Placebo effects in primary insomnia

The effect of nightly use of 150 mg cannabidiol on daytime neurocognitive performance in primary insomnia: a randomized controlled pilot trial

RATIONALE

Cannabidiol (CBD) is increasingly used as a sleep aid for insomnia; yet neurocognitive and subjective state effects following daily therapeutic use are unclear.

OBJECTIVES

To measure the effect of daily CBD use on neurocognitive performance and daily subjective mood in a population with primary insomnia.

METHODS

This study used a randomized, placebo-controlled, parallel design incorporating a single-blind placebo run-in week followed by a two-week double-blind dosing period, during which participants consumed 150 mg CBD (N = 15) or placebo (N = 15) sublingually 60-minutes daily before bed. Attention, executive function, reasoning, information processing, working and episodic memory were assessed using the CogPro system at the beginning of the placebo run-in, after 1-week and 2-weeks of dosing. Subjective states using visual analogue scales and side effects were recorded daily.

RESULTS

Cognitive performance was unaffected by nightly CBD supplementation (all p > 0.05). From baseline to trial conclusion, those receiving CBD reported greater experience of calmness, clear-headedness, coordination and were more likely to report side-effects of dry mouth relative to placebo (all p < 0.05).

CONCLUSIONS

Relative to placebo, daytime cognitive functioning following nightly supplementation as a therapeutic aid for primary insomnia was preserved under trial conditions. Results suggested an overall favourable safety profile, with larger controlled trials and thorough analyses of varying insomnia phenotypes necessary to corroborate these findings.

Cannabidiol for moderate-severe insomnia: a randomized controlled pilot trial of 150 mg of nightly dosing

STUDY OBJECTIVES

Low-dose cannabidiol (CBD) has become readily available in numerous countries; however, little consensus exists on its efficacy as a sleep aid. This trial explored the efficacy of 150 mg of CBD (n = 15) compared with placebo (n = 15) as a sleep aid in primary insomnia. CBD supplementation was hypothesized to decrease insomnia symptoms and improve aspects of psychological health, relative to placebo.

METHODS

Using a randomized, placebo-controlled, parallel design featuring a single-blind placebo run-in week followed by a 2-week double-blind randomized dosing phase, participants consumed the assigned treatment sublingually 60 minutes before bed nightly. Wrist-actigraphy and sleep diaries measured daily sleep. Sleep quality, sleep effort, and well-being were measured weekly over 4 in-laboratory visits. Insomnia severity and trait anxiety were measured at screening and study conclusion.

RESULTS

Insomnia severity, self-reported sleep-onset latency, sleep efficiency, and wake after sleep onset did not differ between treatments throughout the trial (all P > .05). Compared with placebo, the CBD group reported greater well-being scores throughout the trial (trial end mean difference = 2.60; standard error: 1.20), transient elevated behavior following wakefulness scores after 1 week of treatment (mean difference = 3.93; standard error: 1.53), and had superior objective sleep efficiency after 2 weeks of treatment (mean difference = 6.85; standard error: 2.95) (all P < .05). No other significant treatment effects were observed.

CONCLUSIONS

Nightly supplementation of 150 mg CBD was similar to placebo regarding most sleep outcomes while sustaining greater well-being, suggesting more prominent psychological effects. Additional controlled trials examining varying treatment periods and doses are crucial.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Cannabidiol (CBD) treatment for insomnia; URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000070932; Identifier: ACTRN12620000070932.

CITATION

Narayan AJ, Downey LA, Rose S, Di Natale L, Hayley AC. Cannabidiol for moderate-severe insomnia: a randomized controlled pilot trial of 150 mg of nightly dosing. J Clin Sleep Med. 2024;20(5):753-763.

Efficacy and safety of lemborexant in subjects previously treated with placebo for 6 months in a randomized phase 3 study

OBJECTIVE/BACKGROUND

To examine the effects of lemborexant (LEM) 5 mg (LEM5) or LEM 10 mg (LEM10) following extended placebo treatment. This post-hoc analysis used subject-reported sleep outcomes data from a phase 3 trial.

PATIENTS/METHODS

The subjects in these post-hoc analyses were randomized to placebo for 6 months (Time Period [TP]1) in Study E2006-G000-303 (SUNRISE-2; NCT02952820). Following placebo exposure, subjects were re-randomized to LEM5 or LEM10 for another 6 months (TP2). Subject-reported sleep outcomes derived from sleep diaries included sleep onset latency (sSOL), wake after sleep onset (sWASO), sleep efficiency (sSE), and total sleep time (sTST). Magnitude and change rate in parameters were assessed for 7 days before/after initial randomization to placebo and 7 days before/after re-randomization to LEM (6 months later). Month 6 placebo non-responders were assessed for LEM response in TP2 using predetermined responder definitions. Safety was monitored throughout the study.

RESULTS

Overall, 321 subjects received placebo; 258 re-randomized subjects received LEM5 (n = 133) and LEM10 (n = 125). Subjective sleep outcomes improved during TP1 with approximately 62 subjects (∼20%) exhibiting a sustained placebo response. Upon re-randomization to LEM, all measures showed an additional incremental benefit, most prominently in sSOL and sTST. Among Month 6 placebo non-responders, 11%-15% subsequently responded to LEM as assessed at Month 12. The safety profile was similar between treatment periods and treatment groups.

CONCLUSIONS

These data suggest that even when insomnia symptoms have improved over time with placebo treatment, additional and sustained clinical gains in sleep outcomes are possible with active treatment using lemborexant.

Do Placebos Primarily Affect Subjective as Opposed to Objective Measures? A Meta-Analysis of Placebo Responses in Insomnia RCTs

INTRODUCTION

Little is known about the relative magnitude of placebo responses on objective and subjective measures of sleep continuity. To address this issue, the pre-post effects of placebos on objective and subjective measures (i.e., polysomnography [PSG] and sleep diaries) were evaluated meta-analytically. The guiding hypothesis was that large responses would be observed on sleep diary measures and small responses would be observed on PSG measures.

METHODS

PubMed searches, 1967-2016, yielded 329 possible articles, 17 of which met the inclusion and exclusion criteria for the present analysis (including 879 subjects with PSG data, 1,209 subjects with diary data, and six studies with both PSG and sleep diary data). Average change and weighted effect sizes (ESs) were computed via modeling for sleep latency (SL), wake after sleep onset (WASO) and total sleep time (TST).

RESULTS

Pre-to-post change on PSG measures were: SL -13.7 min., ES = -0.37; WASO -14.3 min., ES = -0.36; and TST 29.8 min., ES = 0.50. Pre-to-post change on sleep diary measures were: SL -13.5 min., ES = -0.36; WASO -13.3 min., ES = -0.20; and TST 25.5 min., ES = 0.36. The modeled average objective subjective difference per sleep continuity measure was less than 5 minutes. The modeled average objective subjective difference per sleep continuity measure (in effect sizes) was less than 0.17.

