Nonrestorative sleep as a distinct component of insomnia

Nonrestorative sleep and its association with insomnia severity, sleep debt, and social jetlag in adults: Variations in relevant factors among age groups

OBJECTIVE

Nonrestorative sleep (NRS) is unrefreshing sleep that is harmful to mental and physical health. Although few studies have reported the relationship between NRS and sleep problems, none have evaluated this relationship by age group. This study aimed to determine whether NRS could be associated with insomnia severity, sleep debt, and social jetlag and whether this relationship would vary with age.

METHODS

The 1592 participants were allocated into age groups: 18-25 years (n = 317), 26-40 years (n = 405), 41-65 years (n = 454), and >65 years (n = 416). The study used Restorative Sleep Questionnaire to assess NRS, Athens Insomnia Scale to assess insomnia severity, Sleep Debt Index to assess sleep debt, and the absolute difference in midpoints of sleep between weekdays and days off to assess social jetlag.

RESULTS

Logistic regression analysis was performed to determine the association between NRS and sleep problems. In the 18-25-year group, insomnia severity, sleep debt of ≥2 h, and social jetlag of ≥2 h; in the 26-40-year group, insomnia severity and sleep debt of ≥2 h; in the 41-65-year group, insomnia severity and sleep debt of ≥2 h; and in the >65-year group, insomnia severity were significantly associated with NRS.

CONCLUSION

NRS was associated with insomnia severity in all age groups, with sleep debt in the young and working-age groups and social jetlag in the young age group. Different approaches to improving the NRS are required for different age groups.

Exploring the short-term influence of a proprietary oil extract of black cumin (Nigella sativa) on non-restorative sleep: a randomized, double-blinded, placebo-controlled actigraphy study

Background

Nigella sativa (black cumin, or black seed) is popularly known as the seed of blessings in the Arab system of medicine. Though not widely recommended for sleep, a unique proprietary black cumin extract (BlaQmax®/ThymoDream™; BCO-5) has been shown to be helpful in the management of stress and sleep issues.

Methods

This randomized, double-blind, placebo-controlled trial aimed to investigate the efficacy of BCO-5 on the sleep quality of volunteers characterized with a self-reported non-restorative sleep disorder. Healthy male and female participants (n = 70), aged 18-65 years (BMI 22-28 Kg/m2) were randomized to either placebo or BCO-5 (n = 35/group). Both interventions were supplemented at 200 mg/day for seven days. Actigraphy and a validated restorative sleep questionnaire (RSQ-W) were used to monitor the influence of BCO-5 on sleep.

Results

Compared to placebo, BCO-5 significantly improved sleep quality, as evidenced by both intra-group and inter-group analyses of the actigraphy data. The relative improvements observed were sleep efficiency (7.8%, p < 0.001), total sleep time (19.1%, p < 0.001), sleep onset latency (35.4%; p < 0.001), and wake-after-sleep-onset (22.5%; p < 0.001) compared with placebo. BCO-5 also improved sleep by 75.3% compared to baseline (p < 0.001) and by 68.9% compared to placebo (p < 0.001), when monitored by RSQ-W. BCO-5 was well-tolerated with no reports of side effects or toxicity.

Conclusion

BCO-5 significantly improved non-restorative sleep in seven days, indicating its potential role as a natural sleep aid.

Impact of chronotype, insomnia symptoms, sleep duration, and electronic devices on nonrestorative sleep and daytime sleepiness among Japanese adolescents

OBJECTIVES

Nonrestorative sleep (NRS) and excessive daytime sleepiness (EDS) are important indicators of daytime dysfunction. Electronic media use before bedtime greatly affects adolescent sleep quality. However, few studies have examined factors associated with these symptoms. Therefore, we aimed to investigate the impact of chronotype, electronic device use before bedtime, and insomnia symptoms on NRS and EDS in Japanese adolescents.

METHODS

A web-based cross-sectional survey of 2067 adolescents was conducted in 2022 to mainly assess sleep-related issues (sleep duration, chronotype, insomnia symptoms, NRS, and EDS), time spent using electronic devices, physical activity, and mental health.

