S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen

[Pharmacological treatment of posttraumatic stress disorder]

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Chronic insomnia, REM sleep instability and emotional dysregulation: A pathway to anxiety and depression?

The world-wide prevalence of insomnia disorder reaches up to 10% of the adult population. Women are more often afflicted than men, and insomnia disorder is a risk factor for somatic and mental illness, especially depression and anxiety disorders. Persistent hyperarousals at the cognitive, emotional, cortical and/or physiological levels are central to most theories regarding the pathophysiology of insomnia. Of the defining features of insomnia disorder, the discrepancy between minor objective polysomnographic alterations of sleep continuity and substantive subjective impairment in insomnia disorder remains enigmatic. Microstructural alterations, especially in rapid eye movement sleep ("rapid eye movement sleep instability"), might explain this mismatch between subjective and objective findings. As rapid eye movement sleep represents the most highly aroused brain state during sleep, it might be particularly prone to fragmentation in individuals with persistent hyperarousal. In consequence, mentation during rapid eye movement sleep may be toned more as conscious-like wake experience, reflecting pre-sleep concerns. It is suggested that this instability of rapid eye movement sleep is involved in the mismatch between subjective and objective measures of sleep in insomnia disorder. Furthermore, as rapid eye movement sleep has been linked in previous works to emotional processing, rapid eye movement sleep instability could play a central role in the close association between insomnia and depressive and anxiety disorders.

Device-assessed physical activity and sleep quality of post-COVID patients undergoing a rehabilitation program

BACKGROUND

An infection with SARS-CoV-2 can lead to persistent symptoms more than three months after the acute infection and has also an impact on patients' physical activity behaviour and sleep quality. There is evidence, that inpatient post-COVID rehabilitation can improve physical capacity and mental health impairments, but less is known about the change in physical behaviour and sleep quality.

METHODS

This longitudinal observational study used accelerometery to assess the level of physical activity and sleep quality before and after an inpatient rehabilitation program. The study sample consists of 100 post-COVID patients who acquired COVID-19 in the workplace. Group differences related to sex, age, COVID-19 severity, and pre-existing diseases were also analysed.

RESULTS

Level of physical activity and sleep quality didn't increase after rehabilitation. Overall, there is a high extent of inactivity time and poor sleep quality at both measurement points. Regarding group differences, male patients showed a significantly higher inactivity time before rehabilitation, and younger patients (< 55 years) spend significant more time in vigorous physical activity than older patients. Post-COVID patients with pre-existing cardiovascular, respiratory, and metabolic disease show slightly less physical activity than post-COVID patients without these comorbidities. Female patients and younger patients showed better sleep quality in some sleep parameters at both measurement points. However, no differences could be detected related to COVID-19 severity.

CONCLUSIONS

Ongoing strategies should be implemented to address the high amount of inactivity time and the poor sleep quality in post-COVID patients.

Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method

BACKGROUND

Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered.

METHODS

We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted.

RESULTS

The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia.

CONCLUSIONS

Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

Preferences and experiences regarding the treatment of obstructive sleep apnea with mandibular advancement splints - a cross-sectional pilot survey

OBJECTIVE

To obtain a current overview of the use of mandibular advancement splints (MAS) as a therapeutic option for obstructive sleep apnea (OSA) in the dental profession in Northern Germany.

METHODS

A questionnaire was mailed to 2431 dental professionals, and 8.3% responded. Descriptive data analysis was performed on each question separately.

RESULTS

Most of the surveyed dentists (51.7%) estimated the success rate of MAS therapy to be higher than 75%. Analysis of the relationship between the number of splints prescribed annually and the dental specialization (p = 0.22), work experience (p = 0.14), estimated success rate of MAS therapy (p = 0.96), and discontinuation of MAS therapy (p = 0.57) revealed no significant correlations.

CONCLUSION

Mandibular advancement splints seem to be a safe and successful therapy for OSA. There seems to be a lack of information on the patient side and a lack of education on the dentist side.

[Polypharmacy in patients with dementia]

The number of patients with dementia is expected to grow in the coming years due to an aging population and an increasing life-expectancy. At the same time, in an aging society there will be an increase in multimorbidity and therefore polypharmacy. This combination presents numerous challenges particularly for people with dementia, as the correct administration of the drugs can frequently no longer be guaranteed. The drug treatment of neuropsychiatric symptoms of dementia are often treated with antipsychotics with potentially severe side effects and with limited efficacy. Moreover, many drugs have an anticholinergic potential, which may worsen the cognitive function even further in patients with dementia. The use of anticholinergic drugs should be handled with care and when possible be avoided in patients with dementia.

The Function of Sleep and the Treatment of Primary Insomnia

BACKGROUND

Approximately 21 900 women and 35 300 men developed lung cancer in Germany in 2018, and 16 999 women and 27 882 men died of it. The outcome mainly depends on the tumor stage. In early stages (stage I or II), treatment can be curative; unfortunately, because early-stage lung cancers are generally asymptom - atic, 74% of women and 77% of men already have advanced-stage disease (stage III or IV) at the time of diagnosis. Screening with low-dose computed tomography is an option enabling early diagnosis and curative treatment.

METHODS

This review is based on pertinent articles retrieved by a selective search of the literature on screening for lung cancer.

RESULTS

In the studies of lung cancer screening that have been published to date, sensitivity ranged from 68.5% to 93.8%, and specificity from 73.4% to 99.2%. A meta-analysis by the German Federal Office for Radiation Protection revealed a 15% reduction in lung cancer mortality when low-dose computed tomography was used in persons who were judged to be at high risk for lung cancer (risk ratio [RR] 0.85, 95% confidence interval [0.77; 0.95]). 1.9% of subjects died in the screening arm of the meta-analysis, and 2.2% in the control group. The observation periods ranged from 6.6 to 10 years; false-positive rates ranged from 84.9% to 96.4%. Malignant findings were confirmed in 45% to 70% of the biopsies or resective procedures that were performed.

CONCLUSION

Systematic lung cancer screening with low-dose CT lowers mortality from lung cancer in (current or former) heavy smokers. This benefit must be weighed against the high rate of false-positive findings and overdiagnoses.

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

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Complementary and alternative treatments for insomnia disorder: a systematic umbrella review

Insomnia is a common disorder and cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment. However, CBT-I is not widely distributed and infrequently available while medication is not indicated for long-term use. To close this evident gap in supply, alternative treatments could be utilised. High-quality research on this topic is scarce, and there is currently no comprehensive publication on the effectiveness of alternative treatments. To address this pressing question, we systematically summarised the existing research on alternative treatments for insomnia. A comprehensive search of systematic reviews and (network) meta-analyses of randomised controlled trials investigating the efficacy of alternative treatments compared to waiting-list control or placebo in adults with insomnia disorder with or without comorbidities was conducted in PubMed, MEDLINE, PsycInfo, and PsycArticles on December 6, 2022, yielding 391 records. Finally, 15 eligible studies were included. Evidence on acupuncture, exogenous melatonin, mind-body interventions and exercise, repetitive transcranial magnetic stimulation (rTMS), valerian, and light exposure was found. Acupuncture, rTMS and mind-body exercises significantly improved sleep quality and insomnia severity but effects on objectively assessed outcomes were inconclusive. Melatonin led to a reduction in both self-reported and objectively assessed sleep onset latency. Light exposure and valerian did not significantly improve sleep outcomes. Overall, the quality of studies was rated as low. Results indicate that alternative treatments are effective mostly on subjective outcomes. However, evidence on the efficacy of some intervention types is sparse and there is a need for high-quality original studies. Future research could investigate whether combining different alternative treatment aspects with CBT-I improves individual treatment.