DISCUSSION

The observed outcomes of this analysis suggest that placebos produce comparable effects on objective and subjective measures of sleep continuity. Thus, objective measures do not appear to protect against placebo responses. This being the case and given the importance of the subjective experience of illness severity and recovery, such data suggests that prospectively sampled sleep continuity data (sleep diaries) may be the optimal data for clinical trials, particularly when only one measure is possible.

Intensive sleep retraining treatment for insomnia administered by smartphone in the home: an uncontrolled pilot study

STUDY OBJECTIVES

Intensive sleep retraining (ISR) is a behavioral treatment that involves a patient falling asleep repeatedly over 1 treatment session (< 24 hours in duration) to treat sleep-onset insomnia. ISR relies on high homeostatic sleep and circadian rhythm drives to facilitate rapid sleep onsets overnight. The high cost and inaccessibility of laboratory-based ISR is a significant practical barrier to treatment uptake. Smartphone-delivered ISR offers a significantly more affordable, flexible, and efficient method to treat chronic insomnia. The present study is the first trial of ISR administered via smartphone in the home environment.

METHODS

Smartphone-delivered ISR was investigated with 12 individuals with chronic insomnia (9 women, 3 men, aged 49.75 ± 7.71 years) using a single-group, repeated-measures, case-replication series design. Participants received a single overnight session of home-based ISR treatment administered by smartphone. Sleep onset trials started at 23:00 and concluded after 40 trials or at 11:00 the following morning, whichever occurred first. Sleep diary and psychological variables associated with insomnia were measured at pretreatment, post-treatment, and 4- and 7-week follow-up.

RESULTS

Significant improvements with moderate to strong effects (d = 0.59-1.94) were indicated for sleep-onset latency, sleep efficiency, insomnia symptom severity, sleep self-efficacy, anticipatory sleep anxiety, dysfunctional beliefs about sleep, and daytime fatigue and functioning compared to baseline. Therapeutic benefits were largely maintained at the 7-week follow up.

CONCLUSIONS

This pilot study suggests that ISR may be feasibly administered via smartphone in the home. With fewer trials and a shorter treatment session, smartphone-delivered ISR seemed to achieve similar outcomes to the earlier laboratory-based ISR procedure. Randomized controlled trials are warranted to investigate the efficacy of smartphone-administered ISR.

CITATION

Mair A, Scott H, Lack L. Intensive sleep retraining treatment for insomnia administered by smartphone in the home: an uncontrolled pilot study. J Clin Sleep Med. 2022;18(6):1515-1522.

External Auditory Stimulation as a Non-Pharmacological Sleep Aid

The increased demand for well-being has fueled interest in sleep. Research in technology for monitoring sleep ranges from sleep efficiency and sleep stage analysis to sleep disorder detection, centering on wearable devices such as fitness bands, and some techniques have been commercialized and are available to consumers. Recently, as interest in digital therapeutics has increased, the field of sleep engineering demands a technology that helps people obtain quality sleep that goes beyond the level of monitoring. In particular, interest in sleep aids for people with or without insomnia but who cannot fall asleep easily at night is increasing. In this review, we discuss experiments that have tested the sleep-inducing effects of various auditory stimuli currently used for sleep-inducing purposes. The auditory stimulations were divided into (1) colored noises such as white noise and pink noise, (2) autonomous sensory meridian response sounds such as natural sounds such as rain and firewood burning, sounds of whispers, or rubbing various objects with a brush, and (3) classical music or a preferred type of music. For now, the current clinical method of receiving drugs or cognitive behavioral therapy to induce sleep is expected to dominate. However, it is anticipated that devices or applications with proven ability to induce sleep clinically will begin to appear outside the hospital environment in everyday life.

Effects of electrostatic therapy on nighttime sleep and daytime symptoms in patients with chronic insomnia: Evidences from an open label study

INTRODUCTION

Transcranial electric stimulation (TES) is a neuromodulation approach that applies low-intensity electrical current to the brain and has been proposed as a treatment for insomnia. Electrostatic therapy is a kind of TES and people do not have a feeling of electrical stimuli when the voltage of static electricity is lower than 2,000 volts. However, no studies have examined the effects of electrostatic therapy on objective sleep and daytime symptoms in patients with insomnia.

MATERIALS AND METHODS

Thirty chronic insomnia patients were included. All patients received a 6 week electrostatic therapy and three comprehensive assessments including two consecutive polysomnography (PSG) and daytime symptoms assessments, at pre-treatment, 3 week and 6 week of treatment. Insomnia Severity Index (ISI) was used to assess the severity of insomnia. Multiple sleep latency test (MSLT), Epworth Sleepiness Scale (ESS), and Flinders Fatigue Scale (FFS) were used to assess objective and self-reported daytime sleepiness and fatigue, respectively. Attention network test (ANT) was used to assess attention levels.

RESULTS

Total ISI scores decreased significantly at 3 weeks (p < 0.001) and 6 weeks (p < 0.001) after initiation of treatment. Furthermore, objective total sleep time (TST, p = 0.020) and sleep efficiency (SE, p = 0.009) increased and wake time after sleep onset (p = 0.012) decreased significantly after 6 weeks electrostatic therapy. Regarding daytime symptoms, ESS and FFS scores decreased significantly at 3 weeks (ESS, p = 0.047; FFS, p = 0.017) and 6 weeks (ESS, p = 0.008; FFS, p = 0.003) after initiation of treatment. Moreover, executive control improved significantly from pre-treatment to 3 weeks (p = 0.006) and 6 weeks (p = 0.013) and altering network improved significantly at 6 weeks (p = 0.003) after initiation of treatment. Secondary analyses showed that TST and SE improved significantly after electrostatic therapy in insomnia patients who slept < 390 min (all p-value < 0.05). However, no significant changes regarding TST and SE were observed in insomnia patients who slept ≥ 390 min.

CONCLUSION

Electrostatic therapy improves both nighttime sleep and daytime symptoms in patients with chronic insomnia. The effect on objective sleep appears to be stronger in patient with objective short sleep duration. Electrostatic therapy might be a therapeutic choice for insomnia patients with difficulty maintaining sleep and not responding to behavioral treatments.

CLINICAL TRIAL REGISTRATION

[www.clinicaltrials.gov], identifier [ChiCTR2100051590].