RESULTS

We analyzed data of 1880 adolescents (age, 16.4 ± 0.8 years; males, 56.7%). NRS and EDS prevalence rates were 54.9% and 39.4%, respectively. In multivariate analysis, evening chronotype [odds ratio (OR): 2.14, 95% confidence interval (CI): 1.58-2.89], difficulty initiating sleep (OR: 1.94, 95% CI: 1.43-2.64), <5 h sleep (OR: 1.77, 95% CI: 1.24-2.54), 5-6 h sleep (OR: 1.52, 95% CI: 1.20-1.93), and using electronic devices just before bedtime (OR: 1.48, 95% CI: 1.08-2.04) were associated with NRS. Evening chronotype (OR: 1.40, 95% CI: 1.07-1.82), early morning awakening (OR: 1.60, 95% CI: 1.02-2.50), using electronic devices just before bedtime (OR: 2.08, 95% CI: 1.48-2.93), and using electronic devices 30 min before bedtime (OR: 1.57, 95% CI: 1.07-2.29) were associated with EDS.

CONCLUSION

Chronotype may be an important factor influencing NRS and EDS. Discontinuing electronic device use at least 30 min before bedtime could benefit affected adolescents.

Associations of social isolation and loneliness with the onset of insomnia symptoms among middle-aged and older adults in the United States: A population-based cohort study

There is an inconsistent conclusion regarding the relationship of social isolation and loneliness with poor sleep. We investigated the associations of social isolation and loneliness with new-onset insomnia symptoms in a nationally-representative sample of 9,430 adults aged ≥50 who were free of any insomnia symptoms/sleep disorders at baseline (wave 12/13) and followed up to 4 years from the Health and Retirement Study. Social isolation was measured by Steptoe's Social Isolation Index. Loneliness was measured by the revised 3-item UCLA-Loneliness Scale. Insomnia symptoms were quantified using the modified Jenkins Sleep Questionnaire. During a mean follow-up of 3.52 years, 1,522 (16.1%) participants developed at least one insomnia symptom. Cox models showed that loneliness was associated with the onset of difficulties initiating or maintaining sleep, early-morning awakening, nonrestorative sleep, and at least one of these symptoms after adjusting for potential covariates; while social isolation was not associated with the onset of difficulties maintaining sleep, early-morning awakening, or at least one insomnia symptom after adjusting for health indicators. These results are consistent in sensitivity analyses and stratified analyses by age, sex, race/ethnicity, and obesity. Public health interventions aimed at fostering close emotional relationships may reduce the burden of poor sleep among middle-aged and older adults.

Somatic symptoms in sleep disturbance

Despite sleep disturbance and somatic symptoms being common health complaints, the relationship between these disturbances and single somatic symptoms is not well documented. The objectives of this study were to (i) identify somatic symptoms that are particularly associated with sleep disturbance, here referred to as somatic symptoms related to sleep disturbance (SS-SD), (ii) determine increased risk of sleep disturbance for each SS-SD and for a certain number of SS-SD, with and without controlling for anxiety and depression, and (iii) determine sensitivity and specificity for identifying sleep disturbance based on number of SS-SD in a general Swedish sample. Population-based, cross-sectional data based on validated questionnaire instruments were used from participants who constituted a sleep disturbance (n = 864) or a reference (n = 2340) group. Among 15 common somatic symptoms, stomach pain, back pain nausea/gas/indigestion, dizziness, and constipation/loose bowels/diarrhea were identified as SS-SD, with odds ratios of increased risk of sleep disturbance that ranged from 1.93 to 2.44 (1.36-1.79 and 1.54-1.91 when controlled for anxiety and depression, respectively). The risk of sleep disturbance increased by 1.44 times for each SS-SD (1.25 and 1.30 when controlled for anxiety and depression, respectively). A cutoff of two/three or more SS-SD had a sensitivity of 72.5/54.2% and a specificity of 50.0/69.7% for identifying sleep disturbances. When patients present with these somatic symptoms with or without a pathophysiological explanation, primary care clinicians may consider screening for sleep disturbance.