On the Efficacy of a CBT-I-Based Online Program for Sleep Problems: A Randomized Controlled Trial

There is an urgent need for easily accessible treatment options for sleep problems to reduce the current treatment gap in receiving cognitive behavioral therapy for insomnia (CBT-I). Using a randomized controlled trial, we evaluated the efficacy of a CBT-I-based online program on sleep. Fifty-three volunteers (21-71 years; MAge = 44.6 ± 12.5; 27 female) suffering from impaired sleep were randomly allocated either to the experimental group (EG, n = 27) or to an active control group (CG, n = 26). The EG participated in a 6-week CBT-I-based online program, while the CG received psychoeducation and sleep hygiene instructions. Sleep was assessed both objectively via ambulatory polysomnography (PSG) as well as subjectively via questionnaires at three time points (baseline, pre- and post-intervention). A one-month follow-up assessment was performed using questionnaires. The EG showed small but reliable improvements from pre- to post-intervention in PSG-derived wake after sleep onset (from 58.6 min to 42.5 min; p < 0.05) and sleep efficiency (from 86.0% to 89.2%; p < 0.05). Furthermore, subjective sleep quality (assessed via Pittsburgh Sleep Quality Index) improved significantly during intervention (p = 0.011) and follow-up (p = 0.015) in the EG alone. The Insomnia Severity Index decreased from pre- to post-intervention in both groups (EG: p = 0.003, CG: p = 0.008), while it further improved during follow-up (p = 0.035) in the EG alone. We show that a CBT-I-based online program can improve sleep not only subjectively but also objectively and can be a viable alternative when face-to-face interventions are not available.

Systematic analysis of the pharmacological content of the Tatort (scene of crime) TV series from 2019 to 2021

Tatort (scene of crime) is a must-see programme on Sunday evenings for many Germans. With its enormous reach, the crime series also deals in more than half of its episodes with active pharmacological substances, surprisingly most of them are used curatively. There are lots of ways representing the active pharmacological substances: simply naming the preparation to details such as information on how to take it or how it is manufactured illegally. Diseases of great interest to the public such as hypertension or depression are taken up. In addition to the correct presentation, in 20% of cases the active pharmacological substances were presented incorrectly or implausibly. But even with correct presentation, it may yield a harmful influence on viewers: Stigmatisation of preparations occurred in 14%, especially in the case of active pharmacological substances that are used in psychiatric therapies; presentations that could be considered dangerous occurred in 21% of the mentions. In 29%, content was presented positively to the audience beyond the correct presentation. Analgesics and active pharmacological substances used in psychiatry are frequently titled. But drugs such as amiodarone, insulin or "cortisone" are also mentioned. The potential for misuse is also presented. Tatort also educates the audience about common diseases and their treatment, for example hypertension, depression or the use of antibacterial drugs. However, the series does not educate the general public on the mechanism of action of commonly used drugs. There is a natural dilemma between informing the public and guiding them to misuse medicines. Finally, we discuss how future episodes could be improved with respect to pharmacological content.

Sleep quality, anxiety, symptoms of depression, and caregiver burden among those caring for patients with Dravet syndrome: a prospective multicenter study in Germany

BACKGROUND

This study measured sleep quality among caregivers of patients with Dravet syndrome (DS) and assessed the impacts of mental health problems and caregiver burden on sleep quality.

METHODS

This multicenter, cross-sectional study of patients with DS and their caregivers throughout Germany consisted of a questionnaire and a prospective 4-week diary querying disease characteristics, demographic data, living conditions, nocturnal supervision, and caregivers' work situations. Sleep quality was assessed using the Pittsburgh Sleeping Quality Index (PSQI). The Hospital Anxiety and Depression Scale (HADS) and the Burden Scale for Family Caregivers (BSFC) were used to measure anxiety, symptoms of depression, and caregiver burden.

RESULTS

Our analysis included 108 questionnaires and 82 four-week diaries. Patients with DS were 49.1% male (n = 53), with a mean age of 13.5 ± 10.0 years. Caregivers were 92.6% (n = 100) female, with a mean age of 44.7 ± 10.6 years. The overall mean PSQI score was 8.7 ± 3.5, with 76.9% of participants (n = 83) scoring 6 or higher, indicating abnormal sleep quality. The HADS for anxiety and depression had overall mean scores of 9.3 ± 4.3 and 7.9 ± 3.7, respectively; 61.8% and 50.9% of participants scored above the cutoff value of 8 for anxiety and depression, respectively. Statistical analyses revealed caregiver anxiety levels and patients' sleep disturbances as major factors influencing PSQI scores. The overall mean BSFC score of 41.7 ± 11.7 indicates a moderate burden, with 45.3% of caregivers scoring 42 or higher.

CONCLUSIONS

Sleep quality is severely affected among caregivers of patients with DS, correlating with anxiety, comorbidities, and patients' sleep disturbances. A holistic therapeutic approach should be implemented for patients with DS and their caregivers, focusing on the sleep quality and mental health of caregivers.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00016967. Registered 27 May 2019, http://www.drks.de/DRKS00016967.

Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial

BACKGROUND

A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.

OBJECTIVE

This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.

METHODS

In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.

RESULTS

We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.

CONCLUSIONS

An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

Cognitive behavioural therapy to treat stress and insomnia: A randomized wait list-controlled trial of two online courses

This randomized, wait list-controlled trial aimed to evaluate the efficacy of the cognitive behavioural therapy-based online e-learning course stressfit for better stress management and the cognitive behavioural therapy for insomnia-based online course SweetDreams for coping with insomniac problems. The course modules offer state of the art psychoeducation and cognitive behavioural strategies concerning different aspects of stress, sleep and insomnia. They provide practice-oriented exercises for self-reflection, as well as a variety of evidence-based methods and measures to increase self-efficacy when dealing with stress or insomnia. Study participants were randomly assigned to the three test conditions stressfit, SweetDreams or a wait list. Participants filled in questionnaires on a wide range of scales relevant to stress and insomnia at three points in time (before, 4 weeks after, and 3 months after the treatment). Of the 588 participants in total, data from 347 participants (59%) were finally included in the data analyses. Data analyses showed that both courses yielded significant positive effects compared with the wait list condition 4 weeks and to some degree 3 months after completion in relation to insomnia symptoms, physical and psychological wellbeing, life satisfaction and general health (General Health Questionnaire), as well as on satisfaction with and effectiveness of coping with stress and sleep disorders. In conclusion, SweetDreams and stressfit proved to be feasible and effective online cognitive behavioural therapy (for insomnia) tools to reduce insomnia and stress symptoms on a broad variety of scales at the 4-weeks measurement point as well as at the 3-months follow-up.