Sleep Efficiency and Total Sleep Time in Individuals with Type 2 Diabetes with and without Insomnia Symptoms

There is increasing awareness of the high prevalence of insomnia symptoms in individuals with type 2 diabetes (T2D). Past studies have established the importance of measuring sleep parameters using measures of central tendency and variability. Additionally, subjective and objective methods involve different constructs due to the discrepancies between the two approaches. Therefore, this study is aimed at comparing the averages of sleep parameters in individuals with T2D with and without insomnia symptoms and comparing the variability of sleep parameters in these individuals. This study assessed the between-group differences in the averages and variability of sleep efficiency (SE) and total sleep time (TST) of 59 participants with T2D with and without insomnia symptoms. Actigraph measurements and sleep diaries were used to assess sleep parameter averages and variabilities calculated by the coefficient of variation across 7 nights. Mann-Whitney U tests were utilized to compare group differences in the outcomes. Validated instruments were used to assess the symptoms of depression, anxiety, and pain as covariates. Objective SE was found to be statistically lower on average (85.98 ± 4.29) and highly variable (5.88 ± 2.57) for patients with T2D and insomnia symptoms than in those with T2D only (90.23 ± 6.44 and 3.82 ± 2.05, respectively). The subjective average and variability of SE were also worse in patients with T2D and insomnia symptoms, with symptoms of depression, anxiety, and pain potentially playing a role in this difference. TST did not significantly differ between the groups on averages or in variability even after controlling for age and symptoms of depression, anxiety, and pain. Future studies are needed to investigate the underlying mechanisms of worse averages and variability of SE in individuals with T2D and insomnia symptoms. Additionally, prompting the associated risk factors of insomnia symptoms in individuals with T2D might be warranted.

Pharmacological interventions for the treatment of insomnia: quantitative comparison of drug efficacy

PURPOSE

Although different forms of pharmacological intervention are often prescribed for insomnia disorder, the comparative efficacies among various drugs remain unclear. We therefore conducted this study to quantitatively compare the efficacy of various pharmacotherapies for insomnia by modeling.

METHODS

We searched PubMed, EMBASE and Cochrane Library databases for randomized placebo-controlled trials of insomnia medications that were conducted within a designated time period (from the inception dates to May 16, 2019). Pharmacodynamic models were established to describe the time course of changes from baseline in selected sleep parameters. Sleep quality and dropout rates were also compared by a single-arm meta-analysis.

RESULTS

In sum, 43 studies covering 44 trials (14,535 patients) were included in the analysis. The drugs evaluated included flurazepam, quazepam, temazepam, triazolam, eszopiclone, zaleplon, zolpidem, extended-release zolpidem, suvorexant, ramelteon and doxepin. The established models revealed eszopiclone had the highest efficacy in terms of sleep latency (SL), total sleep time (TST), and sleep quality, and was also associated with the lowest dropout rates. The effect of suvorexant on the parameter 'wake after sleep onset' (WASO) was significantly higher than that of the other drugs analyzed.

CONCLUSIONS

Each drug has its own characteristics in the treatment of insomnia, and this needs to be taken into consideration to meet individual clinical needs. These results serve as a quantitative supplement for clinical practice by reflecting the difference in efficacy of various drugs in the treatment of insomnia.

The influence of placebo administration on the first- night effect in patients with insomnia disorder

OBJECTIVE

We aimed to investigate the effects of placebo on the first-night effect (FNE) in insomniacs.

METHODS

In sum, 36 patients with insomnia disorder who met the DSM-5 criteria were enrolled in this study. Sixteen patients with insomnia disorder were given two days of placebo intervention (placebo-administration group, PL). Twenty patients with insomnia disorder (drug-free group, DF) were not given any interventions. All participants underwent two consecutive nights of polysomnographic (PSG) testing in the sleep laboratory. Sleep diaries were recorded during one week at home before the PSG nights and on two subsequent nights.

RESULTS

The results demonstrated that compared with the DF group, sleep onset latency (SOL), time in bed (TIB) and wake after sleep onset (WASO) significantly increased and sleep efficiency (SE) significantly decreased in the first sleep lab night in the PL group (all p < 0.05). Moreover, compared with the second night, significant differences were observed in lower self-reported total sleep time (TST) and more subjective WASO during the first night in the PL group (all p < 0.05). However, no significant difference was found in the duration and percentage of N1, N2, N3 and REM between the two groups.

CONCLUSION

In patients with insomnia disorder, placebo administration may increase the occurrence of worse sleep without causing a change in the duration and percentage of N1, N2, N3 and REM on the first sleep lab night. In some cases, a placebo may not serve as treatment but may result in a nocebo effect.

Biphasic feature of placebo response in primary insomnia: pooled analysis of data from randomized controlled clinical trials of orexin receptor antagonists

OBJECTIVES

The placebo response to orexin receptor antagonists in primary insomnia is little-known. Our aim was, therefore, to conduct a systematic review of placebo-controlled randomized clinical trials to characterize placebo response.

METHODS

We performed a comprehensive literature search for randomized, placebo-controlled, double-blind clinical trials evaluating the efficacy of orexin receptor antagonists addressing primary insomnia. To pool effect size estimates (Cohen's d) of placebo and orexin receptor antagonists across trials for outcome measures, a meta-analysis was done according to the Cochrane guideline.

RESULTS

The placebo response was significant and robust to improve the symptoms of insomnia in terms of objective and subjective measures, and the effects (0.70 ± 0.51) in subjective measures were smaller than that (1.10 ± 1.14) in objective measures (p = 0.027). The biphasic feature of placebo response showed an initial short-term increase of placebo effect and subsequent changeless long-term effect.

CONCLUSION

The biphasic feature of placebo response is clinically useful, and neuroimaging is essential to clarify the long-term mechanism in the future.

Pavlovian Conditioning of Immunological and Neuroendocrine Functions

The phenomenon of behaviorally conditioned immunological and neuroendocrine functions has been investigated for the past 100 yr. The observation that associative learning processes can modify peripheral immune functions was first reported and investigated by Ivan Petrovic Pavlov and his co-workers. Their work later fell into oblivion, also because so little was known about the immune system’s function and even less about the underlying mechanisms of how learning, a central nervous system activity, could affect peripheral immune responses. With the employment of a taste-avoidance paradigm in rats, this phenomenon was rediscovered 45 yr ago as one of the most fascinating examples of the reciprocal functional interaction between behavior, the brain, and peripheral immune functions, and it established psychoneuroimmunology as a new research field. Relying on growing knowledge about efferent and afferent communication pathways between the brain, neuroendocrine system, primary and secondary immune organs, and immunocompetent cells, experimental animal studies demonstrate that cellular and humoral immune and neuroendocrine functions can be modulated via associative learning protocols. These (from the classical perspective) learned immune responses are clinically relevant, since they affect the development and progression of immune-related diseases and, more importantly, are also inducible in humans. The increased knowledge about the neuropsychological machinery steering learning and memory processes together with recent insight into the mechanisms mediating placebo responses provide fascinating perspectives to exploit these learned immune and neuroendocrine responses as supportive therapies, the aim being to reduce the amount of medication required, diminishing unwanted drug side effects while maximizing the therapeutic effect for the patient’s benefit.