A gut-secreted peptide suppresses arousability from sleep

Suppressing sensory arousal is critical for sleep, with deeper sleep requiring stronger sensory suppression. The mechanisms that enable sleeping animals to largely ignore their surroundings are not well understood. We show that the responsiveness of sleeping flies and mice to mechanical vibrations is better suppressed when the diet is protein rich. In flies, we describe a signaling pathway through which information about ingested proteins is conveyed from the gut to the brain to help suppress arousability. Higher protein concentration in the gut leads to increased activity of enteroendocrine cells that release the peptide CCHa1. CCHa1 signals to a small group of dopamine neurons in the brain to modulate their activity; the dopaminergic activity regulates the behavioral responsiveness of animals to vibrations. The CCHa1 pathway and dietary proteins do not influence responsiveness to all sensory inputs, showing that during sleep, different information streams can be gated through independent mechanisms.

Ashwagandha (Withania somnifera)—Current Research on the Health-Promoting Activities: A Narrative Review

In recent years, there has been a significant surge in reports on the health-promoting benefits of winter cherry (Withania somnifera), also known as Ashwagandha. Its current research covers many aspects of human health, including neuroprotective, sedative and adaptogenic effects and effects on sleep. There are also reports of anti-inflammatory, antimicrobial, cardioprotective and anti-diabetic properties. Furthermore, there are reports of reproductive outcomes and tarcicidal hormone action. This growing body of research on Ashwagandha highlights its potential as a valuable natural remedy for many health concerns. This narrative review delves into the most recent findings and provides a comprehensive overview of the current understanding of ashwagandha’s potential uses and any known safety concerns and contraindications.

Longitudinal assessment of lifestyle factors associated with nonrestorative sleep in Japan

OBJECTIVE

Nonrestorative sleep (NRS) is common in the general global population. This study surveyed the incident/remission rate of NRS and identified related lifestyle factors in a general Japanese adult cohort.

METHODS

Data from a Japanese health check-based cohort between the fiscal years 2011 and 2018 were obtained. NRS was assessed through a single item question, and socio-demographic and clinical data were assessed through self-reports. To identify potential correlates of NRS incidence/remission, Cox regression analysis (or survival analysis) was performed.

RESULTS

Among the 135 609 individuals surveyed at baseline, data from 93 548 were considered for analysis. NRS exhibited incidence and remission rates of 11.3% and 15.4%, respectively. New NRS incidence was predicted by eating fast (hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.04-1.10), dining close to bedtime (HR: 1.33, 95% CI: 1.27-1.38), midnight snacking (HR: 1.09, 95% CI: 1.04-1.13), skipping breakfast (HR: 1.16, 95% CI: 1.10-1.22), non-regular exercise (HR: 1.12, 95% CI: 1.07-1.17), lower levels of physical activity (HR: 1.19, 95% CI: 1.14-1.24), and slow walking speed (HR: 1.34, 95% CI: 1.29-1.39), while heavy drinking was less predictive of NRS. However, the same factors (except for heavy drinking) were found to predict NRS remission.

CONCLUSIONS

We found that unhealthy lifestyle behaviors, particularly dining close to bedtime and slow walking speed, were positively associated with NRS incidence, while they were negatively associated with NRS remission. These results can be useful in developing more effective health promotion policies to achieve good sleep.

Association between insomnia and absenteeism or presenteeism among Korean employees

Background

In Korea, few studies clarify insomnia and its association and absenteeism or presenteeism. Therefore, this study aims to examine the association between insomnia and absenteeism/presenteeism using the sixth Korean Working Conditions Survey.

Methods

Insomnia was evaluated by the Minimal Insomnia Symptoms Scale (MISS). Absenteeism and presenteeism were assessed by asking if the employee had experienced absence or working despite being ill for the prior 12 months at the point of the survey. Multiple logistic analyses were conducted to explore insomnia and its association with absenteeism and presenteeism.

Results

The odds ratios of insomnia for absenteeism and presenteeism were 3.48 (95% confidence interval [CI]: 2.76-4.39) and 3.68 (95% CI: 3.18-4.26) in the fully adjusted model. As the MISS scores increased, absenteeism and presenteeism showed the increasing trend that odd ratios increased accordingly from the first to the fourth quartile.