Impact of Gender on Insomnia

There is a distinct preponderance of female insomniacs when compared to male insomniacs. The aim of this study was to examine possible gender differences in the causes for insomnia, and the phenotypes of insomnia, and to investigate whether gender-specific insomnia diagnosis and treatment could be relevant in clinical practice. Data were collected from 121 insomniac patients by a medical specialist in the framework of normal clinical practice in Germany. The data consist of the patient’s medical history and various sleep-related patient questionnaires. Data from both genders were tested for independence using chi-square tests and Mann–Whitney U tests. We found a correlation between the gender of the patient and insomnia phenotypes in several aspects: concomitant lipometabolic disorders, diabetes mellitus, and high BMIs are more common in male insomniacs (p < 0.05). Frequency of insomnia occurrence in certain age groups, insomnia severity, distribution of SOI (sleep onset insomnia), SMI (sleep maintenance insomnia) and combined SOI + SMI, sleep duration, the time needed to seek medical consultation, trying out sleep-inducing drugs/techniques and the trigger, etiology and familial predisposition of the insomniac disorder were independent of the patient’s gender. We would like to re-evaluate the results with a larger number of patients in a further study.

[Digital health applications in otorhinolaryngology]

BACKGROUND

With the passing of the "Digital Care Act" by the German Bundestag at the end of 2019, it was made possible, among other things, for digital health applications to be reimbursed by statutory health insurance companies under certain conditions. The aim of this work is to identify digital health applications related to ear, nose, and throat medicine and to describe the underlying evidence.

MATERIALS AND METHODS

The digital health applications register was analyzed to identify digital health applications with an indication area relating to an otorhinolaryngologic disease. Digital health applications were included that were either permanently or provisionally included, or currently deleted if further information was available. The underlying evidence was assessed according to the recommendations of the Oxford Center for Evidence-Based Medicine for therapeutic studies.

RESULTS

A total of six digital health applications with a direct or indirect connection to otorhinolaryngology were identified, three of which were permanently and two provisionally included in the directory. One digital health application has currently been withdrawn by the manufacturer. The permanently recorded digital health applications are based on evidence level 1b.

CONCLUSION

The introduction of digital health applications is sometimes also discussed critically, but they represent an innovative approach and various digital health applications with a high level of underlying evidence are already available, especially for the ear, nose, and throat area.

[Anesthesia in obesity surgery : Recommendations from the practice for the practice]

BACKGROUND

Due to unsuccessful conservative treatment concepts and the steady increase in the prevalence of obesity, obesity surgery has gained importance worldwide. In Germany alone, around 20,000 surgical operations for obesity are performed each year. In addition to patient history and physical examination a close interdisciplinary cooperation taking into account the currently applicable standards and guidelines of the professional societies are prerequisites for best patient care and to evaluate and mitigate patient risks.

AIM

The aim of this work was to compile and consent experiences of experts in the implementation of applicable standards and guidelines for anesthesia in obesity surgery for daily clinical practice.

METHOD

Anesthesiologists from five bariatric centers, comprising about 10% of the obesity surgery caseload of Germany per year, have collated their clinical experiences to agree on a consensus for procedures. The procedures for preoperative patient evaluation, drug premedication and PONV prophylaxis, induction of anesthesia and drug dosage recommendations for anesthetics were consented based on the authors' practice.

RESULTS AND CONCLUSION

The procedures described herein were developed as part of a joint work process. The authors describe a practically applicable approach to the anesthesiological care of obesity surgery patients and recommend using a pragmatic formula for dosing the medication calculated on the basis of total body weight (TBW).

[Hair or air: clinical snapshot of an alopecia areata under NIV interface]

An alopecia areata developed under NIV interface.

A low-threshold sleep intervention for improving sleep quality and well-being

BACKGROUND

Approximately one-third of the healthy population suffer from sleep problems, but only a small proportion of those affected receive professional help. Therefore, there is an urgent need for easily accessible, affordable, and efficacious sleep interventions.

OBJECTIVE

A randomized controlled study was conducted to investigate the efficacy of a low-threshold sleep intervention consisting of either (i) sleep data feedback plus sleep education or (ii) sleep data feedback alone in comparison with (iii) no intervention.

MATERIAL AND METHODS

A total of 100 employees of the University of Salzburg (age: 39.51 ± 11.43 years, range: 22-62 years) were randomly assigned to one of the three groups. During the 2-week study period, objective sleep parameters were assessed via actigraphy. In addition, an online questionnaire and a daily digital diary were used to record subjective sleep parameters, work-related factors, as well as mood and well-being. After 1 week, a personal appointment was conducted with participants of both experimental group 1 (EG1) and experimental group 2 (EG2). While the EG2 only received feedback about their sleep data from week 1, the EG1 additionally received a 45-min sleep education intervention containing sleep hygiene rules and recommendations regarding stimulus control. A waiting-list control group (CG) did not receive any feedback until the end of the study.

RESULTS

Results indicate positive effects on sleep and well-being following sleep monitoring over the course of 2 weeks and minimal intervention with a single in-person appointment including sleep data feedback. Improvements are seen in sleep quality, mood, vitality, and actigraphy-measured sleep efficiency (SE; EG1), as well as in well-being and sleep onset latency (SOL) in EG2. The inactive CG did not improve in any parameter.

CONCLUSION

Results suggest small and beneficial effects on sleep and well-being in people being continuously monitored and receiving (actigraphy-based) sleep feedback when paired with a single-time personal intervention.

Role of private prescriptions in the long-term use of benzodiazepines and Z-drugs: A patient-related follow-up study

PURPOSE

To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z-drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions.

METHODS

On basis of anonymized prescriptions from 874 ambulatory practices in Germany, we analysed the percentage of private prescriptions for Z-drugs, benzodiazepines/anxiolytics, and benzodiazepines/hypnotics and sedatives over 6 years (2014 to 2020).

RESULTS

Of 2 200 446 prescriptions for a benzodiazepine or Z-drug, 38% were private prescriptions. In case of Z-drugs, the rate of private prescriptions was 44.1% for single prescriptions and 48.9% for refills. The difference was smaller for anxiolytics (23.3% vs. 26.0%) and, for benzodiazepine/hypnotics and sedatives, the proportion of private prescriptions for refills was even lower than for single prescriptions. In case of Z-drugs, the proportion of private prescriptions was, on average, 42.7% for the first prescription of a series of repeat prescriptions and 49.6% for the tenth prescription. The increase was smaller for anxiolytics and negligible for benzodiazepine/hypnotics and sedatives. Doctors stayed with their initial decision in more than three quarters of repeat prescriptions, be it a SHI or private prescription.

CONCLUSION

While we observed a large number of private prescriptions for benzodiazepines and Z-drugs, the proportion was only slightly higher for refills than for single prescriptions. Doctors do not seem to issue private prescriptions as a strategy to mask especially long-term use of these substances.

