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Li D, Ji A, Lin Z, Liu J, Tan C, Huang X, Xiao H, Tang E, Liu X, Yao C, Li Y, Zhou L, Cai T. Short-term ambient air pollution exposure and adult primary insomnia outpatient visits in Chongqing, China: A time-series analysis. ENVIRONMENTAL RESEARCH 2022; 212:113188. [PMID: 35351452 DOI: 10.1016/j.envres.2022.113188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 06/14/2023]
Abstract
Growing evidence suggest that air pollutants can be associated with sleep disorders. However, no study has explored the association of short-term air pollution exposure with primary insomnia, a specific type of sleep disorders. To evaluate the correlation of short-term air pollution exposure with adult primary insomnia outpatient visits in Chongqing, China, we collected data of adult primary insomnia outpatient visits and air pollutants' concentrations between 2013 and 2019 and the associations were estimated with single-day lags as well as moving average lags using a generalized additive model. Totally, 23,919 outpatient visits for adult primary insomnia were identified. The daily data of adult insomnia outpatient visits, air pollutants (NO2, CO, SO2, O3, PM10 and PM2.5) and meteorological conditions (daily mean temperature and relative humidity) were gathered. Short-term exposure to multiple air pollutants, especially NO2 and SO2, was associated with adult primary insomnia visits. A 10 μg/m3 increase in NO2 and SO2 at lag 05 corresponded to increased primary insomnia outpatient visits 3.87% (95% CI: 1.50%-6.24%) and 7.22% (95% CI: 2.10%-12.35%), respectively. Moreover, stronger links were presented in females and cool seasons for NO2 while in the elderly for SO2. Collectively, this time-series study suggested that short-term exposure to air pollutants, especially to NO2 and SO2, was associated with higher risk of adult primary insomnia outpatient visits, and such association could to be sex-, age-, and season-modified.
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Affiliation(s)
- Dawei Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Ailing Ji
- Department of Preventive Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China
| | - Zhijing Lin
- Department of Toxicology & Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, China
| | - Jianghong Liu
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Chunlei Tan
- Department of Quality Management, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Xiaolong Huang
- Medical Department, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Hua Xiao
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Enjie Tang
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Xiaoling Liu
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Chunyan Yao
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China
| | - Laixin Zhou
- Medical Department, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400038, China.
| | - Tongjian Cai
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, 400038, China.
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Basta M, Vgontzas AN, Fernandez-Mendoza J, Antypa D, Li Y, Zaganas I, Panagiotakis S, Karagkouni E, Simos P. Basal Cortisol Levels Are Increased in Patients with Mild Cognitive Impairment: Role of Insomnia and Short Sleep Duration. J Alzheimers Dis 2022; 87:933-944. [PMID: 35404277 DOI: 10.3233/jad-215523] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mild cognitive impairment (MCI) is frequent in elderly and a risk factor for dementia. Both insomnia and increased cortisol levels are risk factors for MCI. OBJECTIVE We examined cross-sectionally whether increased cortisol levels are associated with short sleep duration (SSD) and/or the insomnia short sleep duration (ISS) phenotype, in elderly with MCI. METHODS One hundred twenty-four participants with MCI and 84 cognitively non-impaired controls (CNI)≥60 years underwent medical history, physical examination, neuropsychiatric evaluation, neuropsychological testing, 3-day actigraphy, assessment of subjective insomnia symptoms, and a single morning plasma cortisol level. The short sleep phenotypes were defined by sleep efficiency below the median of the entire sample (i.e.,≤81%) with at least one insomnia symptom (ISS) or without (SSD). ANOVA models were used to compare the various sleep phenotypes to those who did not present either short sleep or insomnia symptoms [non-insomnia (NI)]. RESULTS MCI participants had higher cortisol levels compared to the CNI group (p = 0.009). MCI participants with insomnia (n = 44) or SSD (n = 38) had higher cortisol levels compared to the NI group (n = 42; p = 0.014 and p = 0.045, respectively). Furthermore, MCI participants with ISS phenotype but not those with insomnia with normal sleep duration had higher cortisol levels compared to NI (p = 0.011 and p = 0.4, respectively). Both linear trend analyses showed that cortisol reached the highest levels in the ISS phenotype. CONCLUSION The ISS and SSD phenotypes are associated with increased cortisol levels in elderly with MCI. Improving sleep quality and duration and decreasing cortisol levels may delay further cognitive decline.
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Affiliation(s)
- Maria Basta
- Department of Psychiatry, University Hospital of Heraklion, Heraklion, Crete, Greece
- Sleep Research and Treatment Center, Department of Psychiatry, Penn State University, Hershey, PA, USA
| | - Alexandros N Vgontzas
- Department of Psychiatry, University Hospital of Heraklion, Heraklion, Crete, Greece
- Sleep Research and Treatment Center, Department of Psychiatry, Penn State University, Hershey, PA, USA
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry, Penn State University, Hershey, PA, USA
| | - Despina Antypa
- Department of Psychiatry, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yun Li
- Department of Sleep Medicine, Mental Health Center of Shantou University, Shantou, Guangdong, China
- Sleep Medicine Center, Shantou University Medical College, Shantou, Guangdong, China
| | - Ioannis Zaganas
- Department of Neurology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Symeon Panagiotakis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Efthalia Karagkouni
- Sleep Research and Treatment Center, Department of Psychiatry, Penn State University, Hershey, PA, USA
| | - Panagiotis Simos
- Department of Psychiatry, University Hospital of Heraklion, Heraklion, Crete, Greece
- Computational Biomedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology-Hellas, Greece
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Dressle RJ, Feige B, Spiegelhalder K, Schmucker C, Benz F, Mey NC, Riemann D. HPA axis activity in patients with chronic insomnia: A systematic review and meta-analysis of case-control studies. Sleep Med Rev 2022; 62:101588. [DOI: 10.1016/j.smrv.2022.101588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/29/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
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Liu X, Li C, Sun X, Yu Y, Si S, Hou L, Yan R, Yu Y, Li M, Li H, Xue F. Genetically Predicted Insomnia in Relation to 14 Cardiovascular Conditions and 17 Cardiometabolic Risk Factors: A Mendelian Randomization Study. J Am Heart Assoc 2021; 10:e020187. [PMID: 34315237 PMCID: PMC8475657 DOI: 10.1161/jaha.120.020187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background This Mendelian randomization study aims to investigate causal associations between genetically predicted insomnia and 14 cardiovascular diseases (CVDs) as well as the potential mediator role of 17 cardiometabolic risk factors. Methods and Results Using genetic association estimates from large genome‐wide association studies and UK Biobank, we performed a 2‐sample Mendelian randomization analysis to estimate the associations of insomnia with 14 CVD conditions in the primary analysis. Then mediation analysis was conducted to explore the potential mediator role of 17 cardiometabolic risk factors using a network Mendelian randomization design. After correcting for multiple testing, genetically predicted insomnia was consistent significantly positively associated with 9 of 14 CVDs, those odds ratios ranged from 1.13 (95% CI, 1.08–1.18) for atrial fibrillation to 1.24 (95% CI, 1.16–1.32) for heart failure. Moreover, genetically predicted insomnia was consistently associated with higher body mass index, triglycerides, and lower high‐density lipoprotein cholesterol, each of which may act as a mediator in the causal pathway from insomnia to several CVD outcomes. Additionally, we found very little evidence to support a causal link between insomnia with abdominal aortic aneurysm, thoracic aortic aneurysm, total cholesterol, low‐density lipoprotein cholesterol, glycemic traits, renal function, and heart rate increase during exercise. Finally, we found no evidence of causal associations of genetically predicted body mass index, high‐density lipoprotein cholesterol, or triglycerides on insomnia. Conclusions This study provides evidence that insomnia is associated with 9 of 14 CVD outcomes, some of which may be partially mediated by 1 or more of higher body mass index, triglycerides, and lower high‐density lipoprotein cholesterol.
