controlled randomised controlled trial for the use of melatonin.

CONCLUSIONS

This review highlights the need for objective measures such as actigraphy and studies with greater experimental control investigating sleep interventions in adults with ID.

Machine learning and big data in psychiatry: toward clinical applications

Psychiatry is a medical field concerned with the treatment of mental illness. Psychiatric disorders broadly relate to higher functions of the brain, and as such are richly intertwined with social, cultural, and experiential factors. This makes them exquisitely complex phenomena that depend on and interact with a large number of variables. Computational psychiatry provides two ways of approaching this complexity. Theory-driven computational approaches employ mechanistic models to make explicit hypotheses at multiple levels of analysis. Data-driven machine-learning approaches can make predictions from high-dimensional data and are generally agnostic as to the underlying mechanisms. Here, we review recent advances in the use of big data and machine-learning approaches toward the aim of alleviating the suffering that arises from psychiatric disorders.

Telecommunication devices use, screen time and sleep in adolescents

PURPOSE

To investigate the association between telecommunication and other screen devices use and subjective and objective sleep measures in adolescents at 17-18 years.

METHODS

Cross-sectional study on adolescents aged 17-18 years from a Spanish population-based birth cohort established in Menorca in 1997-1998. Information on devices use was collected using self-reported questionnaires. Mobile Phone Problematic Use Scale was used to assess mobile phone use dependency. Pittsburgh Sleep Quality Index was used to assess subjective sleep (n = 226). ActiGraph wGT3X-BT for 7 nights was used to assess objective sleep (n = 110).

RESULTS

One or more cordless phone calls/week was associated with a lower sleep quality [Prevalence Ratio (PR) 1.30 (95%Confidence Interval (CI) 1.04; 1.62)]. Habitual and frequent problematic mobile phone use was associated with a lower sleep quality [PR 1.55 (95%CI 1.03; 2.33) and PR 1.67 (95%CI 1.09; 2.56), respectively]. Higher tablet use was associated with decreased sleep efficiency and increased minutes of wake time after sleep onset [β-1.15 (95%CI -1.99; -0.31) and β 7.00 (95%CI 2.40; 11.60) per increase of 10 min/day of use, respectively]. No associations were found between other devices and sleep measures.

CONCLUSIONS

Frequency of cordless phone calls, mobile phone dependency, and tablet use were related to an increase of subjective and objective sleep problems in adolescents. These results seem to indicate that sleep displacement, mental arousal, and exposure to blue light screen emission might play a more important role on sleep than a high RF-EMF exposure to the brain. However, more studies are needed assessing personal RF-EMF levels to draw conclusions.

The effect of cognitive behavioral therapy for insomnia in schizophrenia patients with sleep Disturbance: A non-randomized, assessor-blind trial

This non-randomized, assessor blind study evaluated the effects of cognitive behavioral therapy for insomnia (CBT-I) delivered in a group format on insomnia symptoms as well as psychotic, depressive, and anxiety symptoms in schizophrenia patients (n = 63) recruited from residential or rehabilitative facilities in Seoul, South Korea. Thirty-one patients received four sessions of CBT-I in groups of 2-9 patients in addition to usual care, while the control group (n = 32) received no additional intervention. The Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI), Psychotic Symptoms Rating Scale (PSYRATS), Anxiety Sensitivity Index (ASI), and Beck Depression Inventory (BDI) were administered at baseline, week 4, and week 8. Both groups showed significant time-group interactions on the ISI and PSQI. Post hoc testing showed that, compared to the control group, the CBT-I group showed significant reductions in ISI and PSQI at both week 4 and week 8. For the PSYRATS, ASI, and BDI scores, the CBT-I and control groups showed significant time-group interactions, but post hoc testing revealed no significant group differences at either week 4 or week 8. Therefore, CBT-I was effective for reducing insomnia symptoms in patients with schizophrenia and the effect lasted for 4 weeks after the intervention.

Pre- to post-inpatient treatment of subjective sleep quality in 5,481 patients with mental disorders: A longitudinal analysis

There is only limited evidence of the course of sleep quality and sleep disturbances during acute inpatient treatment and the prediction of/association with treatment outcome in mental disorders. Within this naturalistic study, 5,481 consecutively admitted inpatients completed the Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI-II) at admission and at discharge. Treatment included both individual and group psychotherapy (but no specific interventions for sleep disturbances) and pharmacotherapy based on current national treatment guidelines. Correlation analyses, analyses of variance and linear models were calculated to analyse the datasets. The PSQI improved significantly (p < 0.001) from admission (mean score 9.51 [±4.11]) to discharge (mean score 8.08 [±4.20]) in all diagnostic subgroups. Despite this improvement, 47% of the patients still showed elevated PSQI scores (>5) at discharge. Patients with post-traumatic stress disorder showed the largest sleep disturbances at both time-points; patients with obsessive-compulsive disorder were the least impaired. An improvement of the PSQI was found to be significantly correlated (p < 0.001) to the change of BDI-II values (without the sleep item) during treatment. The likelihood of achieving remission of depressive symptoms (BDI-II total score <14) was significantly associated with less sleep disturbances at admission. The results suggest that almost half of inpatients with mental disorders treated successfully with state-of-the art specific psychotherapy and pharmacotherapy do not have remission of their sleep problems. Therefore, specific treatment programmes for insomnia should be evaluated and implemented in daily clinical routines.