Quantitative analysis of the placebo response in pharmacotherapy of insomnia and its application in clinical trials

Study Objectives

This study aimed to develop a robust placebo response model for the pharmacotherapy for insomnia to guide drug development and clinical practice.

Methods

PubMed, EMBASE, and Cochrane Library databases were systematically searched for randomized placebo-controlled trials of medications for insomnia dating from the inception dates of the databases to April 18, 2018. Three placebo response models were established to describe the time–course of sleep parameters measured by objective (polysomnography or actigraphy) or subjective methods (sleep diary or questionnaires). The established models were applied to simulate placebo response distribution under different conditions using Monte Carlo simulations.

Results

Fifty-four studies involving 6,416 subjects were included. Placebo response increased over time and reached a plateau at approximately 8 weeks from start of therapy. Established models described the observed data reasonably well based on various diagnostic plots. Baseline sleep parameters affected the placebo response. There were significant positive correlations with placebo response and the severity of sleep latency, wake after sleep onset, and total sleep time at baseline. In addition, placebo response, assessed by subjective and objective methods, was consistent after correcting the baseline levels.

Conclusions

The established placebo response models can serve as a tool to predict placebo response at different baseline levels, which can provide valuable reference for clinical trial design, decision-making in drug development, and clinical practice.

Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): A Randomized Clinical Trial

OBJECTIVE

The authors sought to determine whether targeted treatment of insomnia with controlled-release zolpidem (zolpidem-CR) in suicidal adults with insomnia would provide a reduction in suicidal ideation superior to placebo.

METHODS

Reducing Suicidal Ideation Through Insomnia Treatment was an 8-week three-site double-blind placebo-controlled parallel-group randomized controlled trial of zolpidem-CR hypnotic therapy compared with placebo, in conjunction with an open-label selective serotonin reuptake inhibitor. Participants were medication-free 18- to 65-year-olds with major depressive disorder, insomnia, and suicidal ideation. Suicidal ideation was the main outcome, measured first by the Scale for Suicide Ideation and second by the Columbia-Suicide Severity Rating Scale (C-SSRS).

RESULTS

A total of 103 participants were randomly assigned to receive zolpidem-CR (N=51) or placebo (N=52) (64 women and 39 men; mean age=40.5 years). Zolpidem-CR had a robust anti-insomnia effect, especially in patients with the most severe insomnia symptoms. No significant treatment effect was observed on the Scale for Suicide Ideation (least squares mean estimate=-0.56, SE=0.83, 95% CI=-2.19, 1.08), but the reduction in scores was significantly positively related to improvement in insomnia after accounting for the effect of other depression symptoms. The C-SSRS indicated that zolpidem-CR had a significant treatment effect (least squares mean estimate=-0.26, SE=0.12, 95% CI=-0.50, -0.02). The advantage for zolpidem-CR in reducing suicidal ideation on the C-SSRS was greater in patients with more severe insomnia. No deaths or suicide attempts occurred.

CONCLUSIONS

Although the results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that coprescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia.

Placebo analgesia persists during sleep: An experimental study

Although placebo analgesia is a well-recognized phenomenon with important clinical implications, the possibility that placebo effects occur during sleep has received little attention. This experimental study examined whether responsiveness to acute heat pain stimuli applied during sleep could be reduced following a placebo conditioning procedure administered before sleep. Healthy individuals (n = 9) underwent polysomnographic recordings for one habituation night followed by one placebo analgesia night and one control night in counterbalanced order. Conditioning induced robust analgesia expectations before the placebo night. In the morning after the placebo night, participants reported less nocturnal pain, anxiety, and associated sleep disturbance (all p's < 0.05) compared to the control night. Furthermore, placebo induction produced a 10% reduction in brain arousals evoked by noxious stimuli during rapid-eye-movement (REM) sleep (p = 0.03), consistent with our previous findings suggesting that analgesia expectations are reprocessed during REM sleep. In contrast, arousals increased by 14% during slow wave sleep (SWS) (p = 0.02). In the morning after the last recording night, placebo testing administered as a manipulation check confirmed that typical placebo analgesic responses were produced during waking (p's < 0.05). These results suggest that analgesia expectations developed before sleep reduced nocturnal pain perception and subjective sleep disturbances and activated brain processes that modulate incoming nociceptive signals differentially according to sleep stage. These results need to be replicated in future studies exploring how analgesia expectations may be reactivated during different sleep stages to modulate nociceptive responses.

Electroacupuncture for treating insomnia in patients with cancer: a study protocol for a randomised pilot clinical trial

INTRODUCTION

Although insomnia is one of the most prevalent and disturbing symptoms among patients with cancer, it has not been properly managed. Electroacupuncture (EA) has received attention as a promising intervention for insomnia, and a few previous studies have reported that this intervention may be beneficial for treating insomnia in patients with cancer. The aim of this pilot study is to explore the feasibility and preliminary effectiveness of EA on the sleep disturbance of patients with cancer with insomnia using a subjective method, patient-reported questionnaires and an objective tool, actigraphy, to measure the quality of sleep.

METHODS AND ANALYSIS

This is a study protocol for a randomised, three-arm, multicentre, pilot clinical trial. A total of 45 patients with cancer who have continuous insomnia related to cancer treatment or cancer itself will be randomly allocated to an EA group, sham EA group or usual care group in equal proportions. The EA group will receive 10 sessions of EA treatment over 4 weeks. The sham EA group will receive sham EA at non-acupoints using non-penetrating Streitberger acupuncture needles with mock EA. The usual care group will not receive EA treatment. All participants will be provided a brochure on the management of sleep disorders regardless of their group assignment. The primary outcome measure is the mean change in the insomnia severity index from the baseline to week 5. Information related to sleep quality will also be obtained through the Pittsburgh Sleep Quality Index, a sleep diary and actigraphy. Participants will complete the trial by visiting the research centre at week 9 for follow-up assessment.

ETHICS AND DISSEMINATION

This study protocol was approved by the institutional review boards of each research centre. Written informed consent will be obtained from all participants. The result of this study will be published in peer-reviewed journals or presented at academic conferences.

TRIAL REGISTRATION NUMBER

KCT0002162; Pre-results.

Electroacupuncture for insomnia disorder: study protocol for a randomized controlled trial

BACKGROUND

Insomnia is a common sleep disorder that affects many adults either transiently or chronically. The societal cost of insomnia is on the rise, while long-term use of current drug treatments can involve adverse effects. Recently, electroacupuncture (EA) has been used to treat various conditions including insomnia. The objective of this study is to provide scientific evidence for the effect and safety of using EA to treat insomnia.