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Affiliation(s)
- Xinhui Liu
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Chuanbao Li
- Department of Emergency and Chest Pain Center Qilu HospitalCheeloo College of MedicineShandong University Jinan Shandong China
| | - Xiaoru Sun
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Yuanyuan Yu
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Shucheng Si
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Lei Hou
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Ran Yan
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Yifan Yu
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Mingzhuo Li
- Center for Big Data Research in Health and Medicine Shandong Qianfoshan HospitalCheeloo College of MedicineShandong University Jinan Shandong China
| | - Hongkai Li
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
| | - Fuzhong Xue
- Department of Biostatistics School of Public Health Cheeloo College of MedicineShandong University Jinan Shandong China.,Institute for Medical Dataology Cheeloo College of MedicineShandong University Jinan Shandong China
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Vgontzas AN, Puzino K, Fernandez-Mendoza J, Krishnamurthy VB, Basta M, Bixler EO. Effects of trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: a preliminary study. J Clin Sleep Med 2021; 16:2009-2019. [PMID: 32780015 DOI: 10.5664/jcsm.8740] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVES The insomnia with objective short sleep duration phenotype is associated with increased risk for adverse health outcomes, physiological hyperarousal, and a blunted response to cognitive behavioral therapy for insomnia (CBT-I). Whether insomnia with objective short sleep duration responds better to pharmacological treatment compared to CBT-I has not been examined. METHODS Participants included 15 patients with chronic insomnia (86.7% female), aged 45.3 ± 8.1 years. Eight patients were randomized to CBT-I and 7 to trazodone. Patients were examined with 2 weeks of actigraphy, salivary cortisol, and the insomnia severity index at 3 time points (pretreatment, 3-month posttreatment, and 6-month follow-up). Mixed between-within-subjects analysis of variance and univariate analysis of covariance were conducted to assess the impact of trazodone and CBT-I on patients' total sleep time, salivary cortisol, and insomnia severity index scores across the 3 time points. RESULTS Trazodone, but not CBT-I, significantly lengthened total sleep time (when measured with actigraphy) both at posttreatment (51.01 minutes vs -11.73 minutes; P = .051; Cohen's d = 1.383) and at follow-up (50.35 minutes vs -7.56 minutes; P = .012; Cohen's d = 1.725), respectively. In addition, trazodone, but not CBT-I, showed a clinically meaningful decrease in salivary cortisol from pretreatment to posttreatment (-36.07% vs -11.70%; Cohen's d = 0.793) and from pretreatment to follow-up (-21.37% vs -5.79%; Cohen's d = 0.284), respectively. Finally, there were no differences on insomnia severity index scores between the trazodone and the CBT-I groups. CONCLUSIONS The current preliminary, open-label, randomized trial suggests that trazodone, but not CBT-I, significantly improves objective sleep duration and reduces hypothalamic-pituitary-adrenal axis activation, suggesting a differential treatment response in the insomnia with objective short sleep duration phenotype. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Study of Trazodone & Cognitive Behavioral Therapy to Treat Insomnia; URL: https://clinicaltrials.gov/ct2/show/NCT01348542; Identifier: NCT01348542.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research and Treatment Center, Penn State Health Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Kristina Puzino
- Sleep Research and Treatment Center, Penn State Health Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Penn State Health Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Venkatesh Basappa Krishnamurthy
- Sleep Research and Treatment Center, Penn State Health Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Maria Basta
- Department of Psychiatry, University of Crete, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Edward O Bixler
- Sleep Research and Treatment Center, Penn State Health Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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Goldstein SJ, Gaston SA, McGrath JA, Jackson CL. Sleep Health and Serious Psychological Distress: A Nationally Representative Study of the United States among White, Black, and Hispanic/Latinx Adults. Nat Sci Sleep 2020; 12:1091-1104. [PMID: 33299371 PMCID: PMC7721291 DOI: 10.2147/nss.s268087] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Prior studies investigating the relationship between sleep and serious psychological distress (SPD) have lacked racial/ethnic diversity and generalizability. We investigated associations between sleep and SPD among a large, nationally representative, and racially/ethnically diverse sample of US adults. METHODS We pooled cross-sectional data from the 2004 to 2017 National Health Interview Survey. Participants self-reported sleep duration and sleep disturbances (eg, trouble falling and staying asleep). SPD was defined as a Kessler Psychological Distress Scale (K6) score ≥13. Adjusting for sociodemographic, health behavior, and clinical characteristics, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of SPD for each sleep characteristic, overall and by race/ethnicity. RESULTS Among 316,840 participants, the mean age ± standard error was 46.9 ± 0.1 years, 52% were women, 75% were non-Hispanic (NH)-White, 16% NH-Black, and 9% Hispanic/Latinx. The prevalence of SPD was 3.4% for NH-Whites, 4.1% for NH-Blacks, and 4.5% for Hispanics/Latinxs. Participants with <7 hours versus 7-9 hours of sleep duration were more likely to have SPD, and the magnitude of the association was strongest among NH-Black participants (PRNH-Blacks=3.50 [95% CI: 2.97-4.13], PR Hispanics/Latinx=2.95 [2.42-3.61], and PRNH-Whites=2.66 [2.44-2.89]). Positive associations between sleep disturbances and SPD were generally stronger among NH-Black and Hispanic/Latinx compared to NH-White adults. CONCLUSION Poor sleep health was positively associated with SPD, and the magnitude of the association was generally stronger among racial/ethnic minorities. Future investigations should prospectively focus on the determinants and health consequences of SPD attributable to objectively measured sleep across racial/ethnic groups.
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Affiliation(s)
- Samuel J Goldstein
- The University of North Carolina at Chapel Hill, Department of Environmental Sciences and Engineering, Chapel Hill, NC, USA
| | - Symielle A Gaston
- Department of Health and Human Services, Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
| | | | - Chandra L Jackson
- Department of Health and Human Services, Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA.,Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
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Abstract
Pharmacogenetics is the branch of personalized medicine concerned with the variability in drug response occurring because of heredity. Advances in genetics research, and decreasing costs of gene sequencing, are promoting tremendous growth in pharmacogenetics in all areas of medicine, including sleep medicine. This article reviews the body of research indicating that there are genetic variations that affect the therapeutic actions and adverse effects of agents used for the treatment of sleep disorders to show the potential of pharmacogenetics to improve the clinical practice of sleep medicine.
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Galbiati A, Sforza M, Fasiello E, Castronovo V, Ferini-Strambi L. Impact Of Phenotypic Heterogeneity Of Insomnia On The Patients' Response To Cognitive-Behavioral Therapy For Insomnia: Current Perspectives. Nat Sci Sleep 2019; 11:367-376. [PMID: 31819690 PMCID: PMC6890191 DOI: 10.2147/nss.s198812] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 10/22/2019] [Indexed: 11/23/2022] Open
Abstract
Insomnia is one of the most common mental disorders and the most frequent sleep disorder encountered in clinical practice, with a prevalence of about 7% in the European population. Insomnia Disorder (ID) is defined as a disturbance of sleep initiation or maintenance, followed by a feeling of non-restorative sleep and several diurnal consequences ranging from occupational and social difficulties to cognitive impairment. Cognitive-Behavioral Therapy for Insomnia (CBT-I) is considered the first-choice therapy for this disorder because its effectiveness has been proven to be greater in the long term with fewer side effects in comparison to pharmacotherapy. Although its effectiveness has been well established, it has been reported that nearly 40% of patients do not achieve remission after treatment. This finding could be the consequence of heterogeneity of ID between patients. It has been proposed that this heterogeneity might be ascribable to indices that are not related to sleep quality and quantity, such as comorbidities, life events, and personality traits. However, several works focused on the role of sleep markers, in particular objective total sleep time, for the phenotypization of ID and treatment response. The aim of this work is to summarize the available scientific literature regarding the impact of ID subtype on CBT-I response.
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Affiliation(s)
- Andrea Galbiati
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, Milan, Italy.,Faculty of Psychology, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Marco Sforza
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, Milan, Italy.,Faculty of Psychology, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Elisabetta Fasiello
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, Milan, Italy
| | - Vincenza Castronovo
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, Milan, Italy
| | - Luigi Ferini-Strambi
- IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, Milan, Italy.,Faculty of Psychology, "Vita-Salute" San Raffaele University, Milan, Italy
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Lovato N, Miller CB, Gordon CJ, Grunstein RR, Lack L. The efficacy of biofeedback for the treatment of insomnia: a critical review. Sleep Med 2018; 56:192-200. [PMID: 30846410 DOI: 10.1016/j.sleep.2018.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 11/26/2018] [Accepted: 12/03/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The popularity of biofeedback as a non-pharmacological treatment option for insomnia has increased in recent times despite inconsistent empirical evidence for its therapeutic efficacy. OBJECTIVE The purpose of the current review was to systematically assess the efficacy of using biofeedback to treat insomnia. METHODS AND RESULTS A search of electronic databases (PubMED, MEDLINE, OvidSP, Ovid EMBASE, PsychInfo, The Cochrane Library including Cochrane Reviews), clinical trials databases and registries (Clinical Trials Database [US], Australian New Zealand Clinical Trials Registry [ANZCTR]) and online journal (eg, SLEEP, Sleep Medicine) identified 92 studies. Of these, 50 publications were descriptive or review papers about use of biofeedback for the treatment of insomnia, while an additional 37 did not meet the detailed inclusion criteria (ie not original research, participants do not meet the diagnostic criteria for insomnia). Six full-text articles met inclusion criteria and were included in this review. Methodological flaws including poor study design (small sample size, lack of control group) limit the validity of the body of work in this field to date and fail adequately to account for other unspecified factors likely to drive the observed changes, such as care and attention of those administering the treatment, as well as the expectations and motivations of the patient. CONCLUSION There is an urgent need for future studies to clarify the role of unspecific placebo effects when reporting biofeedback effects for the treatment of insomnia.
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Affiliation(s)
- Nicole Lovato
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, Flinders University of South Australia, Australia; CRC for Alertness, Safety and Productivity, Melbourne, VIC, Australia.
| | | | - Christopher J Gordon
- CRC for Alertness, Safety and Productivity, Melbourne, VIC, Australia; CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, NSW, Australia; Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia
| | - Ronald R Grunstein
- CRC for Alertness, Safety and Productivity, Melbourne, VIC, Australia; CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, NSW, Australia; Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Leon Lack
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, Flinders University of South Australia, Australia; School of Psychology, Flinders University of South Australia, Australia
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Insomnia and mortality: A meta-analysis. Sleep Med Rev 2018; 43:71-83. [PMID: 30529432 DOI: 10.1016/j.smrv.2018.10.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 09/27/2018] [Accepted: 10/29/2018] [Indexed: 11/23/2022]
Abstract
The purpose of this review was to evaluate the strength of evidence for a relationship between risk of mortality and frequent and ongoing insomnia using a meta-analytic strategy. Seventeen studies, including a total of 36,938,981 individuals followed up for a mean of 11.6 y, reporting the investigation of the association between mortality and frequent (≥3 nights/wk), ongoing (≥1 mo) insomnia were identified. There was no difference in the odds of mortality for those individuals with symptoms of insomnia when compared to those without symptoms (OR = 1.06, 95%CI = 0.61-1.84, p = .84). This finding was echoed in the assessment of the rate of mortality in those with and without symptoms of insomnia using the outcomes of multivariate models, with the most complete adjustment for potential confounders, as reported by the individual studies included in this meta-analysis (HR = 1.07, 95%CI = .96-.1.19, p = .22). Additional analyses revealed a tendency for an increased risk of mortality associated with hypnotic use. The current evidence reinforces the use of cognitive therapy, within a CBTi framework, as a frontline non-pharmacological treatment for insomnia to reassure patients their longevity will not be impacted as a consequence of suffering from insomnia.