Sleep Disorders in Early Psychosis: Incidence, Severity, and Association With Clinical Symptoms

Sleep disturbance is known to be associated with psychosis, but sleep disorders (eg, insomnia, nightmare disorder, sleep apnea) have rarely been investigated. We aimed to provide the first detailed assessment of sleep disorders and their correlates in patients with early psychosis. Sixty outpatients aged between 18 and 30 with nonaffective psychosis were assessed for sleep disorder presence, severity, and treatment using a structured diagnostic interview, sleep diaries, and actigraphy. Psychotic experiences, mood, and psychological wellbeing were also measured. Forty-eight patients (80%) had at least one sleep disorder, with insomnia and nightmare disorder being the most common. Comorbidity of sleep disorders within this group was high, with an average of 3.3 sleep disorders per patient. Over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment. Treatment according to clinical guidelines was rare, occurring in only 8% of cases (n = 13). Sleep disorders were significantly associated with increased psychotic experiences, depression, anxiety, fatigue, and lower quality of life. Sleep disorders are very common in patients with psychosis, may have wide-ranging negative effects, and merit routine assessment and treatment in psychiatric practice.

Insomnia and risk for suicidal behavior: A test of a mechanistic transdiagnostic model in veterans

BACKGROUND

Insomnia has been shown to have direct and indirect associations with suicidal ideation, attempts, and death in U.S. military and veteran populations. However, transdiagnostic models of insomnia and psychopathology have not been used to examine the contribution of psychopathology.

METHOD

The present study is a secondary analysis examining the associations among insomnia symptoms, posttraumatic stress disorder (PTSD) and depressive symptoms, interpersonal theory of suicide variables, and risk for suicidal behavior in community veterans (n = 392). Serial mediation was used to test sequential associations, allowing for examination of direct and indirect associations.

RESULTS

The model with insomnia, PTSD, and depressive symptoms, and thwarted belongingness, accounted for 29% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and thwarted belongingness. The model with insomnia, PTSD, and depressive symptoms, and perceived burdensomeness accounted for 35% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and perceived burdensomeness.

LIMITATIONS

Data are cross-sectional, precluding the testing of causal associations.

CONCLUSIONS

In veterans, insomnia symptoms may be associated with increased PTSD and depressive symptoms, which may be associated with increased risk for suicidal behavior directly and indirectly through relationship disruptions.

Links between psychotic and neurotic symptoms in the general population: an analysis of longitudinal British National Survey data using Directed Acyclic Graphs

BACKGROUND

Non-psychotic affective symptoms are important components of psychotic syndromes. They are frequent and are now thought to influence the emergence of paranoia and hallucinations. Evidence supporting this model of psychosis comes from recent cross-fertilising epidemiological and intervention studies. Epidemiological studies identify plausible targets for intervention but must be interpreted cautiously. Nevertheless, causal inference can be strengthened substantially using modern statistical methods.

METHODS

Directed Acyclic Graphs were used in a dynamic Bayesian network approach to learn the overall dependence structure of chosen variables. DAG-based inference identifies the most likely directional links between multiple variables, thereby locating them in a putative causal cascade. We used initial and 18-month follow-up data from the 2000 British National Psychiatric Morbidity survey (N = 8580 and N = 2406).

RESULTS

We analysed persecutory ideation, hallucinations, a range of affective symptoms and the effects of cannabis and problematic alcohol use. Worry was central to the links between symptoms, with plausible direct effects on insomnia, depressed mood and generalised anxiety, and recent cannabis use. Worry linked the other affective phenomena with paranoia. Hallucinations were connected only to worry and persecutory ideation. General anxiety, worry, sleep problems, and persecutory ideation were strongly self-predicting. Worry and persecutory ideation were connected over the 18-month interval in an apparent feedback loop.

CONCLUSIONS

These results have implications for understanding dynamic processes in psychosis and for targeting psychological interventions. The reciprocal influence of worry and paranoia implies that treating either symptom is likely to ameliorate the other.