Conclusions

This study observed that insomnia was related to both absenteeism and presenteeism among Korean employees.

Fear of Cancer Recurrence and Sleep in Couples Coping With Early-Stage Breast Cancer

BACKGROUND

Fear of cancer recurrence (FCR) and sleep disturbance are common in cancer survivors. Yet, little research has examined their relationship, and even less is known about what links may exist between these variables among the intimate partners of cancer survivors.

PURPOSE

This study examines the relationship between FCR and sleep disturbance in breast cancer survivors and their partners. Using daily sleep data collected at two distinct periods early in survivorship-the completion of adjuvant treatment and the first post-treatment mammogram-higher survivor and partner FCR was hypothesized to predict greater sleep disturbance.

METHODS

Breast cancer survivors and intimate partners (N = 76 couples; 152 individuals) each reported sleep duration, sleep quality, sleep onset latency, and wake after sleep onset each morning of two 21-day sleep diary bursts during the first year post-diagnosis. Three validated measures formed latent FCR factors for survivors and partners, which were used to predict average daily sleep.

RESULTS

Across both sleep diary bursts, survivor FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Survivor FCR was also associated with their partners' reduced sleep quality and greater sleep onset latency. Partner FCR was associated with their own reduced sleep duration, reduced sleep quality, and greater sleep onset latency. Partner FCR was also associated with survivors' reduced sleep quality.

CONCLUSIONS

Findings revealed intrapersonal and interpersonal associations between FCR and sleep disturbance, addressing gaps in knowledge on FCR and an outcome with known short- and long-term implications for health and mortality.

Associations among Alcohol Drinking, Smoking, and Nonrestorative Sleep: A Population-Based Study in Japan

Nonrestorative sleep (NRS) is a common sleep disorder. It is associated with several unhealthy lifestyle factors, such as skipping breakfast and lack of exercise. However, the associations between alcohol drinking, smoking, and NRS are unclear. This study examined the prevalence of NRS within the Japanese general population and the relationships among alcohol drinking, smoking, and NRS. We analyzed an anonymized dataset from a 2013 nationwide population survey (35,717 men and 39,911 women). NRS was assessed through a single-item question, and socio-demographic and lifestyle factors were assessed through self-reports. Multivariable logistic regression analyses were used to examine the associations between alcohol drinking, smoking, and NRS. The total prevalence of NRS was 22.2% (95% CI 21.8-22.7) in men and 23.4% (95% CI 23.0-23.8) in women. Further, we found that sleep duration and prevalence of NRS shared an inverse J-shaped relationship. Heavy alcohol drinking was significantly associated with NRS in both sexes. Short sleep duration and certain socioeconomic factors modified the effect of smoking on NRS in men. These results could be useful in the development of more effective sleep health policies to establish better sleep hygiene.

A Nationally Representative Survey Assessing Restorative Sleep in US Adults

Restorative sleep is a commonly used term but a poorly defined construct. Few studies have assessed restorative sleep in nationally representative samples. We convened a panel of 7 expert physicians and researchers to evaluate and enhance available measures of restorative sleep. We then developed the revised Restorative Sleep Questionnaire (REST-Q), which comprises 9 items assessing feelings resulting from the prior sleep episode, each with 5-point Likert response scales. Finally, we assessed the prevalence of high, somewhat, and low REST-Q scores in a nationally representative sample of US adults (n= 1,055) and examined the relationship of REST-Q scores with other sleep and demographic characteristics. Pairwise correlations were performed between the REST-Q scores and other self-reported sleep measures. Weighted logistic regression analyses were conducted to compare scores on the REST-Q with demographic variables. The prevalence of higher REST-Q scores (4 or 5 on the Likert scale) was 28.1% in the nationally representative sample. REST-Q scores positively correlated with sleep quality (r=0.61) and sleep duration (r=0.32), and negatively correlated with both difficulty falling asleep (r=-0.40) and falling back asleep after waking (r=-0.41). Higher restorative sleep scores (indicating more feelings of restoration upon waking) were more common among those who were: ≥60 years of age (OR=4.20, 95%CI: 1.92-9.17); widowed (OR=2.35, 95%CI:1.01-5.42), and retired (OR=2.02, 95%CI:1.30-3.14). Higher restorative sleep scores were less frequent among those who were not working (OR=0.36, 95%CI: 0.10-1.00) and living in a household with two or more persons (OR=0.51,95%CI:0.29-0.87). Our findings suggest that the REST-Q may be useful for assessing restorative sleep.