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11
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Mohammadi H, Rezaei M, Amiri SM, Rahimi Z, Mansouri K, Khazaie H. Sleep Architecture and Hypothalamic-Pituitary-Adrenal Activity in Paradoxical and Psychophysiological Insomnia. Basic Clin Neurosci 2018; 9:397-407. [PMID: 30719254 PMCID: PMC6359682 DOI: 10.32598/bcn.9.6.397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/10/2017] [Accepted: 02/25/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction: There are controversial reports about association between sleep and Hypothalamic-Pituitary-Adrenal (HPA) activity. Studies have reported the influence of insomnia on HPA hormones. However, they usually ignored the heterogeneity of insomnia symptoms, so subtypes of the disorder have not been considered in the reports. The present study aimed to investigate the final and intermediate products of HPA system among a group of psychophysiological and paradoxical insomniac patients in comparison to a group of normal sleepers. Methods: We investigated the awakening serum level of Adrenocorticotropic Hormone (ACTH) and cortisol after one night Polysomnography (PSG) in 17 subjects with psychophysiological insomnia, 19 subjects with paradoxical insomnia and 17 subjects with normal sleep profile. Groups were matched for age and Body Mass Index (BMI). Serum levels of ACTH and cortisol were measured by Enzyme-Linked Immunosorbent Assay (ELISA) method. Results: Although, a tendency toward elevation of both ACTH and cortisol was observed among patients with paradoxical insomnia compared to both control and psychophysiological insomnia, the differences were not significant comparing three groups. According to regression analysis, higher Non-Rapid Eye Movement sleep (NREM) arousal and Pulse Transit Time (PTT) significantly predicted higher level of ACTH. Conclusion: These findings could suggest the personality traits hypothesis for paradoxical insomnia. Both cortical and subcortical arousal could lead to more HPA activity and higher ACTH level. Further studies are recommended to confirm the hypothesis.
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Affiliation(s)
- Hiwa Mohammadi
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Department of Neurology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Rezaei
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Seyed Mojtaba Amiri
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Zohreh Rahimi
- Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kamran Mansouri
- Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Habibolah Khazaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Vargas I, Vgontzas AN, Abelson JL, Faghih RT, Morales KH, Perlis ML. Altered ultradian cortisol rhythmicity as a potential neurobiologic substrate for chronic insomnia. Sleep Med Rev 2018; 41:234-243. [PMID: 29678398 PMCID: PMC6524148 DOI: 10.1016/j.smrv.2018.03.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/11/2018] [Accepted: 03/20/2018] [Indexed: 11/19/2022]
Abstract
Chronic insomnia is highly prevalent and associated with significant morbidity (i.e., confers risk for multiple psychiatric and medical disorders, such as depression and hypertension). Therefore, it is essential to identify factors that perpetuate this disorder. One candidate factor in the neurobiology of chronic insomnia is hypothalamic-pituitary-adrenal-axis dysregulation, and in particular, alterations in circadian cortisol rhythmicity. Cortisol secretory patterns, however, fluctuate with both a circadian and an ultradian rhythm (i.e., pulses every 60-120 min). Ultradian cortisol pulses are thought to be involved in the maintenance of wakefulness during the day and their relative absence at night may allow for the consolidation of sleep and/or shorter nocturnal awakenings. It is possible that the wakefulness that occurs in chronic insomnia may be associated with the aberrant occurrence of cortisol pulses at night. While cortisol pulses naturally occur with transient awakenings, it may also be the case that cortisol pulsatility becomes a conditioned phenomenon that predisposes one to awaken and/or experience prolonged nocturnal awakenings. The current review summarizes the literature on cortisol rhythmicity in subjects with chronic insomnia, and proffers the suggestion that it may be abnormalities in the ultradian rather than circadian cortisol that is associated with the pathophysiology of insomnia.
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Affiliation(s)
- Ivan Vargas
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Behavioral Sleep Medicine Program, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Alexandros N Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - James L Abelson
- University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
| | - Rose T Faghih
- Computational Medicine Laboratory, Department of Electrical and Computer Engineering, University of Houston, Houston, TX, USA
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L Perlis
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Behavioral Sleep Medicine Program, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors. RECENT FINDINGS Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities. SUMMARY Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.
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Nano MM, Fonseca P, Vullings R, Aarts RM. Measures of cardiovascular autonomic activity in insomnia disorder: A systematic review. PLoS One 2017; 12:e0186716. [PMID: 29059210 PMCID: PMC5653329 DOI: 10.1371/journal.pone.0186716] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/08/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Insomnia disorder is a widespread sleep disorder with a prevalence of approximately 10%. Even though the link between insomnia and cardiovascular activity is not exactly clear, it is generally assumed that cardiovascular autonomic modifications could occur as a result of sleeplessness, or, alternatively, that autonomic alterations could be an expression of a hyper-arousal state. This review investigates whether cardiovascular measures are different between insomniacs and controls. METHODS Electronic databases were systematically searched, and 34 studies were identified. Heart rate variability features, the association of cardiac and EEG activity, physiologic complexity measures, and cardiovascular activity, assessed by measures such as pre-ejection time, blood pressure, and heart rate dynamics were studied. Given the heterogeneity of the studies, a narrative synthesis of the findings was performed. RESULTS This review study found overall differences in cardiovascular activity between insomniacs and controls in most of the observational studies (21/26), while the expression of cardiovascular regulation varied between the examined insomniac groups. All the studies that investigated the association of cardiac activity and EEG power reported an altered relation between autonomic activity and EEG parameters in insomniacs. CONCLUSION Autonomic regulation tends to be consistent between insomniacs, as long as they are grouped according to their respective phenotype, as shown in the insomnia subgroup with objectively short sleep duration. Our hypothesis is that these differences in the expression of cardiovascular activity could be explained by the heterogeneity of the disorder. Therefore, the determination of insomnia phenotypes, and the study of cardiovascular measures, rather than heart rate variability alone, will give more insight into the link between insomnia and cardiovascular regulation. This study suggests that cardiovascular activity differs between insomniacs and controls. These new findings are of interest to clinicians and researchers for a more accurate insomnia assessment, and the development of personalized technological solutions in insomnia.
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Affiliation(s)
- Marina-Marinela Nano
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Sleep Medicine Centre Kempenhaeghe, Heeze, The Netherlands
- Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Pedro Fonseca
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Ronald M. Aarts
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Philips Research, High Tech Campus, Eindhoven, The Netherlands
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Javaheri S, Redline S. Insomnia and Risk of Cardiovascular Disease. Chest 2017; 152:435-444. [PMID: 28153671 DOI: 10.1016/j.chest.2017.01.026] [Citation(s) in RCA: 322] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/12/2017] [Accepted: 01/21/2017] [Indexed: 11/17/2022] Open
Abstract
Insomnia is the most prevalent sleep disorder in the United States and has high comorbidity with a number of cardiovascular diseases (CVDs). In the past decade, a number of observational studies have demonstrated an association between insomnia and incident cardiovascular disease (CVD) morbidity and mortality, including hypertension (HTN), coronary heart disease (CHD), and heart failure (HF). Despite some inconsistencies in the literature, likely due to variations in how insomnia is defined and measured, the existing data suggest that insomnia, especially when accompanied by short sleep duration, is associated with increased risk for HTN, CHD and recurrent acute coronary syndrome, and HF. Purported mechanisms likely relate to dysregulation of the hypothalamic-pituitary axis, increased sympathetic nervous system activity, and increased inflammation. This paper reviews the most recent studies of insomnia and CVD and the potential pathophysiological mechanisms underlying this relationship and highlights the need for randomized trials to further elucidate the nature of the relationship between insomnia and CVD.
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Affiliation(s)
- Sogol Javaheri
- Department of Medicine, Division of Sleep, Circadian Rhythm, and Neurobiology, Brigham and Women's Hospital, Boston, MA.
| | - Susan Redline
- Department of Medicine, Division of Sleep, Circadian Rhythm, and Neurobiology, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Division of Sleep, Beth Israel Deaconess Medical Center, Boston, MA
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16
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Clinical Sleep-Wake Disorders II: Focus on Insomnia and Circadian Rhythm Sleep Disorders. Handb Exp Pharmacol 2017; 253:261-276. [PMID: 28707143 DOI: 10.1007/164_2017_40] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Insomnia and circadian rhythm sleep disorders affect large proportions of the population and have pronounced effects on quality of life and daytime performance. While the neurobiology of insomnia is not yet fully understood, circadian rhythm sleep disorders are assumed to be caused by a mismatch between the individual circadian phase position and the desired sleep-wake schedule. Benzodiazepines and non-benzodiazepine positive allosteric GABAA receptor modulators improve sleep onset and maintenance in the short-term treatment of insomnia. However, tolerance and dependence are important side effects. Sedating antidepressants are frequently prescribed for insomnia, however, only few randomised controlled trials have been published so far. Melatonin and melatonin receptor agonists are considered to be an option for the treatment of insomnia especially because of their minimal abuse potential and safety. First data on orexin (aka hypocretin) receptor antagonists are promising, however, the risk-benefit ratio needs to be further evaluated. With respect to circadian rhythm sleep disorders, there is solid evidence from meta-analyses supporting the use of melatonin in jet lag disorder to accelerate entrainment to the new time zone, and in delayed sleep phase disorder to advance sleep-wake rhythms. In addition to that, there is evidence supporting the use of melatonin in patients with shift work disorder in order to promote daytime sleep after night shifts.