METHODS/DESIGN

In this multicentre, assessor-blind, three-arm, parallel-design, randomised controlled trial, 150 participants will be assigned to the EA group, the sham EA (SEA) group, or the usual care group. The EA and SEA groups will receive the specific treatments 2-3 times a week for 4 weeks, for a total of 10 sessions, whereas the usual care group will not receive EA and will continue with usual care during the same time period. The primary outcome measure will be changes in the Insomnia Severity Index 5 weeks after randomisation. The secondary outcomes will include the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, a sleep diary, the EuroQoL-5 dimension questionnaire, the levels of melatonin and cortisol, and the Patient Global Impression of Change. Safety will be assessed at each visit.

DISCUSSION

The results of this multicentre randomised controlled trial will contribute to provide rigorous clinical evidence for the effects and safety of EA for insomnia disorder.

TRIAL REGISTRATION

Korean Clinical Trial Registry, CRIS, KCT0001685 . Registered on 2 November 2015 (retrospectively registered). Date of enrolment of the first participant to the trial 13 October 2015.

Pilot Study of a Sleep Health Promotion Program for College Students

OBJECTIVES

We conducted a pilot study of a sleep health promotion program for college students. The aims of the study were to 1) determine the feasibility of the program, and 2) explore changes in sleep knowledge and sleep diary parameters.

DESIGN

Open trial of a sleep health promotion program for college students.

SETTING

A small liberal arts university in southwestern Pennsylvania.

PARTICIPANTS

University students (primarily female).

INTERVENTION

Active intervention components included individualized email feedback based on each participant's baseline sleep diary and an in-person, group format presentation on sleep health.

MEASUREMENTS

Participants completed online questionnaires and sleep diaries before and after the health promotion intervention. Online questionnaires focused on sleep knowledge and attitudes toward sleep, as well as Patient Reported Outcomes Measurement Information System (PROMIS) sleep and psychosocial assessments.

RESULTS

Of participants who completed some aspect of the study, 89% completed at least one intervention component (in-person lecture and/or sleep diary). Participants reported significant improvement in sleep knowledge and changes in sleep diary parameters (decreased sleep onset latency and time spent in bed, resulting in greater sleep efficiency). Sleep duration also increased by 30 minutes among short sleepers who obtained <7 hours sleep at baseline.

CONCLUSIONS

Preliminary evaluation of a brief program to promote sleep health suggests that it is feasible and acceptable to implement, and that it can favorably alter sleep knowledge and behaviors reported on the sleep diary in college students. Controlled trials are warranted.

Neuro-Bio-Behavioral Mechanisms of Placebo and Nocebo Responses: Implications for Clinical Trials and Clinical Practice

The placebo effect has often been considered a nuisance in basic and particularly clinical research. This view has gradually changed in recent years due to deeper insight into the neuro-bio-behavioral mechanisms steering both the placebo and nocebo responses, the evil twin of placebo. For the neuroscientist, placebo and nocebo responses have evolved as indispensable tools to understand brain mechanisms that link cognitive and emotional factors with symptom perception as well as peripheral physiologic systems and end organ functioning. For the clinical investigator, better understanding of the mechanisms driving placebo and nocebo responses allow the control of these responses and thereby help to more precisely define the efficacy of a specific pharmacological intervention. Finally, in the clinical context, the systematic exploitation of these mechanisms will help to maximize placebo responses and minimize nocebo responses for the patient's benefit. In this review, we summarize and critically examine the neuro-bio-behavioral mechanisms underlying placebo and nocebo responses that are currently known in terms of different diseases and physiologic systems. We subsequently elaborate on the consequences of this knowledge for pharmacological treatments of patients and the implications for pharmacological research, the training of healthcare professionals, and for the health care system and future research strategies on placebo and nocebo responses.

Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors

STUDY OBJECTIVES

This study involves the analysis of a secondary outcome of a trial examining whether cognitive behavior therapy for insomnia (CBT-I), a wake-promoting medication (armodafinil), or both results in greater improvement in prospectively assessed sleep continuity and daytime sleepiness than a placebo-alone group among a heterogeneous group of cancer survivors. Whether or not armodafinil alone, and/or when combined with CBT-I, affected adherence with CBT-I was evaluated.

DESIGN

This study is a randomized, placebo-controlled, clinical trial.

SETTING

This study was conducted at two northeastern academic medical centers.

PARTICIPANTS

Eighty-eight cancer survivors with chronic insomnia were recruited between October 2008 and November 2012. Participants were assigned to one of four conditions: 1) CBT-I and placebo (CBT-I+P); 2) CBT-I and armodafinil (CBT-I + A); 2) armodafinil alone (ARM); or 4) placebo alone (PLA).

INTERVENTIONS

CBT-I was delivered in seven weekly individual therapy sessions (three in person, four via telephone). The armodafinil dosage was 50 mg BID.

MEASUREMENTS AND RESULTS

Sleep continuity was measured with daily sleep diaries assessing sleep latency (SL), wake after sleep onset (WASO), and total sleep time (TST). The Epworth Sleepiness Scale (ESS) measured daytime sleepiness. Compared to the PLA group, the CBT-I+P and CBT-I+A groups reported a significant reduction in SL with effect sizes of 0.67 and 0.58, respectively. A significant reduction was observed in WASO in the CBT-I+A group with an effect size of 0.64. An increasing trend of TST was observed in the CBT-I+P, CBT-I+A, and PLA groups, but not in the ARM group. No statistically significant reductions in daytime sleepiness (ESS) were observed for any of the groups.

CONCLUSION

CBT-I alone and in combination with armodafinil caused significant improvement in sleep continuity. The addition of armodafinil did not appear to improve daytime sleepiness or enhance adherence to CBT-I.

Effect of Placebo Conditions on Polysomnographic Parameters in Primary Insomnia: A Meta-Analysis

STUDY OBJECTIVES

Little is known about the role of placebo response in the pharmacotherapy of primary insomnia, especially about the effect of placebo intake on objectively assessed outcome variables. Our aim was therefore to conduct an effect-size analysis of placebo conditions in randomized controlled drug trials addressing primary insomnia also including polysomnography.

DESIGN

We conducted a comprehensive literature search using PubMed, PsycINFO, PSYNDEX, PQDT OPEN, OpenGREY, ISI Web of Knowledge, Cochrane Clinical Trials, and the World Health Organization International Clinical Trials Registry Platform. The meta-analysis used a random effects model and was based on 32 studies reporting 82 treatment conditions covering a total of 3,969 participants. Special emphasis was given to the comparison of objective and subjective outcomes and the proportion of the placebo response to the drug response.

MEASUREMENTS AND RESULTS

Effect sizes estimates (Hedges g) suggest that there is a small to moderate yet significant and robust placebo response reducing the symptoms of insomnia in terms of sleep onset latency (-0.35), total sleep time (0.42), wake after sleep onset (-0.29), sleep efficiency (0.31), subjective sleep onset latency (-0.29), subjective total sleep time (0.43), subjective wake after sleep onset (-0.32), subjective sleep efficiency (0.25) and sleep quality (0.31). Thus, the placebo response was also evident in objective, physiological (polysomnographic) variables. Our results indicate that 63.56% of the drug responses are achieved even in the placebo groups.