Association of insomnia symptoms and non-restorative sleep with Typus melancholicus: a Japanese general population survey

This study aimed to investigate the association between insomnia symptoms and non-restorative sleep (NRS) in individuals with Typus melancholicus, a personality trait linked to depression, in the general population. We analyzed data from a Japanese cross-sectional survey of 2519 randomly sampled adults. Typus melancholicus was evaluated using a modified version of Kasahara's Typus melancholicus inventory (modified-KTM). Logistic regression analysis was used to examine the associations of insomnia symptoms and NRS with modified-KTM scores. We demonstrated that insomnia symptoms and NRS were both positively associated with modified-KTM scores. Our results provide evidence for an association between Typus melancholicus and insomnia.

Longitudinal associations between insomnia symptoms and all-cause mortality among middle-aged and older adults: a population-based cohort study

To date, there is no scientific consensus on whether insomnia symptoms increase mortality risk. We investigated longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and nonrestorative sleep) and all-cause mortality among middle-aged and older adults during 14 years of follow-up. Data were obtained from 2004 through 2018 survey waves of the Health and Retirement Study in the United States for a population-representative sample of 15 511 respondents who were ≥50 years old in 2004. Respondents were interviewed biennially and followed through the end of the 2018 survey wave for the outcome. Marginal structural discrete-time survival analyses were employed to account for time-varying confounding and selection bias. Of the 15 511 cohort respondents (mean [±SD] age at baseline, 63.7 [±10.2] years; 56.0% females), 5878 (31.9%) died during follow-up. At baseline (2004), 41.6% reported experiencing at least one insomnia symptom. Respondents who experienced one (HR = 1.11; 95% CI: 1.03-1.20), two (HR = 1.12; 95% CI: 1.01-1.23), three (HR = 1.15; 95% CI: 1.05-1.27), or four (HR = 1.32; 95% CI: 1.12-1.56) insomnia symptoms had on average a higher hazard of all-cause mortality, compared to those who were symptom-free. For each insomnia symptom, respondents who experienced difficulty initiating sleep (HR = 1.12; 95% CI: 1.02-1.22), early-morning awakening (HR = 1.09; 95% CI: 1.01-1.18), and nonrestorative sleep (HR = 1.17; 95% CI: 1.09-1.26), had a higher hazard of all-cause mortality compared to those not experiencing the symptom. The findings demonstrate significant associations between insomnia symptoms and all-cause mortality, both on a cumulative scale and independently, except for difficulty maintaining sleep. Further research should investigate the underlying mechanisms linking insomnia symptoms and mortality.

Associations of nonrestorative sleep and insomnia symptoms with incident depressive symptoms over 1-2 years: Longitudinal results from the Hispanic Community Health Study/Study of Latinos and Sueño Ancillary Study

BACKGROUND

Nonrestorative sleep (NRS), defined as insufficiently rested or refreshed sleep, is considered to play an important role in the development of depression. The aim of this study is to investigate the predictive ability of insomnia-related symptoms, including NRS, for incident depressive symptoms (DEPs) in a longitudinal manner.

METHODS

We used data of 1196 samples aged 18-64 years who participated in both the Hispanic Community Health Study/Study of Latinos conducted in 2008-2010 and the follow-up study (Sueño Ancillary Study) conducted in 2010-2013. DEPs and insomnia-related symptoms (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], early morning awakening [EMA], difficulty returning to sleep [DRS], and NRS) were evaluated by the 10-item Center for Epidemiologic Studies Depression Scale and the Women's Health Initiative Insomnia Rating Scale, respectively. A logistic regression analysis was used to evaluate the predictive ability of each insomnia-related symptom at baseline for incident DEPs in couple-years.