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Abstract
Sleep and wake states involve interaction among many brain centers via multiple neurotransmitters, including dopamine, norepinephrine, hypocretin, acetylcholine, histamine and serotonin (wake promoting), and γ amino butyric acid (GABA) and melatonin (sleep promoting). Most medications for insomnia or hypersomnia act on elements of these neural systems. Initial treatment of insomnia includes sleep hygiene measures. Cognitive-behavioral therapy for insomnia is useful. Medications approved by the Food and Drug Administration for insomnia act on GABA receptors or on melatonin receptors. A frequent cause of insomnia is restless legs syndrome, which is linked to reduced dopaminergic activity in brain structures; idiopathic restless legs syndrome is best treated with dopamine agonists such as ropinerole or pramipexole. Excessive daytime sleepiness is most often due to insufficient sleep hours or sleep apnea but is also caused by medications, illnesses, narcolepsy, or idiopathic hypersomnia. Stimulants generally act through enhanced dopamine action (amphetamines, methylphenidate) or acetylcholine action (caffeine). Modafinil may act through enhanced central histamine, hypocretin, and possibly dopamine action. A newer agent, γ -hydroxybutyrate (GHB), acts on GABA and GHB receptors to consolidate sleep, improving daytime sleepiness in narcolepsy. Improving knowledge of sleep/wake mechanisms should lead to more specific and rational treatments for sleep disorders.
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Affiliation(s)
- Jeremiah Suhl
- Sleep Disorders Center, Lexington Veterans Affairs Medical Center, and voluntary assistant professor of medicine, Neurology Department, University of Kentucky College of Medicine, Lexington, Kentucky,
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18
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Comparing and contrasting therapeutic effects of cognitive - behavior therapy for older adults suffering from insomnia with short and long objective sleep duration. Sleep Med 2016; 22:4-12. [DOI: 10.1016/j.sleep.2016.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/17/2016] [Accepted: 04/09/2016] [Indexed: 11/15/2022]
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Li Y, Yang Y, Li Q, Yang X, Wang Y, Ku WL, Li H. The impact of the improvement of insomnia on blood pressure in hypertensive patients. J Sleep Res 2016; 26:105-114. [PMID: 27095167 DOI: 10.1111/jsr.12411] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 02/07/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Yuan Li
- Department of Cell Biology and Molecular Genetics; University of Maryland; College Park MD USA
| | - Yiling Yang
- Department of Diagnostics of TCM; School of Preclinical Medicine; Beijing University of Chinese Medicine; Beijing China
| | - Qiubing Li
- Department of Geriatrics; China-Japan Friendship Hospital; Beijing China
| | - Xueqing Yang
- Department of Geriatrics; China-Japan Friendship Hospital; Beijing China
| | - Yan Wang
- Department of Geriatrics; China-Japan Friendship Hospital; Beijing China
| | - Wai Lim Ku
- Systems Biology Center; Division of Intramural Research; National Heart, Lung, and Blood Institute; National Institutes of Health; Bethesda Maryland 20892 USA
| | - Haicong Li
- Department of Geriatrics; China-Japan Friendship Hospital; Beijing China
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Miller CB, Kyle SD, Gordon CJ, Espie CA, Grunstein RR, Mullins AE, Postnova S, Bartlett DJ. Physiological Markers of Arousal Change with Psychological Treatment for Insomnia: A Preliminary Investigation. PLoS One 2015; 10:e0145317. [PMID: 26683607 PMCID: PMC4689577 DOI: 10.1371/journal.pone.0145317] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/30/2015] [Indexed: 01/04/2023] Open
Abstract
Objectives The aim of this preliminary study was to evaluate if Sleep Restriction Therapy for insomnia is associated with modifications to physiological arousal, indexed through overnight measures of plasma cortisol concentrations and core body temperature. Methods In a pre-to-post open label study design, eleven patients with chronic and severe Psychophysiological Insomnia underwent 5 weeks of Sleep Restriction Therapy. Results Eight (73%) patients out of 11 consented completed therapy and showed a decrease in insomnia severity pre-to-post treatment (mean (SD): 18.1 (2.8) versus 8.4 (4.8); p = .001). Six patients were analyzed with pre-to-post overnight measures of temperature and cortisol. Contrary to our hypothesis, significantly higher levels of plasma cortisol concentrations were found during the early morning at post-treatment compared to baseline (p < .01), while no change was observed in the pre-sleep phase or early part of the night. Core body temperature during sleep was however reduced significantly (overall mean [95% CI]: 36.54 (°C) [36.3, 36.8] versus 36.45 [36.2, 36.7]; p < .05). Conclusions Sleep Restriction Therapy therefore was associated with increased early morning cortisol concentrations and decreased core body temperature, supporting the premise of physiological changes in functioning after effective therapy. Future work should evaluate change in physiological variables associated with clinical treatment response. Trial Registration Australian New Zealand Clinical Trials Registry ANZCTR 12612000049875
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Affiliation(s)
- Christopher B. Miller
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- * E-mail:
| | - Simon D. Kyle
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Christopher J. Gordon
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Colin A. Espie
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Ronald R. Grunstein
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, Australia
| | - Anna E. Mullins
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Delwyn J. Bartlett
- Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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Morin CM, Drake CL, Harvey AG, Krystal AD, Manber R, Riemann D, Spiegelhalder K. Insomnia disorder. Nat Rev Dis Primers 2015; 1:15026. [PMID: 27189779 DOI: 10.1038/nrdp.2015.26] [Citation(s) in RCA: 333] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Insomnia disorder affects a large proportion of the population on a situational, recurrent or chronic basis and is among the most common complaints in medical practice. The disorder is predominantly characterized by dissatisfaction with sleep duration or quality and difficulties initiating or maintaining sleep, along with substantial distress and impairments of daytime functioning. It can present as the chief complaint or, more often, co-occurs with other medical or psychiatric disorders, such as pain and depression. Persistent insomnia has been linked with adverse long-term health outcomes, including diminished quality of life and physical and psychological morbidity. Despite its high prevalence and burden, the aetiology and pathophysiology of insomnia is poorly understood. In the past decade, important changes in classification and diagnostic paradigms have instigated a move from a purely symptom-based conceptualization to the recognition of insomnia as a disorder in its own right. These changes have been paralleled by key advances in therapy, with generic pharmacological and psychological interventions being increasingly replaced by approaches that have sleep-specific and insomnia-specific therapeutic targets. Psychological and pharmacological therapies effectively reduce the time it takes to fall asleep and the time spent awake after sleep onset, and produce a modest increase in total sleep time; these are outcomes that correlate with improvements in daytime functioning. Despite this progress, several challenges remain, including the need to improve our knowledge of the mechanisms that underlie insomnia and to develop more cost-effective, efficient and accessible therapies.
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Affiliation(s)
- Charles M Morin
- Université Laval, École de psychologie, 2325 rue des Bibliothèques, Québec City, Québec G1V 0A6, Canada
| | - Christopher L Drake
- Henry Ford Hospital Sleep Disorders and Research Center, Detroit, Michigan, USA
| | - Allison G Harvey
- Department of Psychology, University of California, Berkeley, Berkeley, California, USA
| | - Andrew D Krystal
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Dieter Riemann
- Department of Clinical Psychology and Psychophysiology/Sleep Medicine, Center for Mental Disorders, University of Freiburg Medical Center, Freiburg, Germany
| | - Kai Spiegelhalder
- Department of Clinical Psychology and Psychophysiology/Sleep Medicine, Center for Mental Disorders, University of Freiburg Medical Center, Freiburg, Germany
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22
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D’Aurea C, Poyares D, Piovezan RD, Passos GS, Tufik S, Mello MTD. Objective short sleep duration is associated with the activity of the hypothalamic-pituitary-adrenal axis in insomnia. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:516-9. [DOI: 10.1590/0004-282x20150053] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/13/2015] [Indexed: 12/27/2022]
Abstract
Objective To evaluate the association between objective short sleep duration in patients with insomnia and changes in blood parameters related to hypothalamic-pituitary-adrenal (HPA) axis activity.Method A cross-sectional pilot study was conducted in 30 middle-aged adults with chronic insomnia who were divided into 2 groups according to polysomnography (PSG) total sleep time (TST) (TST > 5h and < 5h). All patients underwent subjective analysis of sleep quality, anthropometric measurements, PSG, and determination off asting blood parameters.Results The results revealed lower sleep efficiency and higher sleep latency for those with a TST < 5h. The subjective sleep quality was worse in the TST < 5h. Significantly, higher glucose and cortisol levels were observed with a TST < 5h. Glucose, cortisol and ACTH levels were inversely correlated with the PSG total sleep time.Conclusion Patients with insomnia with objective short sleep duration had HPA-associated endocrine and metabolic imbalances chronically linked to increases in cardiovascular risk observed with this more severe insomnia phenotype.
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23
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Doxepin and diphenhydramine increased non-rapid eye movement sleep through blockade of histamine H1 receptors. Pharmacol Biochem Behav 2015; 129:56-64. [DOI: 10.1016/j.pbb.2014.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/04/2014] [Accepted: 12/08/2014] [Indexed: 11/23/2022]
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Abstract
There is an interdependent relationship between insomnia and fatigue in the medical literature, but both remain distinct entities. Insomnia entails problematic sleep initiation, maintenance, or restoration with an accompanying decrease in perceived daytime function. Lethargy is a symptom that has a wide differential diagnosis that heavily overlaps with cancer-related fatigue; however, insomnia may contribute to worsened fatigue and lethargy in cancer patients. Insomnia is a major risk factor for mood disturbances such as depression, which may also contribute to lethargy in this at-risk population. The pathophysiology of fatigue and insomnia is discussed in this review, including their differential diagnoses as well as the emerging understanding of the roles of neurotransmitters, branched-chain amino acids, and inflammatory cytokines. Treatment approaches for insomnia and fatigue are also discussed and reviewed, including the role of hypnotics, psychotropics, hormonal agents, and alternative therapies.