Prescription of Silexan Is Associated with Less Frequent General Practitioner Repeat Consultations Due to Disturbed Sleep Compared to Benzodiazepine Receptor Agonists: A Retrospective Database Analysis

The aim of the present study was to analyze the association between the prescription of Silexan and the recurrence of general practitioner (GP) repeat consultations because of disturbed sleep versus benzodiazepine receptor agonists including zolpidem, zopiclone, and zaleplon (Z-drugs). This retrospective cohort study was based on data from the IQVIA Disease Analyzer (DA) database. The study included adult patients treated by 1284 GPs in Germany with a documented sleep disorder and their first prescription of Silexan or Z-drug (prescription between January 2010 and October 2020). The recurrence of seeking medical advice because of sleep disorders in the 15-365 days after the first prescription was evaluated. Multivariate regression models were used, adjusted for age, sex, insurance status, and defined co-diagnoses. Data were available for 95,320 (Silexan: 5204; Z-Drug: 90,526) patients. In total, 15.6% of the Silexan patients and 28.6% of the Z-drug patients had a further documented GP consultation because of a sleep disorder. Silexan prescription was associated with significantly lower odds of recurrent sleep disorder diagnosis in the 15-365 days after the index date (Odds Ratio (OR): 0.56; 95% confidence intervals (CI): 0.51-0.60), although mental burden levels appeared higher in this group. Our study shows that the prescription of Silexan to adult patients consulting GPs for disturbed sleep results in less frequent repeat consultations than Z-drugs. This may support Silexan's role as an efficacious, self-enabling, well-tolerated, and sustained treatment option. Because Silexan is a proven anxiolytic, its impact in improving undiagnosed anxiety disorders may have had a lasting effect for certain patients.

Pharmacopuncture Effects on Insomnia Disorder: Protocol for a Multi-Site, Randomized, Acupuncture-Controlled, Clinical Trial

Insomnia is a common health problem that can lead to various diseases and negatively impact quality of life. Pharmacopuncture is a new type of acupuncture that involves applying herbal medicine extracts to acupoints. Korean medicine doctors frequently use it to treat insomnia disorder. However, there is insufficient evidence to support the effectiveness and safety of pharmacopuncture for insomnia disorder. We designed a pragmatic randomized controlled trial to compare the effectiveness of pharmacopuncture and acupuncture for insomnia disorder. This multi-site, randomized, acupuncture-controlled trial will enroll 138 insomnia patients. The subjects will be randomly assigned to one of two groups, pharmacopuncture or acupuncture, at a 2:1 ratio. For 4 weeks, the participants will receive ten sessions of pharmacopuncture or acupuncture treatment and will be followed up for 4 weeks after the treatment ends. The Pittsburgh Sleep Quality Index score is the primary outcome measure. Insomnia severity index score, sleep parameters recorded using actigraphy and sleep diaries, physical symptoms associated with insomnia, emotions, quality of life, medical costs, and safety are the secondary outcome measures. The findings of this trial willprovide evidence that will be useful in clinical decision-making for insomnia treatment strategies.

Systematic Review of Clinical Practice Guidelines for Insomnia Disorder

OBJECTIVE

This systematic review assessed the quality of clinical practice guidelines (CPGs) on the treatment of insomnia disorder and their reporting of recommendations, while summarizing the evidence and providing guidance on an algorithmic approach to appropriate pharmacological treatment.

METHODS

The PubMed and EMBASE databases, guideline repositories, and specialist association websites were searched. The quality of the CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, complemented by the AGREE-REX (Appraisal of Guidelines REsearch and Evaluation-Recommendations EXcellence). A multidisciplinary team identified the key clinical questions that a clinician would consider when taking an algorithmic approach to the use of medication for patients with insomnia disorder. By using a meta-synthesis approach, recommendations from the CPGs were characterized and summarized via a recommendation matrix.

RESULTS

A total of 10 records that met the inclusion criteria were included and appraised. Four CPGs were rated as high and 3 CPGs were rated as moderate in overall quality. Most of the CPGs recommended pharmacotherapy only if cognitive behavioral therapy for insomnia or other nonpharmacological interventions were unavailable, unsuccessful, or declined by patients. Recommendations on types of medicines and dose and duration of treatment varied and were nonspecific. Few of the CPGs provided recommendations on pharmacotherapy in special populations.

CONCLUSIONS

Indications for starting medications are the only common thread in all of the reviewed CPGs. The CPGs diverged in the choice of first-line pharmacotherapy, and most of the CPGs did not provide recommendations on all subsequent clinical considerations.

Do ginger footbaths improve symptoms of insomnia more than footbaths with warm water only? - A randomized controlled study

OBJECTIVES

To compare the effects between warm water (WW) and ginger footbaths (WW+ginger) on sleep quality and warmth regulation in adults with self-reported insomnia symptoms.

METHODS

A prospective randomized-controlled study in which 28 participants (mean age 50.9 years, 64.3% women, insomnia symptom duration 11.4 years) were randomized to receive WW (n = 13) or WW+ginger (n = 15) daily for 2 weeks. Treatment involved nightly footbaths (12 liters of 38-42 °C warm tap water, maximum duration 20 min) with and without topical ginger (80 g of powdered ginger rhizomes).

MAIN OUTCOME MEASURES

The primary outcome measure was self-reported sleep quality (global score from Pittsburgh Sleep Quality Index, PSQI) at 2 weeks. Secondary outcomes included measures of insomnia severity (Insomnia Severity Index, ISI) and warmth regulation (Herdecke Warmth Perception Questionnaire, HWPQ and 24-hour distal-proximal skin temperature gradient, DPG).

RESULTS

WW+ginger had no greater effect on PSQI (mean between-difference 0.0 [95% CI -3.0 to 2.9], Cohen's d=0.0) or ISI (-0.2 [-3.9 to 3.4], 0.0) than WW. Nor were there any significant differences in HWPQ perceived warmth (0.1 ≥d≥0.5) or DPG (0.1 ≥d≥0.4) between WW and WW+ginger. Both groups improved over time in PSQI (WW+ginger: d=0.7, WW: d=1.3) and ISI (WW+ginger: d=0.8, WW: d=1.0). Perceived warmth of the feet increased only in WW+ginger over time (d=0.6, WW: d=0.0).

CONCLUSIONS

This dose of ginger (6.67 g/liter) did not have greater effects on sleep quality, insomnia severity or warmth regulation than WW. Considering effect sizes, costs and risks, the use of WW would be recommended over WW+ginger in this patient population.

Valerian and postoperative sleep: a retrospective cohort analysis of gynecological, urologic, and general surgical patients

Study Objectives

Postoperative sleep disturbances appear to be a common complication after surgery being treated with sleep-promoting medication such as valerian, but robust data and evidence of medicinal approaches are lacking.

Methods

We performed a retrospective cohort analysis of all 21 168 urological, gynecological, and general surgical patients of the University Medical Center Freiburg, Germany, who underwent surgery between 2015 and 2020. Target parameters were the usage of sleep-promoting medication to estimate the occurrence of postoperative sleep disturbances as well as the kind of sleep medication with a special focus on herbal medication such as valerian.