RESULTS

In the univariate logistic regression analysis, all insomnia-related symptoms had significant associations with incident DEPs (DIS, odds ratio [OR] = 1.6; DMS, OR = 1.6; EMA, OR = 1.5; DRS, OR = 1.9; NRS, OR = 2.5). After adjusting for sociodemographic factors and the confounding effects of other insomnia-related symptoms, only NRS (OR = 2.2, 95% confidence interval = 1.4-3.5, p = .001) was significantly associated with incident DEPs.

CONCLUSIONS

NRS was a risk factor for incident DEPs, which includes a predictive ability for other insomnia-related symptoms. Our results suggest that focusing on NRS is an effective strategy for preventing depression in public health promotions.

Leisure-Time Physical Activity and General Health Mitigate Effects of Job Demands on Nonrestorative Sleep: CDC National Healthy Worksite Project

OBJECTIVE

We sought to determine if leisure-time physical activity (LTPA) modified the adverse relationship between high job demands and nonrestorative sleep (NRS).

METHODS

We conducted a multivariate logistic regression analysis among workers from the cross-sectional National Healthy Worksite Project (n = 4683) using self-report Likert-Scale data on psychological and physical demands of jobs, LTPA and general health in relation to NRS.

RESULTS

Not engaging in LTPA was associated with NRS for workers with jobs at the lowest or highest levels of the physical demand scale (OR 1.64, 95% CI: 0.96-2.81, OR 2.06, 95% CI: 0.95-4.45; respectively) in comparison to those who met LTPA recommendations. When assessing psychological demands, poor general health was associated with NRS at all levels of the scale independent of LTPA.

CONCLUSIONS

LTPA may reduce NRS for workers with jobs at either extreme of physical demands.

Insomnia Disorders: Nosology and Classification Past, Present, and Future

Insomnia is the most common sleep disorder in the adult population. However, the definition of insomnia disorder has varied across major classification systems and changed over time. In the present study, the investigators traced the evolution of insomnia disorder across classification systems, contemplated the empirical basis for its current definitions, and surveyed ongoing research efforts that may clarify insomnia nosology in the future. Three major classification systems for insomnia are the International Classification of Sleep Disorders, the International Classification of Diseases, and DSM. Despite their divergent origins, these classification systems have converged to nearly identical contemporary insomnia definitions. Over time, the emphasis in classification approaches has shifted from symptomatology to etiology to treatment implications. Additionally, the historical multitude of insomnia subtypes has gradually consolidated into a few core diagnoses, reflecting inadequate evidence with which to support subtyping. Current insomnia definitions include frequency and duration criteria to operationalize these diagnoses, while the diagnostic criterion of nonrestorative sleep has been eliminated (with some controversy). In ongoing research efforts, the quest for insomnia biomarkers has not thus far yielded clinically deployable breakthroughs. Data-driven insomnia subtyping suggests a promising new approach in deriving empirically based subtypes; conversely, the transdiagnostic perspective proposes the elimination of categorical distinctions in favor of finding common processes underlying all psychiatric disorders. The continual evolution of insomnia nosology highlights that much remains to be learned about these conditions; all current diagnostic classification systems are best regarded as "works in progress." Nevertheless, refinement and convergence of classification approaches is essential to standardizing insomnia research, diagnosis, and treatment.

The association between nonrestorative sleep and health-related quality of life in Chinese adults: a cross-sectional study

PURPOSE

Sleep problems are prevalent among the general population and can cause various health problems, which may lead to decreased quality of life. However, little is known about nonrestorative sleep and its implications. This study aimed to examine the association between nonrestorative sleep and health-related quality of life (HRQL) in Chinese adults.

METHODS

Data were collected through a cross-sectional study of 500 adults in Hong Kong (66.4% female, average age of 39 years). The Short-Form-12 Health Survey version 2 (SF-12v2), Nonrestorative Sleep Scale (NRSS), Pittsburgh Sleep Quality Index, ENRICHD Social Support Instrument, Patient Health Questionnaire, Perceived Stress Scale, and Hospital Anxiety and Depression Scale were administered. Objective sleep parameters were based on participants' sleep condition over 1 week, as measured using an ActiGraph GT9X Link.