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25
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Tsai HJ, Kuo TBJ, Lee GS, Yang CCH. Efficacy of paced breathing for insomnia: enhances vagal activity and improves sleep quality. Psychophysiology 2014; 52:388-96. [PMID: 25234581 DOI: 10.1111/psyp.12333] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 08/12/2014] [Indexed: 11/29/2022]
Abstract
Fourteen self-reported insomniacs (SRI) and 14 good sleepers (GS) had their cardiac neuronal activity assessed by heart rate variability (HRV) under controlled respiration at a slow frequency rate of 0.1 Hz, and a forced rate of 0.2 Hz during daytime rest. Nighttime sleep was measured by polysomnography. The SRI showed depressed high frequency power of HRV compared to the GS. An increased total power of HRV was observed among the SRI during slow, paced breathing compared with spontaneous breathing and 0.2 Hz. Sleep onset latency, number of awakenings, and awakening time during sleep were decreased and sleep efficiency was increased if SRI practiced slow, paced breathing exercises for 20 min before going to sleep. Our results indicate that there is autonomic dysfunction among insomniacs, especially in relation to vagal activity; however, this decreased vagal activity can be facilitated by practicing slow, paced breathing, thereby improving sleep quality.
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Affiliation(s)
- H J Tsai
- Sleep Research Center, National Yang-Ming University, Taipei, Taiwan; Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
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26
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Fernandez-Mendoza J, Vgontzas AN, Calhoun SL, Vgontzas A, Tsaoussoglou M, Gaines J, Liao D, Chrousos GP, Bixler EO. Insomnia symptoms, objective sleep duration and hypothalamic-pituitary-adrenal activity in children. Eur J Clin Invest 2014; 44:493-500. [PMID: 24635035 PMCID: PMC7090377 DOI: 10.1111/eci.12263] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/12/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Insomnia symptoms are the most common parent-reported sleep complaints in children; however, little is known about the pathophysiology of childhood insomnia symptoms, including their association with hypothalamic-pituitary-adrenal (HPA) axis activation. The objective of this study is to examine the association between parent-reported insomnia symptoms, objective short sleep duration and cortisol levels in a population-based sample of school-aged children. DESIGN A sample of 327 children from the Penn State Child Cohort (5-12 years old) underwent 9-h overnight polysomnography and provided evening and morning saliva samples to assay for cortisol. Objective short sleep duration was defined based on the median total sleep time (i.e., <7·7 h). Parent-reported insomnia symptoms of difficulty initiating and/or maintaining sleep were ascertained with the Pediatric Behavior Scale. RESULTS Children with parent-reported insomnia symptoms and objective short sleep duration showed significantly increased evening (0·33±0·03 μg/dL) and morning (1·38±0·08 μg/dL) cortisol levels. In contrast, children with parent-reported insomnia symptoms and 'normal' sleep duration showed similar evening and morning cortisol levels (0·23±0·03 μg/dL and 1·13±0·08 μg/dL) compared with controls with 'normal' (0·28±0·02 μg/dL and 1·10±0·04 μg/dL) or short (0·28±0·02 μg/dL and 1·13±0·04 μg/dL) sleep duration. CONCLUSIONS Our findings suggest that insomnia symptoms with short sleep duration in children may be related to 24-h basal or responsive physiological hyperarousal. Future studies should explore the association of insomnia symptoms with short sleep duration with physical and mental health morbidity.
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Affiliation(s)
- Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA, USA
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27
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Suh M, Choi-Kwon S, Kim JS. Sleep disturbances after cerebral infarction: role of depression and fatigue. J Stroke Cerebrovasc Dis 2014; 23:1949-55. [PMID: 24794949 DOI: 10.1016/j.jstrokecerebrovasdis.2014.01.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Poststroke sleep disturbances (PSSDs) are frequent and reported to be associated with unfavorable clinical outcomes. PSSDs appear to be related to a multitude of factors including lesion location and environmental causes. Moreover, depression and fatigue, which frequently develop in stroke patients may also contribute to PSSD development. The purpose of this study was to evaluate the prevalence and characteristics of PSSDs and factors related to PSSDs including depression and fatigue in hospitalized stroke patients. METHODS Patients who were hospitalized with acute stroke at the Asan Medical Center were evaluated. The quality (Verran-Snyder-Halpern [VSH] Sleep Scale score), duration and latency of night-time sleep, the frequency of waking after sleep onset, and daytime sleepiness were evaluated during the hospitalization period. To validate the self-reported night-time sleep, an actigraphy was performed in a subset of patients. The location, circulation, and laterality of each lesion were determined from brain magnetic resonance images obtained within 7 days of stroke onset. Depression and fatigue were assessed using the Beck Depression Inventory and the Fatigue Severity Scale, respectively. For environmental factors, the duration of hospitalization and the number of other patients in the same room were recorded. Univariate, multiple regression, and multiple logistic regression analyses were used to evaluate predictors of PSSD development. RESULTS A total of 282 patients completed the study. The mean age of the patients was 62.3 (±12.76) years and 58.9% of them were male. Sixty patients (21.3%) reported sleep duration less than 6 hours/night and 110 (39.0%) reported more daytime sleepiness than before the stroke. In 54 patients who agreed to wear an actigraph, self-reported sleep duration was significantly correlated with time in bed measured with an actigraph (r = .407, P = .002) and, VSH Sleep Scale score and sleep efficiency in actigraphy were also significantly correlated (r = .305, P = .026). Quality of night-time sleep was independently related to cortical lesion location (P = .002), diabetes mellitus (P = .020), and depression (P < .001), whereas increased daytime sleepiness was independently associated with subcortical lesion location (P = .031), fatigue (P = .001), and quality of night-time sleep (P = .001). CONCLUSIONS PSSDs are common in hospitalized stroke patients. The most powerful factor predicting night-time sleep disturbances in stroke patients was depression. Cortical brain lesion and diabetes mellitus were also associated with night-time sleep disturbances. On the other hand, although poststroke daytime sleepiness is in part caused by night-time sleep disturbance, it is more closely associated with fatigue and subcortical lesion location.
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Affiliation(s)
| | - Smi Choi-Kwon
- The Research Institute of Nursing Science, Seoul National University, Seoul.
| | - Jong S Kim
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Bonnet MH, Burton GG, Arand DL. Physiological and medical findings in insomnia: Implications for diagnosis and care. Sleep Med Rev 2014; 18:111-22. [DOI: 10.1016/j.smrv.2013.02.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/29/2013] [Accepted: 02/16/2013] [Indexed: 12/28/2022]
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Pepin JL, Borel AL, Tamisier R, Baguet JP, Levy P, Dauvilliers Y. Hypertension and sleep: overview of a tight relationship. Sleep Med Rev 2014; 18:509-19. [PMID: 24846771 DOI: 10.1016/j.smrv.2014.03.003] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/05/2014] [Accepted: 03/05/2014] [Indexed: 01/12/2023]
Abstract
Autonomic cardiovascular control changes across sleep stages. Thus, blood pressure (BP), heart rate and peripheral vascular resistance progressively decrease in non-rapid eye movement sleep. Any deterioration in sleep quality or quantity may be associated with an increase in nocturnal BP which could participate in the development or poor control of hypertension. In the present report, sleep problems/disorders, which impact either the quality or quantity of sleep, are reviewed for their interaction with BP regulation and their potential association with prevalent or incident hypertension. Obstructive sleep apnea syndrome, sleep duration/deprivation, insomnia, restless legs syndrome and narcolepsy are successively reviewed. Obstructive sleep apnea is clearly associated with the development of hypertension that is only slightly reduced by continuous positive airway pressure treatment. Shorter and longer sleep durations are associated with prevalent or incident hypertension but age, gender, environmental exposures and ethnic differences are clear confounders. Insomnia with objective short sleep duration, restless legs syndrome and narcolepsy may impact BP control, needing additional studies to establish their impact in the development of permanent hypertension. Addressing sleep disorders or sleep habits seems a relevant issue when considering the risk of developing hypertension or the control of pre-existent hypertension. Combined sleep problems may have potential synergistic deleterious effects.
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Affiliation(s)
- Jean-Louis Pepin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; Grenoble University Hospital, EFCR Laboratory, Locomotion, Rehabilitation and Physiology Department, Grenoble, France.
| | - Anne-Laure Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; Grenoble University Hospital, Endocrinology Department, Grenoble, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; Grenoble University Hospital, EFCR Laboratory, Locomotion, Rehabilitation and Physiology Department, Grenoble, France
| | | | - Patrick Levy
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; Grenoble University Hospital, EFCR Laboratory, Locomotion, Rehabilitation and Physiology Department, Grenoble, France
| | - Yves Dauvilliers
- Sleep Unit, Department of Neurology, Hopital-Gui-de Chauliac, CHU Montpellier, National Reference Network for Narcolepsy, and INSERM U1061, Montpellier, France
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Abstract
In contrast to the association of insomnia with mental health, its association with physical health has remained largely unexplored until recently. Based on findings that insomnia with objective short sleep duration is associated with activation of both limbs of the stress system and other indices of physiological hyperarousal, which should adversely affect physical and mental health, we have recently demonstrated that this insomnia phenotype is associated with a significant risk of cardiometabolic and neurocognitive morbidity and mortality. In contrast, insomnia with normal sleep duration is associated with sleep misperception and cognitive-emotional arousal, but not with signs of physiological hyperarousal or cardiometabolic or neurocognitive morbidity. Interestingly, both insomnia phenotypes are associated with mental health, although most likely through different pathophysiological mechanisms. We propose that objective measures of sleep duration may become part of the routine evaluation and diagnosis of insomnia, and that these two insomnia phenotypes may respond differentially to biological versus psychological treatments.