Results

Drug-treated sleep disturbances occurred in 15% (n = 3083) of the patients. Valerian was the second most applied drug (n = 814, 26.4%) after classic benzodiazepines (n = 1 138, 36.9%). The majority of patients got valerian as monotherapy. Age, length of stay, and comorbidities were associated with demand for sleep medication in general (p &lt; .001). Valerian monotherapy was more common in women (OR 1.53, 95% CI: 1.33–1.77, p &lt; .001), elderly patients (OR 1.50, 95% CI: 1.29–1.75, p &lt; .001), and patients with prolonged hospital stay (OR 2.23, 95% CI: 1.91–2.61, p &lt; .001).

Conclusions

Valerian plays an important role in the treatment of postoperative sleep disturbances clinically, and it appears to be a promising therapeutic approach especially in women, older and sicker patients, and those with prolonged hospital stay. Further research has to clarify the efficacy of valerian postoperatively.

Clinical trial registration

DRKS00027903, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027903

[Prevalence of sleep disturbance in intensive care nurses: a post hoc analysis of a cross-sectional study]

Background

Intensive care nurses have irregular and unusual working hours due to shift work, which can disrupt the natural light-dark rhythm and thus increase the risk for sleep disorders.

Aim of the work

The aim of this post hoc analysis was to investigate the prevalence of self-reported sleep problems and associated factors among intensive care nurses working in Germany.

Methods

This analysis was a post hoc analysis of a cross-sectional study, which was performed as an online survey. Collected data were sociodemographic, work-related and health-related data. These data were used to calculate the prevalence and respective 95% confidence intervals (95% CI) of sleep problems. Factors associated with sleep problems were identified using the χ2-test, Fisher's exact test, and logistic regression analysis.

Results

The link to the online survey was accessed 1163 times and 490 intensive care nurses participated in the survey. A total of 432 intensive care nurses were included in this analysis, of whom 82.87% were women. A total of 57.64% (95% CI: 52.83-62.35%) reported sleep problems. Significantly associated with sleep problems were age (50-59 years odds ratio [OR]: 2.05, 95% CI: 1.00-4.21, p = 0.047 vs. 20-29 years) and living in a family (OR: 0.50, 95% CI: 0.27-0.93, p = 0.029 vs. single/living alone). In addition, depression (OR: 1.09, 95% CI: 1.06-1.12, p ≤ 0.001), anxiety (OR: 1.10, 95% CI: 1.06-1.14, p ≤ 0.001) and stress (OR: 1.09, 95% CI: 1.06-1.12, p ≤ 0.001) levels were significantly associated with sleep problems.

Conclusion

Sleep problems were present in one out of every two participating intensive care nurses and in particular mental health was associated with sleep problems.

[Cognitive disorders and sleep disturbances in long COVID]

Hintergrund

In den letzten 2 Jahren der COVID-19(„coronavirus disease 2019“)-Pandemie ist das Wissen um Langzeitfolgen der Erkrankung, das sog. „Long-COVID“, rapide gewachsen. Es bleiben jedoch noch viele Fragen offen, v. a. was die Ursachen überdauernder Beschwerden und ihre Prognose betrifft. Kognitive Störungen und Schlafstörungen gehören zu den häufig beklagten Beschwerden. Beide gehen mit starkem Leidensdruck und deutlicher Alltagsbeeinträchtigung einher.

Ziel der Arbeit

Wie ist die Datenlage zum Auftreten kognitiver Störungen und Schlafstörungen bei Long-COVID? Welches sind Einflussfaktoren und was ist bekannt zum Verlauf und zu möglichen zugrunde liegenden Mechanismen? Welche Therapieoptionen gibt es?

Material und Methode

In einem narrativen Review werden die wichtigsten Befunde zu kognitiven Störungen und Schlafstörungen bei Long-COVID dargestellt. Es wird ein Überblick gegeben über die Kohortenstudien mit Daten zu Prävalenz und Einflussfaktoren beider Symptomkomplexe. Es werden derzeitige Kenntnisse und Hypothesen zu pathophysiologischen Mechanismen dargestellt und ein Ausblick auf Behandlungsansätze gegeben.

Ergebnisse

Etwa ein Fünftel der Betroffenen berichtet mehr als 3 Monate nach einer SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Infektion über kognitive Einschränkungen, etwa ein Drittel über Schlafstörungen, wobei es neben insomnischen auch zu hypersomnische Beschwerden kommt. Kognitive Störungen und Schlafstörungen treten bei Betroffenen aller Schweregrade auf. Es gibt Hinweise auf eine Besserung kognitiver Defizite im Verlauf, allerdings sind weitere Längsschnittstudien notwendig.

Diskussion

Neben der Prognose sind die zugrunde liegenden Krankheitsmechanismen noch unzureichend verstanden. Zudem besteht großer Forschungsbedarf zur Wirksamkeit und zu spezifischen Wirkfaktoren therapeutischer Interventionen.

Insomnia disorder: State of the science and challenges for the future

Insomnia disorder comprises symptoms during night and day that strongly affect quality of life and wellbeing. Prolonged sleep latency, difficulties to maintain sleep and early morning wakening characterize sleep complaints, whereas fatigue, reduced attention, impaired cognitive functioning, irritability, anxiety and low mood are key daytime impairments. Insomnia disorder is well acknowledged in all relevant diagnostic systems: Diagnostic and Statistical Manual of the American Psychiatric Association, 5th revision, International Classification of Sleep Disorders, 3rd version, and International Classification of Diseases, 11th revision. Insomnia disorder as a chronic condition is frequent (up to 10% of the adult population, with a preponderance of females), and signifies an important and independent risk factor for physical and, especially, mental health. Insomnia disorder diagnosis primarily rests on self-report. Objective measures like actigraphy or polysomnography are not (yet) part of the routine diagnostic canon, but play an important role in research. Disease concepts of insomnia range from cognitive-behavioural models to (epi-) genetics and psychoneurobiological approaches. The latter is derived from knowledge about basic sleep-wake regulation and encompass theories like rapid eye movement sleep instability/restless rapid eye movement sleep. Cognitive-behavioural models of insomnia led to the conceptualization of cognitive-behavioural therapy for insomnia, which is now considered as first-line treatment for insomnia worldwide. Future research strategies will include the combination of experimental paradigms with neuroimaging and may benefit from more attention to dysfunctional overnight alleviation of distress in insomnia. With respect to therapy, cognitive-behavioural therapy for insomnia merits widespread implementation, and digital cognitive-behavioural therapy may assist delivery along treatment guidelines. However, given the still considerable proportion of patients responding insufficiently to cognitive-behavioural therapy for insomnia, fundamental studies are highly necessary to better understand the brain and behavioural mechanisms underlying insomnia. Mediators and moderators of treatment response/non-response and the associated development of tailored and novel interventions also require investigation. Recent studies suggest that treatment of insomnia may prove to add significantly as a preventive strategy to combat the global burden of mental disorders.