Sleep duration and psychotic experiences in patients at risk of psychosis: A secondary analysis of the EDIE-2 trial

Sleep disturbance is common among individuals at risk of psychosis, yet few studies have investigated the relationship between sleep disturbance and clinical trajectory. The Early Detection and Intervention Evaluation (EDIE-2) trial provides longitudinal data on sleep duration and individual psychotic experiences from a cohort of individuals at risk of psychosis, which this study utilises in an opportunistic secondary analysis. Shorter and more variable sleep was hypothesised to be associated with more severe psychotic experiences and lower psychological wellbeing. Mixed effect models were used to test sleep duration and range as predictors of individual psychotic experiences and psychological wellbeing over the 12-24 months (with assessments every 3 months) in 160 participants. Shorter sleep duration was associated with more severe delusional ideas and hallucinations cross-sectionally and longitudinally. The longitudinal relationships did not remain significant after conservative controls were added for the previous severity of psychotic experiences. No significant relationships were found between the sleep variables and other psychotic experiences (e.g. cognitive disorganisation), or psychological wellbeing. The results support a relationship between shorter sleep duration and delusional ideas and hallucinations. Future studies should focus on improving sleep disturbance measurement, and test whether treating sleep improves clinical trajectory in the at-risk group.

Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial

BACKGROUND

Insomnia and depression are highly comorbid and mutually exacerbate clinical trajectories and outcomes. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces both insomnia and depression severity, and can be delivered digitally. This could substantially increase the accessibility to CBT-I, which could reduce the health disparities related to insomnia; however, the efficacy of digital CBT-I (dCBT-I) across a range of demographic groups has not yet been adequately examined. This randomized placebo-controlled trial examined the efficacy of dCBT-I in reducing both insomnia and depression across a wide range of demographic groups.

METHODS

Of 1358 individuals with insomnia randomized, a final sample of 358 were retained in the dCBT-I condition and 300 in the online sleep education condition. Severity of insomnia and depression was examined as a dependent variable. Race, socioeconomic status (SES; household income and education), gender, and age were also tested as independent moderators of treatment effects.

RESULTS

The dCBT-I condition yielded greater reductions in both insomnia and depression severity than sleep education, with significantly higher rates of remission following treatment. Demographic variables (i.e. income, race, sex, age, education) were not significant moderators of the treatment effects, suggesting that dCBT-I is comparably efficacious across a wide range of demographic groups. Furthermore, while differences in attrition were found based on SES, attrition did not differ between white and black participants.

CONCLUSIONS

Results provide evidence that the wide dissemination of dCBT-I may effectively target both insomnia and comorbid depression across a wide spectrum of the population.

Schizophrenia liability shares common molecular genetic risk factors with sleep duration and nightmares in childhood

Background: Sleep abnormalities are common in schizophrenia, often appearing before psychosis onset; however, the mechanisms behind this are uncertain. We investigated whether genetic risk for schizophrenia is associated with sleep phenotypes. Methods: We used data from 6,058 children and 2,302 mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC). We examined associations between a polygenic risk score for schizophrenia and sleep duration in both children and mothers, and nightmares in children, along with genetic covariances between these traits. Results: Polygenic risk for schizophrenia was associated with increased risk of nightmares (OR=1.07, 95% CI: 1.01, 1.14, p=0.02) in children, and also with less sleep (β=-44.52, 95% CI: -88.98, -0.07; p=0.05). We observed a similar relationship with sleep duration in mothers, although evidence was much weaker (p=0.38). Finally, we found evidence of genetic covariance between schizophrenia risk and reduced sleep duration in children and mothers, and between schizophrenia risk and nightmares in children. Conclusions: These molecular genetic results support recent findings from twin analysis that show genetic overlap between sleep disturbances and psychotic-like experiences. They also show, to our knowledge for the first time, a genetic correlation between schizophrenia liability and risk of nightmares in childhood.

Sleep problem, suicide and self-harm in university students: A systematic review

Suicide and self-harm behaviours represent public health concerns, and university students are a particularly high risk group. Identifying modifiable risk factors for the development and maintenance of suicidal thoughts and behaviours is a research priority, as prevention is crucial. Research examining the relationship between poor sleep and self-harm/suicidality within university students is, for the first time, systematically evaluated, critically appraised, and synthesised. This literature consistently demonstrates that insomnia and nightmares are associated with elevated suicide risk of suicidal thoughts and behaviours within this subpopulation of young adults. However, as findings are predominantly derived from cross-sectional investigations, the directionality of this relationship is not yet clear. While research investigating the psychological processes driving these relationships is in its infancy, preliminary findings suggest that thwarted belongingness, socio-cognitive factors and emotional dysregulation could be partly responsible. Methodological limitations are highlighted and a research agenda suggesting the key directions for future research is proposed. Continued research in this area - employing longitudinal designs, and testing novel theoretically derived hypotheses - will be crucial to the development of suicide prevention and intervention efforts.