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Affiliation(s)
- Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, 500 University Drive H073, Hershey, PA, 17033, USA,
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31
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Abstract
Sleep is a complex biological process that involves cyclic changes of brain activity. The smooth transition between wakefulness and sleep and cyclic succession of sleep stages depend on the function of numerous neurotransmitters that reciprocally influence each other. For this reason sleep is a very sensitive biomarker of brain functioning. This article provides an overview of sleep changes in depression, mechanisms involved in sleep regulation and pathophysiology underlying depression, studies on sleep as a biomarker for depression, effects of antidepressants on sleep EEG, and studies in depression with the use of quantitative sleep EEG analysis. Research on sleep in depression has provided several valuable biomarkers that are related to increased risk for depression, show worsening during depressive episode, and are related to treatment outcome and relapse risk during remission phase. Among many sleep parameters, increased REM density and diminished delta sleep ratio deserve special interest. Sleep studies are also an important research tool for antidepressant drug development. However, due to sensitivity of sleep parameters to pharmacological interventions, the patients have to be investigated before the start of pharmacological treatment or after washout from the antidepressant drug, to obtain reliable data on disease-related biological processes from polysomnography.
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Affiliation(s)
- Adam Wichniak
- Third Department of Psychiatry, Institute of Psychiatry and Neurology , Warsaw , Poland
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32
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Vgontzas AN, Fernandez-Mendoza J. Insomnia with Short Sleep Duration: Nosological, Diagnostic, and Treatment Implications. Sleep Med Clin 2013; 8:309-322. [PMID: 24072989 PMCID: PMC3780422 DOI: 10.1016/j.jsmc.2013.04.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The diagnosis of insomnia is based solely on subjective complaints. This has contributed to the low reliability and validity of the current nosology of insomnia as well as to its lack of firm association with clinically relevant outcomes such as cardiometabolic and neurocognitive morbidity. We review evidence that insomnia with objective short sleep duration is associated with physiological hyperarousal, higher risk for hypertension, diabetes, neurocognitive impairment, and mortality as well as with a persistent course. It also appears that objective short sleep duration in poor sleepers is a biological marker of genetic predisposition to chronic insomnia. In contrast, insomnia with objective normal sleep duration is associated with cognitive-emotional and cortical arousal and sleep misperception but not with signs of physiological hyperarousal or medical complications. Thus, short sleep duration in insomnia may be a reliable marker of the biological severity and medical impact of the disorder. We propose that (a) objective measures of sleep be included in the diagnosis of insomnia and its subtypes, (b) objective measures of sleep obtained in the home environment of the patient would become part of the routine assessment and diagnosis of insomnia in a clinician's office setting, and (c) insomnia with short sleep duration may respond better to biological treatments, whereas insomnia with normal sleep duration may respond primarily to psychological therapies.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research & Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
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33
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Minkel J, Krystal AD. Optimizing the Pharmacologic Treatment of Insomnia: Current Status and Future Horizons. Sleep Med Clin 2013; 8:333-350. [PMID: 24015116 PMCID: PMC3763861 DOI: 10.1016/j.jsmc.2013.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A number of medications are available for treating patients with insomnia. These medications include agents approved as insomnia therapies by the U.S. Food and Drug Administration (FDA), agents approved by the FDA for another condition that are used "off-label" to treat insomnia, and agents available "over-the-counter" that are taken by individuals with insomnia. These agents differ in their properties, their safety and efficacy when used for different insomnia patient subtypes, and the available data on their efficacy and safety in these subtypes. As a result, optimizing the medication treatment of insomnia for a given patient requires that the clinician select an agent for use which has characteristics that make it most likely to effectively and safely address the type of sleep difficulty experienced by that individual. This article is intended to assist clinicians and researchers in carrying out this optimization. It begins by reviewing the basic characteristics of the medications used to treat insomnia. This is followed by a review of the fundamental ways that individuals with insomnia may differ and affect the choice of medication therapy. This review includes discussions that illustrate how to best choose a medication based on the characteristics of the available medications, the key differences among insomnia patients, and the available research literature. Lastly, we discuss future directions for the optimizing pharmacologic management of insomnia. It is hoped that the treatment tailoring methods discussed herein serve as a means of improving the clinical management of insomnia and, thus, improve the lives of the many patients who suffer from this common and impairing condition.
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Vgontzas AN, Fernandez-Mendoza J, Liao D, Bixler EO. Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder. Sleep Med Rev 2013; 17:241-54. [PMID: 23419741 PMCID: PMC3672328 DOI: 10.1016/j.smrv.2012.09.005] [Citation(s) in RCA: 487] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 09/17/2012] [Accepted: 09/18/2012] [Indexed: 01/11/2023]
Abstract
Until recently, the association of chronic insomnia with significant medical morbidity was not established and its diagnosis was based solely on subjective complaints. We present evidence that insomnia with objective short sleep duration is the most biologically severe phenotype of the disorder, as it is associated with cognitive-emotional and cortical arousal, activation of both limbs of the stress system, and a higher risk for hypertension, impaired heart rate variability, diabetes, neurocognitive impairment, and mortality. Also, it appears that objective short sleep duration is a biological marker of genetic predisposition to chronic insomnia. In contrast, insomnia with objective normal sleep duration is associated with cognitive-emotional and cortical arousal and sleep misperception but not with signs of activation of both limbs of the stress system or medical complications. Furthermore, the first phenotype is associated with unremitting course, whereas the latter is more likely to remit. We propose that short sleep duration in insomnia is a reliable marker of the biological severity and medical impact of the disorder. Objective measures of sleep obtained in the home environment of the patient would become part of the routine assessment of insomnia patients in a clinician's office setting. We speculate that insomnia with objective short sleep duration has primarily biological roots and may respond better to biological treatments, whereas insomnia with objective normal sleep duration has primarily psychological roots and may respond better to psychological interventions alone.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research & Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
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35
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Fernandez-Mendoza J, Vgontzas AN, Liao D, Shaffer ML, Vela-Bueno A, Basta M, Bixler EO. Insomnia with objective short sleep duration and incident hypertension: the Penn State Cohort. Hypertension 2012; 60:929-35. [PMID: 22892811 PMCID: PMC3679545 DOI: 10.1161/hypertensionaha.112.193268] [Citation(s) in RCA: 283] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/19/2012] [Indexed: 11/16/2022]
Abstract
Insomnia with objective short sleep duration appears to be a biologically more severe phenotype of the disorder. No longitudinal study to date has examined the association of this type of insomnia with incident hypertension using polysomnography. From a random, general population sample of 1741 adults of the Penn State Cohort, 1395 were followed-up after 7.5 years, and 786 did not have hypertension at baseline. Hypertension was determined by a self-report of receiving treatment for high blood pressure. Chronic insomnia was defined as a complaint of insomnia lasting ≥1 year, whereas poor sleep was defined as moderate-to-severe sleep difficulties. All of the subjects underwent 8-hour polysomnography. Sleep-disordered breathing (SDB) was defined as an obstructive apnea/hypopnea index≥5. We used the median polysomnographic percentage of sleep time to define short sleep duration (ie, <6 hours). We controlled for sex, race, age, caffeine, cigarettes and alcohol consumption, depression, sleep-disordered breathing, diabetes mellitus, obesity, and blood pressure in our analyses. Compared with normal sleepers who slept≥6 hours, the highest risk for incident hypertension was in chronic insomniacs with short sleep duration (odds ratio, 3.8 [95% CI, 1.6-9.0]). The risk for incident hypertension in poor sleepers with short sleep duration was significantly increased but became marginally significant after controlling for obesity (odds ratio, 1.6 [95% CI, 0.9-2.8]). Chronic insomnia with short sleep duration is associated with an increased risk for incident hypertension in a degree comparable to sleep-disordered breathing. Objective short sleep duration in insomnia may serve as a useful predictor of the biological severity of the disorder.
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Affiliation(s)
- Julio Fernandez-Mendoza
- Sleep Research & Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Alexandros N. Vgontzas
- Sleep Research & Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Duanping Liao
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - Michele L. Shaffer
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - Antonio Vela-Bueno
- Department of Psychiatry, School of Medicine, Autonomous University, Madrid, Spain
| | - Maria Basta
- Department of Psychiatry, School of Medicine, University of Crete, Crete, Greece
| | - Edward O. Bixler
- Sleep Research & Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
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36
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Ji-Rong Y, Hui W, Chang-Quan H, Bi-Rong D. Association between sleep quality and arterial blood pressure among Chinese nonagenarians/centenarians. Med Sci Monit 2012; 18:PH36-42. [PMID: 22367137 PMCID: PMC3560755 DOI: 10.12659/msm.882512] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background There is association between sleep quality and arterial blood pressure, but it is still unclear if the association also exists in the very elderly. We examined the individual association between sleep quality and arterial blood pressure among the very elderly. Material/Methods The present study analyzed data from a survey that was conducted on all residents aged 90 years or older in a district with 2,311,709 inhabitants in 2005. Sleep quality was measured using The Pittsburgh Sleep Quality Index (PSQI). Results The subjects included in the statistical analysis were 216 men and 444 women. There were no significant differences in sleep quality scores, sleep latency, and sleep efficiency percentage and prevalence of poor sleep quality between subjects with and without hypertension. None of the differences in systolic blood pressure, diastolic blood pressure, and prevalence of hypertension, systolic hypertension and diastolic hypertension among subjects with well, fairly and poor sleep quality were significant. Multiple logistic regressions showed that unadjusted and adjusted Odds Ratio (ORs) of poor sleep quality for increased risk for hypertension were significant. Conclusions Among very elderly subjects, there was no association between sleep quality and arterial blood pressure.