[Personal factors influencing daytime sleepiness]

Hintergrund und Zielsetzung

Während der ersten Coronawelle kam das öffentliche Leben weitgehend zum Erliegen. Viele Beschäftigte haben zum Schutz vor Ansteckung im Homeoffice gearbeitet. Mit der vorliegenden Befragung wurden Veränderungen im Schlafverhalten und der Tagesmüdigkeit bei Personen untersucht, die coronabedingt ins Homeoffice gewechselt hatten.

Methode

Büroangestellte wurden online zu ihrem Chronotyp, ihren üblichen Schlafenszeiten und dem Auftreten von Tagesmüdigkeit befragt. Die Datenerhebung fand zwischen dem 15.07. und 07.08.2020 statt. Zur Chronotypermittlung wurde die Composite Scale of Morningness (CSM) in der deutschsprachigen Version verwendet. Der Zusammenhang von Alter, Geschlecht, Chronotyp, Schlafqualität und Schlafdauer mit der selbst eingeschätzten Tagesmüdigkeit wurde mittels multivariabler logistischer Regression untersucht.

Ergebnisse

Die Daten von n = 228 Personen konnten ausgewertet werden. Unter Homeoffice-Bedingungen verlängerte sich die Schlafdauer. Der Anteil an Personen mit einer „Zeit-im-Bett“ von weniger als 7,5 h verringerte sich von 57 % auf 33 %, und der Anteil mit mehr als 8 h „Zeit-im-Bett“ erhöhte sich von 43 % vor Pandemiebeginn auf 67 % beim Arbeiten im Homeoffice. Der Anteil an Personen, die sich bei der Arbeit immer oder häufig müde fühlten, verringerte sich von 47 % vor Pandemiebeginn mit Präsenzpflicht im Büro auf 15 % unter Lockdown-Bedingungen beim Arbeiten im Homeoffice. Der Chronotyp zeigte einen signifikanten Einfluss auf die Tagesmüdigkeit an Büroarbeitstagen, nicht aber beim Arbeiten im Homeoffice unter Lockdownbedingungen.

Diskussion

Die längere Schlafdauer und die höhere Zufriedenheit mit der eigenen Schlafqualität könnten die Verringerung im Auftreten von Tagesmüdigkeit erklären. Späte Chronotypen scheinen besonders vom Arbeiten im Homeoffice zu profitieren. Ein flexibler Arbeitsbeginn unter Einbeziehung des Chronotyps sowie Maßnahmen für gesundheitsförderlichen Schlaf könnten die Tagesmüdigkeit verringern und dadurch die Gesundheit und Arbeitssicherheit verbessern.

The Many Faces of Sleep Disorders in Post-Traumatic Stress Disorder: An Update on Clinical Features and Treatment

Sleep disorders and nightmares are core symptoms of post-traumatic stress disorder (PTSD). The relationship seems to be bidirectional, and persistent disturbed sleep may influence the course of the disorder. With regard to sleep quality, insomnia and nocturnal anxiety symptoms, as well as nightmares and stressful dreams, are the most prominent sleep symptoms. Polysomnographic measurements reveal alterations of the sleep architecture and fragmentation of rapid eye movement sleep. In addition, sleep disorders, such as sleep-related breathing disorders and parasomnias are frequent comorbid conditions. The complex etiology and symptomatology of trauma-related sleep disorders with frequent psychiatric comorbidity require the application of multimodal treatment concepts, including psychological and pharmacological interventions. However, there is little empirical evidence on the effectiveness of long-term drug treatment for insomnia and nightmares. For nondrug interventions, challenges arise from the current lack of PTSD-treatment concepts integrating sleep- and trauma-focused therapies. Effective therapy for sleep disturbances may consequently also improve well-being during the day and probably even the course of PTSD. Whether early sleep interventions exert a preventive effect on the development of PTSD remains to be clarified in future studies.

Die primäre und die psychiatrisch-„komorbide“, nichtorganische Insomnie in einem neurologisch geführten Schlaflabor

Patientinnen und Patienten, die in einem neurologischen Schlaflabor die Abschlussdiagnose nichtorganische Insomnie erhalten, leiden zu einem großen Teil (34 von 43 Personen) unter einer psychiatrischen Erkrankung: Persönlichkeitsstörungen, mit und ohne zusätzliche affektive Störung, Depression, Dysthymie, Zyklothymie, bipolare Störung, Angststörungen (generalisierte Angststörung, soziale Phobie), somatoforme (autonome) Funktionsstörung, hypochondrische Störung, Zwangsstörung, Anpassungsstörungen nach dramatischen Lebensereignissen sowie posttraumatische Belastungsstörungen. Sie befinden sich in laufender psychiatrischer und psychotherapeutischer Behandlung, leiden aber anhaltend unter den Symptomen der Insomnie. Allen Patientinnen und Patienten mit nichtorganischer Insomnie wird die kognitive Verhaltenstherapie der Insomnie angeboten.

[Sleep medicine in psychiatry and psychotherapy]

Sleep medicine is a cross-disciplinary subject with high relevance for psychiatry and psychotherapy. The three most common sleep disorders (insomnia, sleep apnea syndrome and restless legs syndrome) are presented here with practical relevance. Cognitive behavioral therapy is the treatment of choice for insomnia, whereas symptomatic drug treatment (especially with GABA receptor agonists) should be used with caution. Sleep-related breathing disorders have a high prevalence of around 24% among psychiatric inpatients in Germany. Typical symptoms of obstructive sleep apnea syndrome should lead to a staged diagnostic process and, if necessary, cardiorespiratory polysomnography. It is not unusual for restless legs syndrome to be caused by psychopharmacological treatment. The primary form was usually treated with dopamine or dopamine agonists but due to the risk of augmentation, alternatives should be considered more often.

Patient characteristics as predictors of sleep disturbances in multimorbid primary care patients - A secondary analysis

OBJECTIVE

The aim of the study was to identify patient characteristics (adult attachment, health status, number and severity of chronic conditions, social support) predictive sleep disturbances after 12 months.

METHODS

In a secondary analysis of a prospective longitudinal study dealing with adult attachment and self-management, attachment- and health-related characteristics, socio-demographic data at baseline and symptoms of insomnia at the follow up (12 month later) was recorded by 219 patients between the ages of 50 and 85 years with multimorbidity in primary care. Adult attachment was measured by the ECR-RD12. The overall health status was measured using a visual analogue scale (VAS) and a standardized list of chronic conditions. The number and severity of chronic diseases (CIRS-G) was assessed by general practitioners (GPs). Sleep disturbances was measured by the ISI 12 month later.

RESULTS

Approximately 19% of the respondents were found to have clinically relevant symptoms of insomnia, and a further 34% to be subclinical insomnia. Attachment-related anxiety, a poorer perceived social support, the number of chronic conditions and a better general health status could predict higher levels of sleep disturbance after 12 month.

CONCLUSION

Sleep disorders can play a major role in patients with multimorbidity. Attachment anxiety and lack of social support may also be possible risk factors for the development of sleep disturbances.