CONCLUSIONS

In light of these strong placebo responses, future studies should investigate how to exploit placebo mechanisms in clinical practice.

Sleep variability and cardiac autonomic modulation in adolescents - Penn State Child Cohort (PSCC) study

OBJECTIVE

To investigate the effects of objectively measured habitual sleep patterns on cardiac autonomic modulation (CAM) in a population-based sample of adolescents.

METHODS

We used data from 421 adolescents who completed the follow-up examination in the Penn State Children Cohort study. CAM was assessed by heart rate (HR) variability (HRV) analysis of beat-to-beat normal R-R intervals from a 39-h electrocardiogram, on a 30-min basis. The HRV indices included frequency domain (HF, LF, and LF/HF ratio), and time domain (SDNN, RMSSD, and heart rate or HR) variables. Actigraphy was used for seven consecutive nights to estimate nightly sleep duration and time in bed. The seven-night mean (SD) of sleep duration and sleep efficiency were used to represent sleep duration, duration variability, sleep efficiency, and efficiency variability, respectively. HF and LF were log-transformed for statistical analysis. Linear mixed-effect models were used to analyze the association between sleep patterns and CAM.

RESULTS

After adjusting for major confounders, increased sleep duration variability and efficiency variability were significantly associated with lower HRV and higher HR during the 39-h, as well as separated by daytime and nighttime. For instance, a 1-h increase in sleep duration variability is associated with -0.14(0.04), -0.12(0.06), and -0.16(0.05) ms(2) decrease in total, daytime, and nighttime HF, respectively. No associations were found between sleep duration, or sleep efficiency and HRV.

CONCLUSION

Higher habitual sleep duration variability and efficiency variability are associated with lower HRV and higher HR, suggesting that an irregular sleep pattern has an adverse impact on CAM, even in healthy adolescents.

The incidence and temporal patterning of insomnia: a second study

Whether subjects with insomnia exhibit good sleep on some interval basis is unclear. Prior research suggests that patients with insomnia are highly variable with respect to night-to-night sleep continuity, that more than 40% of patients exhibit temporal patterning of good sleep, and that nearly 90% of patients exhibit better than average sleep following 1 to 3 nights of relatively poor sleep. The aim of the present study was to replicate and extend the above-noted findings utilizing: (i) a large sample studied over an extended time interval (ii) absolute standards for 'good' and 'poor' sleep; and (iii) a formal statistical methodology to assess temporal patterning and the association of time in bed with bout duration of poor or average sleep. Thirty-three subjects with insomnia and 33 good sleepers completed sleep diaries over the course of 110 days. It was found that subjects with insomnia (compared to good sleepers) had more poor nights (e.g. about 39 versus 7% of the assessed nights), a higher probability of a having a poor night on any given occasion (60% greater probability than good sleepers) and more consecutive nights of poor sleep between good sleep nights (median bout duration of approximately three versus one night). Lastly, it was found that (as would be predicted by both the Spielman model and the two-process model) time in bed moderated bout duration in the insomnia group. That is, longer times in bed were associated with longer bouts of poor sleep.

Variability of sleep duration is related to subjective sleep quality and subjective well-being: an actigraphy study

While there is a large body of evidence that poor subjective sleep quality is related to lower subjective well-being, studies on the relation of objective sleep measures and subjective well-being are fewer in number and less consistent in their findings. Using data of the Survey of Mid-Life in the United States (MIDUS), we investigated whether duration and quality of sleep, assessed by actigraphy, were related to subjective well-being and whether this relationship was mediated by subjective sleep quality. Three hundred and thirteen mainly white American individuals from the general population and 128 urban-dwelling African American individuals between 35 and 85 years of age were studied cross-sectionally. Sleep duration, variability of sleep duration, sleep onset latency, and time awake after sleep onset were assessed by actigraphy over a period of 7 days. Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index, positive psychological well-being and symptoms of psychological distress were assessed with the Satisfaction with Life Scale and the Mood and Anxiety Symptom Questionnaire. In both white and African Americans high day-to-day variability in sleep duration was related to lower levels of subjective well-being controlling age, gender, educational and marital status, and BMI. By contrast, sleep duration, sleep onset latency, and time awake after sleep onset were not related to subjective well-being controlling covariates and other sleep variables. Moreover, the relationship between variability in sleep duration and well-being was partially mediated by subjective sleep quality. The findings show that great day-to-day variability in sleep duration – more than average sleep duration – is related to poor subjective sleep quality and poor subjective well-being.

Dissection of the factors driving the placebo effect in hypnotic treatment of depressed insomniacs

OBJECTIVES

Our prior work has shown that there is improvement in self-reported sleep in persons receiving placebo in hypnotic clinical trials. We examined the components of the "placebo response" in a hypnotic clinical trial.

METHODS

This was an exploratory analysis of a randomized, double-blind clinical trial of eszopiclone versus placebo in the treatment of persons with depression and insomnia who were also receiving fluoxetine at a clinic of a teaching hospital. Sixty adults with both depression and insomnia symptoms, who were free of significant primary sleep disorders, received open-label fluoxetine for 9weeks. Patients were further randomized 1:1 to receive either masked eszopiclone 3mg or placebo at bedtime after the first week of fluoxetine. We examined the respective contributions of three factors associated with the "placebo effect": (1) regression to the mean, (2) expectancy, and (3) social desirability.

RESULTS

There was evidence for regression to the mean for the continuous measurement of the Insomnia Severity Index (ISI) and the Hamilton Depression Rating Scale. There was evidence for expectancy in self-reported Wake After Sleep Onset, continuous measurement of ISI, and dichotomous remission/non-remitter measurement of ISI. There was evidence of social desirability affecting self-reported Total Sleep Time.

CONCLUSIONS

Factors that have been associated with the "placebo effect" are operating in hypnotic clinical trials. However, the role of each factor differs depending upon which self-reported variable is being considered. The findings have implications for clinical trial design in insomnia.

Predictability of sleep in patients with insomnia

STUDY OBJECTIVES

To evaluate whether the night-to-night variability in insomnia follows specific predictable patterns and to characterize sleep patterns using objective sleep and clinical variables.

DESIGN

Prospective observational study.

SETTING

University-affiliated sleep disorders center.

PARTICIPANTS

146 participants suffering from chronic and primary insomnia.