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Affiliation(s)
- Yue Ji-Rong
- Department of Geriatrics, West China Hospital, Sichuan University, China
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37
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Abstract
INTRODUCTION Insomnia is one of the most prevalent sleep disorders in developed countries, being surpassed only by chronic sleep deprivation. Patients with insomnia tend to have an altered quality of life, impaired daytime functioning and an increased risk of work accidents and motor vehicle crashes. Insomnia is commonly associated with chronic medical conditions, metabolic illnesses and mental disorders (such as depression and anxiety), with which there is a dual, reciprocal relationship. AREAS COVERED This paper focuses on current pharmacotherapy options for the treatment of insomnia, particularly benzodiazepine receptor agonists, which nowadays represent the mainstay of hypnotic therapy. The melatonin receptor antagonist, ramelteon, is reviewed (an alternative for some patients with only sleep-onset difficulty), as are sedating antidepressants, which are commonly used 'off-label' to treat insomnia, despite limited efficacy data and potential significant safety concerns. Orexin (OX) antagonists are also discussed, especially those that block OX2 or both OX1 and OX2 receptors, as these are the most promising new agents for the treatment of insomnia, with encouraging results in preliminary clinical trials. EXPERT OPINION Research to evaluate and formulate treatments for insomnia is often complicated by the fact that insomnia is usually of multifactorial etiology. Understanding the molecular and receptor mechanisms involved in promoting sleep in varied disorders could provide future approaches in new drug development. In the long term, more randomized controlled trials are needed to assess both short-term and long-term effects of these medications and their efficacy in comorbid diseases that affect sleep quality or quantity.
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Affiliation(s)
- Octavian C Ioachimescu
- Emory School of Medicine, Atlanta VA Medical Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Atlanta, GA, USA
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Vgontzas AN, Fernandez-Mendoza J, Bixler EO, Singareddy R, Shaffer ML, Calhoun SL, Liao D, Basta M, Chrousos GP. Persistent insomnia: the role of objective short sleep duration and mental health. Sleep 2012; 35:61-8. [PMID: 22215919 PMCID: PMC3242689 DOI: 10.5665/sleep.1586] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Few population-based, longitudinal studies have examined risk factors for persistent insomnia, and the results are inconsistent. Furthermore, none of these studies have examined the role of polysomnographic (PSG) variables such as sleep duration or sleep apnea on the persistence of insomnia. DESIGN Representative longitudinal study. SETTING Sleep laboratory. PARTICIPANTS From a random, general population sample of 1741 individuals of the adult Penn State Cohort, 1395 were followed-up after 7.5 years. MEASUREMENTS Individuals underwent one-night PSG and full medical evaluation at baseline and a telephone interview at follow-up. PSG sleep duration was analyzed as a continuous variable and as a categorical variable: < 6 h sleep (short sleep duration) and ≥ 6 h sleep (longer sleep duration). RESULTS The rates of insomnia persistence, partial remission, and full remission were 44.0%, 30.0%, and 26.0%, respectively. Objective short sleep duration significantly increased the odds of persistent insomnia as compared to normal sleep (OR = 3.19) and to fully remitted insomnia (OR = 4.92). Mental health problems at baseline were strongly associated with persistent insomnia as compared to normal sleep (OR = 9.67) and to a lesser degree compared to fully remitted insomnia (OR = 3.68). Smoking, caffeine, and alcohol consumption and sleep apnea did not predict persistent insomnia. CONCLUSIONS Objective short sleep duration and mental health problems are the strongest predictors of persistent insomnia. These data further support the validity and clinical utility of objective short sleep duration as a novel marker of the biological severity of insomnia.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
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39
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Affiliation(s)
- Emeran A Mayer
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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40
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Krystal AD, Lankford A, Durrence HH, Ludington E, Jochelson P, Rogowski R, Roth T. Efficacy and safety of doxepin 3 and 6 mg in a 35-day sleep laboratory trial in adults with chronic primary insomnia. Sleep 2011; 34:1433-42. [PMID: 21966075 PMCID: PMC3174845 DOI: 10.5665/sleep.1294] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the efficacy and safety of doxepin (DXP) 3 mg and 6 mg in adults diagnosed with primary insomnia. DESIGN AND METHODS The study was a randomized, double-blind, parallel-group, placebo-controlled trial. Patients meeting DSM-IV-TR criteria for primary insomnia were randomized to 35 days of nightly treatment with DXP 3 mg (n=75), DXP 6 mg (n=73), or placebo (PBO; n=73), followed by 2 nights of single-blind PBO to evaluate discontinuation (DC) effects. Efficacy was assessed using polysomnography (PSG) and patient reports. Efficacy data were examined for Night (N) 1, N15, and N29. Safety assessments were conducted throughout the study. RESULTS Compared with PBO, DXP 3 and 6 mg significantly improved wake time after sleep onset (WASO) on N1 (3 mg and 6 mg; P<0.0001), N15 (3 mg P=0.0025; 6 mg P=0.0009), and N29 (3 mg P=0.0248; 6 mg P=0.0009), latency to persistent sleep (LPS) on N1 (3 mg P=0.0047; 6 mg P=0.0007), and total sleep time (TST) on N1 (3 mg and 6 mg P<0.0001), N15 (6 mg P=0.0035), and N29 (3 mg P=0.0261; 6 mg P<0.0001). In terms of early morning awakenings, DXP 3 and 6 mg demonstrated significant improvements in SE in the final quarter of the night on N1, N15, and N29, with the exception of 3 mg on N29 (P=0.0691). Rates of discontinuation were low, and the safety profiles were comparable across the 3 treatment groups. There were no significant next-day residual effects, and there were no spontaneous reports of memory impairment, complex sleep behaviors, anticholinergic effects, weight gain, or increased appetite. Additionally, there was no evidence of rebound insomnia after DXP discontinuation. CONCLUSIONS Five weeks of nightly administration of DXP 3 mg and 6 mg to adults with chronic primary insomnia resulted in significant and sustained improvements in sleep maintenance and early morning awakenings (with the exception of SE in the final quarter of the night on N29 for 3 mg [P=0.0691]). These sleep improvements were not accompanied by next-day residual effects or followed by rebound insomnia or withdrawal effects upon discontinuation. These findings confirm the unique profile of sleep maintenance efficacy and safety of DXP observed in prior studies.
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Kohyama J. Neurochemical and neuropharmacological aspects of circadian disruptions: an introduction to asynchronization. Curr Neuropharmacol 2011; 9:330-41. [PMID: 22131941 PMCID: PMC3131723 DOI: 10.2174/157015911795596522] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 03/04/2010] [Accepted: 10/28/2010] [Indexed: 02/06/2023] Open
Abstract
Circadian disruptions are common in modern society, and there is an urgent need for effective treatment strategies. According to standard diagnostic criteria, most adolescents showing both insomnia and daytime sleepiness are diagnosed as having behavioral-induced sleep efficiency syndrome resulting from insomnia due to inadequate sleep hygiene. However, a simple intervention of adequate sleep hygiene often fails to treat them. As a solution to this clinical problem, the present review first overviews the basic neurochemical and neuropharmachological aspects of sleep and circadian rhythm regulation, then explains several circadian disruptions from similar viewpoints, and finally introduces the clinical notion of asynchronization. Asynchronization is designated to explain the pathophysiology/pathogenesis of exhibition of both insomnia and hypersomnia in adolescents, which comprises disturbances in various aspects of biological rhythms. The major triggers for asynchronization are considered to be a combination of light exposure during the night, which disturbs the biological clock and decreases melatonin secretion, as well as a lack of light exposure in the morning, which prohibits normal synchronization of the biological clock to the 24-hour cycle of the earth and decreases the activity of serotonin. In the chronic phase of asynchronization, involvement of both wake- and sleep-promoting systems is suggested. Both conventional and alternative therapeutic approaches for potential treatment of asynchronization are suggested.
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Affiliation(s)
- Jun Kohyama
- Tokyo Bay Urayasu/Ichikawa Medical Center, 3-4-32 Toudaizima, Urayasu 279-0001, Japan
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42
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Chen YK, Lu JY, Mok VCT, Ungvari GS, Chu WCW, Wong KS, Tang WK. Clinical and radiologic correlates of insomnia symptoms in ischemic stroke patients. Int J Geriatr Psychiatry 2011; 26:451-7. [PMID: 20845399 DOI: 10.1002/gps.2547] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 04/16/2010] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Insomnia is a common complaint in stroke survivors. The purpose of this study was to investigate the clinical and magnetic resonance imaging (MRI) correlates of insomnia symptoms in Chinese ischemic stroke survivors. METHODS A comprehensive psychiatric assessment was performed involving 508 ischemic stroke patients 3 months after their first-ever or recurrent acute stroke. Insomnia symptoms were evaluated with a standard insomnia questionnaire. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS).The evaluation of the MRI scans focused on infarctions, white matter lesions, and microbleeds. RESULTS One hundred and eight-six patients (36.6% of the sample) had insomnia symptoms. Sixty-four patients (12.6%) had insomnia symptoms with daytime consequences. In the multivariate logistic regression analysis, GDS score (OR = 1.157, p < 0.001) and acute frontal lobe infarction (OR = 1.933, p = 0.039) were significant predictors of insomnia symptoms, while the GDS score (OR = 1.251, p < 0.001) and diabetes mellitus (OR = 1.959, p = 0.017) were significant predictors of insomnia symptoms with daytime consequences. CONCLUSIONS Insomnia symptoms have a multi-factorial origin in stroke. Besides depressive symptoms, frontal lobe infarction and diabetes mellitus predict insomnia symptoms.
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Affiliation(s)
- Yang-Kun Chen
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
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43
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Abstract
Doxepin (Silenor®) is a tricyclic antidepressant with a subnanomolar affinity for the H1 histamine receptor. Recent work has investigated its use at low doses (3 and 6 mg) in patients with primary insomnia. Many agents with H1 activity have therapeutic limitations, including residual sedation, anticholinergic effects, rapid development of sedative tolerance and weight gain. Low-dose doxepin offers a unique combination of potency and selectivity for H1, which may prove advantageous in the treatment of insomnia. This article reviews doxepin clinical trials in insomnia and discusses the potential role of this compound in clinical practice. Two Phase II studies and four Phase III studies have investigated low-dose doxepin’s efficacy on sleep measures in adult and elderly patients. It was effective on a variety of sleep maintenance parameters with no change to sleep architecture. There was no signal for tolerance, psychomotor impairment, residual sedation, rebound insomnia or discontinuation symptoms. Adverse events were comparable with placebo, the most common being sedation/somnolence and headache. Selective H1 antagonism is emerging as a novel approach to the treatment of insomnia without the limitation of tolerance, weight gain or the need for the restrictive prescription scheduling required of other hypnotics.