Schlafstörungen aus psychiatrischer Sicht

Schlafstörungen gehören zu den häufigsten Gesundheitsbeeinträchtigungen überhaupt und sind fakultative oder obligate diagnoserelevante Frühsymptome sowie regelhaft auftretende Begleitsymptome psychischer Erkrankungen und Symptome. Diese sogenannten nichtorganischen Schlafstörungen persistieren häufig über den aktuellen Erkrankungszeitraum hinaus und stellen einen hohen Risikofaktor für Krankheitsausbrüche wie auch für Rückfälle dar. Trotz einer hohen Rate an Komorbidität gibt es auch isolierte Schlafstörungen als eigenständige Diagnosen. Besonders Insomnien, z. B. in Form von Ein- und/oder Durchschlafproblemen, sind oft Initialsymptome psychischer Störungen. Aktuell stehen zur diagnostischen Klassifikation von Schlafstörungen die ICD-10, das DSM‑V und die ICSD‑3 (Internationale Klassifikation der Schlafstörungen) zur Verfügung. Das ICD-11 reiht, im Gegensatz zum ICD-10 und zum DSM‑V Schlafstörungen nicht mehr bei den psychiatrischen Erkrankungen, sondern als eigenständige Krankheitsgruppe. Aufgrund der engen Verbindung zu psychischen Störungen sollte dies ebenso kritisch diskutiert werden wie die mangelnde Berücksichtigung psychiatrischer Themen im aktuellen Österreichische Ärztekammer(ÖÄK)-Spezialisierungs-Curriculum. Daneben geht es auch um die Verbindung zu Sucht, Suizidalität, die Themen Traum, Trauma, Albtraum und Schlafstörungen bei COVID-19.

Can You Sleep? - Effect of Retrospective Recall of Child Maltreatment on Sleep Parameters and the Mediating Role of Psychological Distress Among Students of Two German Universities

PURPOSE

Child maltreatment may be linked with long-term sleeping disorders and limited coping with stress. Yet, the potential relationships are only marginally studied.

PATIENTS AND METHODS

Based on a sample of young adults (n = 312) this study aims at exploring the effects of child maltreatment and the experience of threat to personal safety and life in childhood on sleep disturbances in early adulthood. Data were collected at the two study sites, Ulm University and Bielefeld University, by an online survey. For both risk factors, child maltreatment and the experience of threat to personal safety and life in childhood, a direct impact on sleep disturbances and an indirect path via psychological distress were tested using Structural Equation Modelling (SEM).

RESULTS

In these models, the direct path to sleep disturbances turned out to be significant for the experience of threat to personal safety and life (Path C: b = 0.18, p = 0.013), but not for child maltreatment (Path C: b = 0.05, p = 0.491). However, the current level of psychological distress was found to have a mediating effect on sleep disturbances for both risk factors, thereby confirming indirect significant effects.

CONCLUSION

Considering that the etiological pathway of child maltreatment on sleeping disturbances is mediated via psychological distress, this provides a venue to test in future research whether stress reduction interventions can reduce the negative consequences of child maltreatment on sleep disorders.

The acute effects of aerobic exercise on sleep in patients with unipolar depression: a randomized controlled trial

STUDY OBJECTIVES

Insomnia increases the risk of negative disease trajectory, relapse, and suicide in patients with depression. We aimed at investigating the effects of a single bout of aerobic exercise, performed after 02:00 pm, on the subsequent night's sleep in patients with depression.

METHODS

The study was designed as a two-arm parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients between 18 and 65 years of age with a primary diagnosis of unipolar depression were included. The intervention was a single 30-minute bout of moderate aerobic exercise. The control group sat and read for 30 minutes. The primary outcome was sleep efficiency measured by polysomnography. Secondary outcomes were other polysomnographic variables, subjective sleep quality, daytime sleepiness, mood states, and adverse events.

RESULTS

Ninety-two patients were randomized to the exercise (N = 46) or control group (N = 46). There were no clinically relevant differences at baseline. Intent-to-treat analysis ANCOVA of follow-up sleep efficiency, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = -0.93, p = 0.59). There was no evidence for significant differences between both groups in any other objective or subjective sleep outcomes, daytime sleepiness, or adverse events. The intervention had an immediate positive effect on mood states, including depressiveness (β = -0.40, p = 0.003).

CONCLUSIONS

This is the first trial to study the effects of a single bout of aerobic exercise on sleep in patients with depression to the best of our knowledge. Aerobic exercise had no effect on sleep efficiency but had a strong beneficial effect on mood and did not increase adverse outcomes. These results add to the growing body of evidence that, contrary to sleep hygiene recommendations, exercise after 02:00 pm is not detrimental for sleep.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03673397. Protocol registered on September 17, 2018.

Requirements and Architecture of a Cloud Based Insomnia Therapy and Diagnosis Platform: A Smart Cities Approach

Insomnia is the most common sleep disorder worldwide. Its effects generate economic costs in the millions but could be effectively reduced using digitally provisioned cognitive behavioural therapy. However, traditional acquisition and maintenance of the necessary technical infrastructure requires high financial and personnel expenses. Sleep analysis is still mostly done in artificial settings in clinical environments. Nevertheless, innovative IT infrastructure, such as mHealth and cloud service solutions for home monitoring, are available and allow context-aware service provision following the Smart Cities paradigm. This paper aims to conceptualise a digital, cloud-based platform with context-aware data storage that supports diagnosis and therapy of non-organic insomnia. In a first step, requirements needed for a remote diagnosis, therapy, and monitoring system are identified. Then, the software architecture is drafted based on the above mentioned requirements. Lastly, an implementation concept of the software architecture is proposed through selecting and combining eleven cloud computing services. This paper shows how treatment and diagnosis of a common medical issue could be supported effectively and cost-efficiently by utilising state-of-the-art technology. The paper demonstrates the relevance of context-aware data collection and disease understanding as well as the requirements regarding health service provision in a Smart Cities context. In contrast to existing systems, we provide a cloud-based and requirement-driven reference architecture. The applied methodology can be used for the development, design, and evaluation of other remote and context-aware diagnosis and therapy systems. Considerations of additional aspects regarding cost, methods for data analytics as well as general data security and safety are discussed.

[Chronic obstructive pulmonary disease, sleep-disordered breathing and hypoventilation-Influence on the cardiorenal system]

Comorbidities are frequently observed in patients suffering from pulmonary diseases due to shared risk factors and intricate interactions between various organ systems. This article aims to characterize the effects of selected diseases of the respiratory system on the cardiovascular system and kidneys. Advanced chronic obstructive pulmonary disease (COPD) often leads to a prognostically unfavorable increased pressure in the pulmonary circulation. In this respect treatment of these patients is primarily aimed at the underlying pulmonary disease and targeted treatment of the pulmonary hypertension should only be carried out according to invasive diagnostics and in an individualized manner. So far, the fact that there is a substantial overlap between COPD and heart failure with preserved ejection fraction has been completely ignored, which should be considered in the diagnostic procedure. Obstructive sleep apnea (OSA) has several unfavorable effects on the cardiovascular system and has been identified as an independent risk factor for cardiovascular diseases. The established treatment of OSA with continuous positive airway pressure (CPAP) has been shown to improve daytime sleepiness and the quality of life; however, an effect of CPAP on the occurrence of cardiovascular events, especially in asymptomatic patients, has so far not been demonstrated in randomized trials. Peripheral edema is frequently observed in patients suffering from chronic hypercapnia, which can be explained by several pathophysiological mechanisms, including pulmonary vasoconstriction and a direct effect of the hypercapnia on renal blood flow. Apart from the administration of diuretics, recompensation of such patients always requires treatment of the hypercapnia by noninvasive ventilation.