MEASUREMENTS AND RESULTS

Daily sleep diaries were completed for an average of 48 days and self-reported questionnaires once. Three nights were spent in the sleep laboratory for polysomnographic (PSG) assessment. Sleep efficiency, sleep onset latency, wake after sleep onset, and total sleep time were derived from sleep diaries and PSG. Time-series diary data were used to compute conditional probabilities of having an insomnia night after 1, 2, or 3 consecutive insomnia night(s). Conditional probabilities were submitted to a k-means cluster analysis. A 3-cluster solution was retained. One cluster included 38 participants exhibiting an unpredictable insomnia pattern. Another included 30 participants with a low and decreasing probability to have an insomnia night. The last cluster included 49 participants exhibiting a high probability to have insomnia every night. Clusters differed on age, insomnia severity, and mental fatigue, and on subjective sleep variables, but not on PSG sleep variables.

CONCLUSION

These findings replicate our previous study and provide additional evidence that unpredictability is a less prevalent feature of insomnia than suggested previously in the literature. The presence of the 3 clusters is discussed in term of sleep perception and sleep homeostasis dysregulation.

Do mobile phone base stations affect sleep of residents? Results from an experimental double-blind sham-controlled field study

OBJECTIVES

The aim of the present double-blind, sham-controlled, balanced randomized cross-over study was to disentangle effects of electromagnetic fields (EMF) and non-EMF effects of mobile phone base stations on objective and subjective sleep quality.

METHODS

In total 397 residents aged 18-81 years (50.9% female) from 10 German sites, where no mobile phone service was available, were exposed to sham and GSM (Global System for Mobile Communications, 900 MHz and 1,800 MHz) base station signals by an experimental base station while their sleep was monitored at their homes during 12 nights. Participants were randomly exposed to real (GSM) or sham exposure for five nights each. Individual measurement of EMF exposure, questionnaires on sleep disorders, overall sleep quality, attitude towards mobile communication, and on subjective sleep quality (morning and evening protocols) as well as objective sleep data (frontal EEG and EOG recordings) were gathered.

RESULTS

Analysis of the subjective and objective sleep data did not reveal any significant differences between the real and sham condition. During sham exposure nights, objective and subjective sleep efficiency, wake after sleep onset, and subjective sleep latency were significantly worse in participants with concerns about possible health risks resulting from base stations than in participants who were not concerned.

CONCLUSIONS

The study did not provide any evidence for short-term physiological effects of EMF emitted by mobile phone base stations on objective and subjective sleep quality. However, the results indicate that mobile phone base stations as such (not the electromagnetic fields) may have a significant negative impact on sleep quality.

Polysomnographic and subjective profiles of sleep continuity before and after mindfulness-based cognitive therapy in partially remitted depression

OBJECTIVES

To examine whether mindfulness meditation (MM) was associated with changes in objectively measured polysomnographic (PSG) sleep profiles and to relate changes in PSG sleep to subjectively reported changes in sleep and depression within the context of a randomized controlled trial. Previous studies have indicated that mindfulness and other forms of meditation training are associated with improvements in sleep quality. However, none of these studies used objective PSG sleep recordings within longitudinal randomized controlled trials of naïve subjects.

METHODS

Twenty-six individuals with partially remitted depression were randomized into an 8-week Mindfulness-Based Cognitive Therapy (MBCT) course or a waitlist control condition. Pre-post measurements included PSG sleep studies and subjectively reported sleep and depression symptoms.

RESULTS

According to PSG sleep, MM practice was associated with several indices of increased cortical arousal, including more awakenings and stage 1 sleep and less slow-wave sleep relative to controls, in proportion to amount of MM practice. According to sleep diaries, subjectively reported sleep improved post MBCT but not above and beyond controls. Beck Depression Inventory scores decreased more in the MBCT group than controls. Improvements in depression were associated with increased subjective sleep continuity and increased PSG arousal.

CONCLUSIONS

MM is associated with increases in objectively measured arousal during sleep with simultaneous improvements in subjectively reported sleep quality and mood disturbance. This pattern is similar to the profiles of positive responders to common antidepressant medications.

Neurophysiology of sleep and wakefulness: basic science and clinical implications

Increased attention to the prevalence of excessive sleepiness has led to a clear need to treat this symptom, thus reinforcing the need for a greater understanding of the neurobiology of sleep and wakefulness. Although the physiological mechanisms of sleep and wakefulness are highly interrelated, recent research reveals that there are distinct differences in the active brain processing and the specific neurochemical systems involved in the two states. In this review, we will examine the specific neuronal pathways, transmitters, and receptors composing the ascending arousal system that flow from the brainstem through the thalamus, hypothalamus, and basal forebrain to the cerebral cortex. We will also discuss the mutually inhibitory interaction between the core neuronal components of this arousal system and the sleep-active neurons in the ventrolateral preoptic nucleus, which serves as a brainstem-switch, regulating the stability of the sleep-wake states. In addition, we will review the role of homeostatic and circadian processes in the sleep-wake cycle, including the influence of the suprachiasmatic nucleus on coordination of sleep-wake systems. Finally, we will summarize how the above processes are reflected in disorders of sleep and wakefulness, including insomnia, narcolepsy, disorders associated with fragmented sleep, circadian rhythm sleep disorders, and primary neurological disorders such as Parkinson’s and Alzheimer’s diseases.

Night-to-night sleep variability in older adults with and without chronic insomnia

OBJECTIVES

(1) To quantify night-to-night variability in sleep behaviors and sleep measures among older chronic insomnia (CI) subjects and non-insomnia (NI) controls; (2) to investigate systematic temporal patterns of sleep behaviors and sleep measures across nights; and (3) to examine clinical correlates of sleep variability.

METHODS

Sixty-one older adults with CI (71.4years old, 67% F) and 31 older adults with NI (70.7years old, 65% F) completed questionnaires, kept sleep diaries and wore wrist actigraphs for 2 weeks. Mixed models were used to estimate within-subject mean and standard deviation values; these were then compared across groups. Mixed models were also used to determine associations across nights of sleep measures.

RESULTS

CI and NI differed on mean values for clinical ratings and sleep diary measures, but not for actigraphy measures. CI also showed significantly greater variability than NI on most sleep diary measures and on actigraphically measured wakefulness after sleep onset (WASO) and sleep efficiency. Among CI, neither diary nor actigraphy measures from one night correlated with values from the previous night. Diary WASO, sleep time, actigraphy sleep latency and sleep time, however, positively correlated with values from the previous two nights. Variability measures were not correlated with other global clinical measures among CI.

CONCLUSIONS

Compared to NI, older adults with CI report worse sleep and greater night-to-night variability, which was confirmed with actigraphy. There was little evidence for positive or negative correlation of sleep measures across nights. Variability of sleep may be an important target for insomnia treatments.