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Affiliation(s)
- Alan Lankford
- Sleep Disorders Center of Georgia, 5505 Peachtree Dunwoody Road, Suite 548, Atlanta, GA 30342, USA
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44
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Fernandez-Mendoza J, Calhoun SL, Bixler EO, Karataraki M, Liao D, Vela-Bueno A, Ramos-Platon MJ, Sauder KA, Basta M, Vgontzas AN. Sleep misperception and chronic insomnia in the general population: role of objective sleep duration and psychological profiles. Psychosom Med 2011; 73:88-97. [PMID: 20978224 PMCID: PMC3408864 DOI: 10.1097/psy.0b013e3181fe365a] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the role of objective sleep duration, a novel marker in phenotyping insomnia, and psychological profiles on sleep misperception in a large, general population sample. Sleep misperception is considered by some investigators a common characteristic of chronic insomnia, whereas others propose it as a separate diagnosis. The frequency and the determinants of sleep misperception in general population samples are unknown. METHODS A total of 142 insomniacs and 724 controls selected from a general random sample of 1,741 individuals (aged ≥20 years) underwent a polysomnographic evaluation, completed the Minnesota Multiphasic Personality Inventory-2, and were split into two groups based on their objective sleep duration: "normal sleep duration" (≥6 hours) and "short sleep duration" (<6 hours). RESULTS The discrepancy between subjective and objective sleep duration was determined by two independent factors. Short sleepers reported more sleep than they objectively had, and insomniacs reported less sleep than controls with similar objective sleep duration. The additive effect of these two factors resulted in underestimation only in insomniacs with normal sleep duration. Insomniacs with normal sleep duration showed a Minnesota Multiphasic Personality Inventory-2 profile of high depression and anxiety and low ego strength, whereas insomniacs with short sleep duration showed a profile of a medical disorder. CONCLUSIONS Underestimation of sleep duration is prevalent among insomniacs with objective normal sleep duration. Anxious-ruminative traits and poor resources for coping with stress seem to mediate the underestimation of sleep duration. These data further support the validity and clinical utility of objective sleep measures in phenotyping insomnia.
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Affiliation(s)
- Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
- Department of Psychobiology, Complutense University, Madrid, Spain
- Department of Psychiatry, Autonomous University, Madrid, Spain
| | - Susan L. Calhoun
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | - Edward O. Bixler
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | - Maria Karataraki
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | - Duanping Liao
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | | | | | - Katherine A. Sauder
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | - Maria Basta
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
| | - Alexandros N. Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033
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45
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Affiliation(s)
- Andrew D. Krystal
- Director, Insomnia and Sleep Research Program, Professor of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Box 3309, Duke University Medical Center, Durham, NC, 27710, Phone: 919-681-8742, FAX: 919-681-8744
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Vgontzas AN, Liao D, Pejovic S, Calhoun S, Karataraki M, Basta M, Fernández-Mendoza J, Bixler EO. Insomnia with short sleep duration and mortality: the Penn State cohort. Sleep 2010; 33:1159-64. [PMID: 20857861 PMCID: PMC2938855 DOI: 10.1093/sleep/33.9.1159] [Citation(s) in RCA: 279] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
STUDY OBJECTIVES Because insomnia with objective short sleep duration is associated with increased morbidity, we examined the effects of this insomnia subtype on all-cause mortality. DESIGN Longitudinal. SETTING Sleep laboratory. PARTICIPANTS 1,741 men and women randomly selected from Central Pennsylvania. MEASUREMENTS Participants were studied in the sleep laboratory and were followed-up for 14 years (men) and 10 years (women). "Insomnia" was defined by a complaint of insomnia with duration > or = 1 year. "Normal sleeping" was defined as absence of insomnia. Polysomnographic sleep duration was classified into two categories: the "normal sleep duration group" subjects who slept > or = 6 h and the "short sleep duration group" subjects who slept < 6 h. We adjusted for age, race, education, body mass index, smoking, alcohol, depression, sleep disordered breathing, and sampling weight. RESULTS The mortality rate was 21% for men and 5% for women. In men, mortality risk was significantly increased in insomniacs who slept less than 6 hours compared to the "normal sleep duration, no insomnia" group, (OR = 4.00, CI 1.14-13.99) after adjusting for diabetes, hypertension, and other confounders. Furthermore, there was a marginally significant trend (P = 0.15) towards higher mortality risk from insomnia and short sleep in patients with diabetes or hypertension (OR = 7.17, 95% CI 1.41-36.62) than in those without these comorbid conditions (OR = 1.45, 95% CI 0.13-16.14). In women, mortality was not associated with insomnia and short sleep duration. CONCLUSIONS Insomnia with objective short sleep duration in men is associated with increased mortality, a risk that has been underestimated.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
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Pejovic S, Vgontzas AN. Neurobiological Disturbances in Insomnia: Clinical Utility of Objective Measures of Sleep. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/9781420080803.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Abstract
Doxepin binds with high specificity and affinity to the histamine H(1) receptor compared with other receptors. Therefore, at low doses, doxepin selectively antagonises H(1) receptors, which is believed to promote the initiation and maintenance of sleep. In three large, well designed, phase III trials in adult or elderly patients with chronic primary insomnia, oral, low-dose doxepin 3 or 6 mg once daily improved wake time after sleep onset, total sleep time and sleep efficiency to a significantly greater extent than placebo. Significant between-group differences in polysomnographic sleep recordings that favoured low-dose doxepin were evident after a single administration of the drug. Other efficacy measures, including patient-reported sleep quality, also favoured low-dose doxepin over placebo. Symptom control was maintained for up to 12 weeks of low-dose doxepin administration and there was no evidence of physical dependence or worsening insomnia after doxepin withdrawal. Oral, low-dose doxepin 6 mg was also significantly more effective than placebo in a large, well designed trial modelling transient insomnia in healthy adults, according to polysomnographic recordings (e.g. in latency to persistent sleep). Oral, low-dose doxepin was generally well tolerated in clinical trials.
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Affiliation(s)
- Juliane Weber
- Adis, a Wolters Kluwer Business, Auckland, New Zealand
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Fernandez-Mendoza J, Calhoun S, Bixler EO, Pejovic S, Karataraki M, Liao D, Vela-Bueno A, Ramos-Platon MJ, Sauder KA, Vgontzas AN. Insomnia with objective short sleep duration is associated with deficits in neuropsychological performance: a general population study. Sleep 2010; 33:459-65. [PMID: 20394314 PMCID: PMC2849784 DOI: 10.1093/sleep/33.4.459] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
STUDY OBJECTIVES To examine the joint effect of insomnia and objective short sleep duration on neuropsychological performance. DESIGN Representative cross-sectional study. SETTING Sleep laboratory. PARTICIPANTS 1,741 men and women randomly selected from central Pennsylvania. INTERVENTIONS None. MEASUREMENTS Insomnia (n = 116) was defined by a complaint of insomnia with a duration > or = 1 year and the absence of sleep disordered breathing (SDB), while normal sleep (n = 562) was defined as the absence of insomnia, excessive daytime sleepiness, and SDB. Both groups were split according to polysomnographic sleep duration into 2 categories: > or = 6 h of sleep ("normal sleep duration") and < 6 h of sleep ("short sleep duration"). We compared the groups' performance on a comprehensive neuropsychological battery that measured processing speed, attention, visual memory, and verbal fluency, while controlling for age, race, gender, education, body mass index, and physical and mental health. RESULTS No significant differences were detected between insomniacs and controls. However, the insomnia with short sleep duration group compared to the control with normal or short sleep duration groups showed poorer neuropsychological performance in variables such as processing speed, set-switching attention, and number of visual memory errors and omissions. In contrast, the insomnia with normal sleep duration group showed no significant deficits. CONCLUSIONS Insomnia with objective short sleep duration is associated with deficits in set-switching attentional abilities, a key component of the "executive control of attention." These findings suggest that objective sleep duration may predict the severity of chronic insomnia, including its effect on neurocognitive function.
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Affiliation(s)
- Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
- Department of Psychiatry, Autonomous University, Madrid, Spain
- Department of Psychobiology, Complutense University, Madrid, Spain
| | - Susan Calhoun
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Edward O. Bixler
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Slobodanka Pejovic
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Maria Karataraki
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Duanping Liao
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | | | | | - Katherine A. Sauder
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
| | - Alexandros N. Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA
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50
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Staner L. Comorbidity of insomnia and depression. Sleep Med Rev 2009; 14:35-46. [PMID: 19939713 DOI: 10.1016/j.smrv.2009.09.003] [Citation(s) in RCA: 301] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 09/08/2009] [Accepted: 09/09/2009] [Indexed: 12/18/2022]
Abstract
During the last decade, several studies have shown that insomnia, rather than a symptom of depression, could be a medical condition on its own, showing high comorbidity with depression. Epidemiological research indicates that insomnia could lead to depression and/or that common causalities underlie the two disorders. Neurobiological and sleep EEG studies suggest that a heightened level of arousal may play a common role in both conditions and that signs of REM sleep disinhibition may appear in individuals prone to depression. The effects of antidepressant drugs on non-REM and REM sleep are discussed in relation to their use in insomnia comorbid with depression. Empirical treatment approaches are behavioral management of sleep combined with prescription of a sedative antidepressant alone, co-prescription of two antidepressants, or of an antidepressant with a hypnotic drug.
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Affiliation(s)
- Luc Staner
- Sleep Laboratory, Forenap, Centre Hospitalier de Rouffach, 27 rue du 4ème R.S.M. F-68250 Rouffach, France.
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