Subtypen der Insomnie – exemplarische Ansätze und offene Fragen

Verschiedene Autorinnen und Autoren nehmen an, dass es klinisch nützlich und wissenschaftlich erkenntnisbringend sein könnte, Subtypen der Insomnie zu identifizieren, um diese spezifisch und damit möglicherweise effektiver zu behandeln, als dies derzeit geschieht. Im vorliegenden Beitrag werden folgende exemplarisch ausgewählte Ansätze zur Einteilung der Insomnie in Subtypen vorgestellt: 1) Einteilungen nach klinischen Symptomen; 2) Primäre vs. sekundäre Insomnie; 3) Subtypen nach ICSD‑2; 4) Insomnie mit und ohne objektiv messbare kurze Schlafdauer; 5) Subtypen aus der Netherlands Sleep Registry. Anschließend werden die Stabilität der Zuordnung von einzelnen Patienten zu den verschiedenen Subtypen sowie die klinische Relevanz der Einteilungen kritisch diskutiert.

[Sleep disorders reduce the therapeutic success of inpatient psychosomatic treatments for depressive disorders]

Sleep disorders reduce the therapeutic success of inpatient psychosomatic treatments for depressive disorders Objective: What influence do difficulties in falling and staying asleep in patients with depressive disorders have on the success of psychosomatic treatment? Method: The Data were collected in a naturalistic, multicenter observational study (STOP-D) at the beginning (T1), the end (T2) and six months later after discharge (T3). The sample consisted of female patients with depressive disorders (N = 487) who were treated for M = 61.7 days (SD = 26.8). An insomnia scale with a total of seven items was created subsequently to T1 from Items of the Beck Depression Inventory (BDI-I), from the Hamilton Depression Scale (HAMD) and from the Global Severe Index (GSI) from the Symptom Checklist 90 (SCL-90-R). Then groups were formed on changes in insomnia symptoms from T1 to T2. These two groups "sleep improver" and "sleep deteriorators" were tested by analysis of variance. Results: The subsequently constructed insomnia scale showed good psychometric characteristics in the performed analyses. Patients who reported an improvement in their sleep disturbances during inpatient psychosomatic treatment had significantly lower depression scores in the self-evaluation inventories (BDI-I und SCL-90-R) than patients without improvements in their sleep patterns. This effect was even more pronounced for the catamnestic period. Discussion: Insomnia symptoms in depressed female patients can be an important indicator of the effect of inpatient psychosomatic treatment and can have negative impact on the sustainability of the therapy success.

[Better Sleep and Less Pain? Sleep Training in Orthopedic Rehabilitation]

PURPOSE

There is high comorbidity between chronic pain and insomnia. Not only does chronic pain impair sleep, poor sleep quality can also exacerbate the sensation of pain. However, usually, the respective symptoms are treated separately. We evaluate a new cognitive behavioral sleep-pain-training aiming at improving symptoms of both insomnia and chronic pain in the setting of ambulant orthopedic rehabilitation.

METHODS

N=41 patients participated in the study (with 15 participants being enrolled in the control group). The training consists of 4 modules á 90min and was explicitly developed for patients suffering from chronic pain and comorbid insomnia. It includes several methods of cognitive behavioral therapy for the treatment of insomnia and pain (e. g., sleep hygiene, sleep restriction, sleep-pain-protocol, cognitive restructuring) and specifically addresses the relationship between the two. Sleep quality, sleep related thoughts (focusing, rumination), internal health locus of control, pain intensity (day and night) as well as pain related thoughts (pain related anxiety, pain related depression/helplessness) were assessed pre and post training by means of a questionnaire.

RESULTS

Mixed ANOVAS revealed small (η²=: 0,010) to medium (η²=: 0,068) interaction effects for most dependent variables (sleep quality, sleep efficiency, focusing, rumination, internal health locus of control, average day and night pain, maximum night pain, pain related anxiety and pain related depression/helplessness) for the interaction of time and group. However, effects for rumination and average day pain were not significant. There was no interaction effect for maximum day pain. Effect sizes for single group analyses revealed medium (internal sleep locus of control: d=0,52) to large (sleep quality: d=1,73) significant effects for the training group and no (focusing: d=0,00) to small (maximum day pain: d=-0,43) and non-significant effects for the control group.

CONCLUSION

The training analyzed in this study may constitute a complement to existing treatment possibilities for patients suffering from chronic pain and should be further evaluated in larger samples.

Anonymous online cognitive behavioral therapy for sleep disorders in shift workers-a study protocol for a randomized controlled trial

Background

Many shift workers suffer from sleep issues, which negatively affect quality of life and performance. Scientifically evaluated, structured programs for prevention and treatment are scarce. We developed an anonymous online cognitive behavioral therapy for insomnia (CBT-I) program. After successful completion of a feasibility study, we now start this prospective, randomized, controlled superiority trial to compare outcomes of two parallel groups, namely an intervention group and a waiting-list control-group. Additionally, we will compare these outcomes to those of a face-to-face CBT-I outpatient sample.

Methods

Collaborating companies will offer our anonymous online intervention to their shift-working employees. Company physicians and counseling services will screen those interested for inclusion and exclusion criteria. Participants will receive access to our online service, where they will complete psychometric assessment and receive random assignment to either the intervention group or the waiting-list control group. Participants and providers will be aware of the group assignment. We aim to allocate at least N = 60 participants to the trial. The intervention consists of psychoeducation, sleep restriction, stimulus control, relaxation techniques, and individual feedback delivered via four e-mail contacts. During the intervention, as well as during the waiting period, participants will fill out weekly sleep diaries. Immediately after completion of the program, the post-intervention assessment takes place. Participants in the control group will be able to participate in the program after all study assessments. To recruit an additional sample, collaborating outpatient sleep clinics will provide six sessions of standard face-to-face CBT-I to an ad hoc sample of shift working patients. We expect both the online and the face-to-face CBT-I interventions to have beneficial effects compared to the control group on the following primary outcomes: self-reported symptoms of depression and insomnia, sleep quality, and daytime sleepiness.

Conclusions

The online intervention allows shift workers to follow a CBT-I program independently of their working schedule and location. Forthcoming results might contribute to further improvement of prevention and therapy of sleep issues in shift workers.

Trial registration

German Clinical Trials Register DRKS DRKS00017777. Registered on 14 January 2020—retrospectively registered.