The incidence and temporal patterning of insomnia: a pilot study

To date very little research has been conducted on night-to-night variability in the incidence of insomnia. It is unclear from prior research whether subjects with primary insomnia (PI) exhibit good sleep (or better than average sleep) on some interval basis. In the present study, pilot data are provided on: (1) the frequency with which 'good sleep' occurs in subjects with PI; and (2) whether these events occur in a non-random manner. Ten subjects with PI participated in this 'naturalistic' study. All subjects completed daily sleep diaries for a minimum of 20 days. None of the subjects received treatment for their insomnia during the monitoring period. The night-to-night data were evaluated by typing each night's sleep as 'Good' or 'Bad', and then by determining the number of bad nights that occurred prior to a good night for each subject. Good and bad nights were typed in two ways: (1) using a > or =85% cut-off and (2) using a better than the individual's mean sleep efficiency (idiographic cut-off). Subjects exhibited good sleep on between 29% (>85% criteria) and 55% (idiographic criteria) of the nights evaluated. The temporal patterning analysis (based on an idiographic cut-off) revealed that better than average sleep most frequently occurred (>89% of instances) following one to three nights of poor sleep. These data suggest that insomnia severity may be mediated/moderated by sleep homeostasis and that the homeostat, or input to the homeostat, may be abnormal in patients with PI.

Ramelteon 8 mg/d versus placebo in patients with chronic insomnia: post hoc analysis of a 5-week trial using 50% or greater reduction in latency to persistent sleep as a measure of treatment effect

BACKGROUND

Ramelteon is a selective MT1/MT2 melatonin receptor agonist approved by the US Food and Drug Administration for insomnia treatment.

OBJECTIVE

The aim of this post hoc analysis was to compare the efficacy and tolerability of ramelteon 8 mg/d versus placebo in adults with chronic insomnia.

METHODS

This study analyzed data from a previously published 5-week, randomized, double-blind, placebo-controlled study. Patients aged 18 to 64 years with chronic insomnia were randomly assigned to receive ramelteon 8 or 16 mg/d or placebo QD for 5 weeks. Sleep parameters were evaluated using polysomnography at weeks 1, 3, 5, and 6 (placebo runout). In this post hoc analysis, patients who received ramelteon 8 mg (approved dose) or placebo in the original study were evaluated using a primary end point of a=50% reduction from baseline in latency to persistent sleep (LPS).

RESULTS

A total of 270 adults (ramelteon 8 mg, 139 patients, mean age, 38.0 years; placebo, 131 patients, mean age, 39.7 years) met the criteria for inclusion in this analysis. One patient from the original study (ramelteon 8-mg/d group) was excluded from the post hoc analysis based on a lack of evaluable LPS data. Ramelteon was associated with significantly greater proportions of patients who achieved a > or = 50% reduction in LPS compared with placebo at weeks 1 (63.0% vs 39.7%; P < 0.001), 3 (63.0% vs 41.2%; P < 0.001), and 5 (65.9% vs 48.9%; P < 0.005). No rebound insomnia or withdrawal effects were observed. Headache (19.4% and 18.3%), fatigue (9.4% and 2.3%), and somnolence (7.9% and 1.5%) were the most common adverse events.

CONCLUSIONS

In this post hoc analysis of data from patients with chronic insomnia, a significantly greater percentage experienced a > or = 50% reduction in LPS with ramelteon 8 mg/d versus placebo. This improvement was evident at week 1 and was sustained through 5 weeks of treatment. Ramelteon 8 mg was well tolerated in this study, with no evidence of withdrawal or rebound insomnia.

The effect of placebo administration on the first-night effect in healthy young volunteers

The first-night effect is a well-known phenomenon that is considered to result from a subject's lack of adaptation to the unfamiliar environment of a sleep laboratory and to the technical equipment used for polysomnography. The effect has been explored as a laboratory model for transient insomnia. The main characteristics of this effect are short total sleep time (TST) and rapid eye movement (REM) sleep, a lower sleep efficiency index, and longer REM sleep latency. Previous studies have reported that personality traits (such as trait anxiety) are a potential cause of the first-night effect and that the placebo effect is closely related to the anxiety levels of the subjects. To the best of our knowledge, there are no reports regarding the effects of a placebo on first-night sleep. This omission can be explained by the fact that the polysomnographic recordings obtained during the first night of a study are generally excluded from the analysis in order to avoid the inclusion of the first-night effect. In the present study, 8 male university students were subjected to polysomnographic examinations during drug-free, placebo-administration, and benzodiazepine-administration conditions in order to clarify the placebo effect on sleep during consecutive nights, particularly on the first night. The recordings for each condition were conducted for 4 consecutive nights. A placebo or 5 mg nitrazepam was administered at 2230 h using a double-blind crossover design, while no drug was administered during the drug-free condition. There was a 10-day interval between the examination of each condition. Polysomnographic recording was started at 2300 h and continued until the natural awakening of the subjects on the next morning. Subsequently, the subjects were requested to fill in a rating scale that is used to evaluate the subjective perception of sleep. An increase in stage-2 sleep associated with the first-night effect was observed on the first night during the drug-free and placebo-administration conditions. However, REM sleep reduction associated with the first-night effect was detected on the first night during the drug-free condition; this decrease in REM sleep was counteracted by the placebo during the placebo-administration condition. The nitrazepam, but not the placebo, decreased both slow-wave sleep (SWS) and REM sleep. The values for the tendency to fall asleep, feeling refreshed upon awakening in the morning, and the tension upon awakening in the morning were improved to a greater extent by the placebo and nitrazepam administrations than when no drug was administered. These results demonstrate the possibility that placebo administration may have a hypnotic/anxiolytic effect and may improve transient insomnia without causing SWS and REM sleep reductions.

Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia

OBJECTIVE

To investigate the effect of melatonin treatment on sleep, behavior, cognition, and quality of life in children with attention-deficit/hyperactivity disorder (ADHD) and chronic sleep onset insomnia.

METHOD

A total of 105 medication-free children, ages 6 to 12 years, with rigorously diagnosed ADHD and chronic sleep onset insomnia participated in a randomized, double-blind, placebo-controlled trial using 3 or 6 mg melatonin (depending on body weight), or placebo for 4 weeks. Primary outcome parameters were actigraphy-derived sleep onset, total time asleep, and salivary dim light melatonin onset.

RESULTS

Sleep onset advanced by 26.9 +/- 47.8 minutes with melatonin and delayed by 10.5 +/- 37.4 minutes with placebo (p < .0001). There was an advance in dim light melatonin onset of 44.4 +/- 67.9 minutes in melatonin and a delay of 12.8 +/- 60.0 minutes in placebo (p < .0001). Total time asleep increased with melatonin (19.8 +/- 61.9 minutes) as compared to placebo (-13.6 +/- 50.6 minutes; p = .01). There was no significant effect on behavior, cognition, and quality of life, and significant adverse events did not occur.

CONCLUSION

Melatonin advanced circadian rhythms of sleep-wake and endogenous melatonin and enhanced total time asleep in children with ADHD and chronic sleep onset insomnia; however, no effect was found on problem behavior, cognitive performance, or quality of life.