RESULTS

Mean standardized scores for the physical component summary (PCS) and mental component summary (MCS) of the SF-12v2 and the NRSS were 50.33 ± 6.50, 49.00 ± 9.03, and 64.77 ± 12.75, respectively. After adjusting for sociodemographic and lifestyle characteristics, sleep quality, objective sleep parameters, social support, somatic symptoms, stress, anxiety, and depression, NRSS scores were associated with PCS (b = 0.12, 95%CI: 0.06 to 0.18, p < 0.001) and MCS (b = 0.08, 95%CI: 0.02 to 0.15, p = 0.013) scores. Furthermore, associations of NRSS score with PCS as well as MCS scores were stronger in women than in men.

CONCLUSION

Nonrestorative sleep is a potentially modifiable risk factor for poor HRQL. Thus, interventions to relieve or decrease nonrestorative sleep could be beneficial for improving HRQL.

Longitudinal effects of nocturnal insomnia symptom subtypes and nonrestorative sleep on the incidence of depression among community-dwelling older adults: results from the Health and Retirement Study

OBJECTIVE

The relationships between different insomnia symptom subtypes and the onset of depression among older adults are inconsistent. It may be that each subtype has a distinct temporal effect on depression not easily captured by the different follow-up intervals used in past studies. We systemically investigated the temporal effects by examining the links between subtypes and the onset of depression at different follow-up intervals among community-dwelling older adults.

METHODS

We used the 2006 wave of the Health and Retirement Study as baseline (n = 9151). The outcome was the onset of depression at 2-year (2008 wave), 4-year (2010 wave), and 6-year (2012 wave) follow-ups. The independent variables were difficulty with falling asleep (initial insomnia), waking up during the night (middle insomnia), waking up too early and being unable to fall asleep again (late insomnia), and nonrestorative sleep at baseline. Factors known to be related to depression among older adults were included as covariates.

RESULTS

Our findings showed that each insomnia symptom subtype had distinct temporal effects on the onset of depression. It appeared that the effects of initial insomnia may take longer to emerge than indicated in previous studies. Middle insomnia and late insomnia had weak relationships with depression. Nonrestorative sleep predicted the onset of depression at every follow-up period.

CONCLUSIONS

We found that documenting the temporal effects of insomnia symptom subtypes helps both to classify individuals' insomnia symptoms and predict the onset of depression. We recommend taking temporal effects of insomnia symptom subtypes into account in future investigations and clinical practice.

Sleep disturbance, associated symptoms, and quality of life in adults living with HIV in Jakarta, Indonesia

Adverse symptom experiences, including sleep disturbances, are important negative predictors of quality of life (QoL), but few studies conducted in low-income countries have examined the impact of poor sleep and its associated symptoms on QoL among people living with HIV (PLWH). To this end, 200 PLWH who were receiving treatment with antiretroviral therapy (ART) were recruited through a community nongovernment organization in Jakarta, Indonesia. Validated instruments measured QoL, sleep disturbance, fatigue, pain, ART adherence, substance use, drug use severity, and methadone treatment. Descriptive statistics, bivariate correlations, and multivariate linear regression were conducted to identify independent correlates of QoL. Overall, participants perceived their QoL as being good to very good (mean = 105.70, standard deviation = 14.7) and higher among women than men (p < 0.05). After adjusting for sex, education, drug-use severity, and ART adherence, QoL was negatively associated with fatigue, insomnia, and pharmacological treatment with methadone. Along with other known symptoms of HIV, sleep problems and their complications are important to clinically address and research more fully to assure satisfying QoL among PLWH.

Number of Chronic Nighttime Insomnia Symptoms and Risk of Chronic Widespread Pain and Pain-Related Disability: The HUNT Study

STUDY OBJECTIVES

To examine the association between the number of chronic nighttime insomnia symptoms and the risk of chronic widespread pain (CWP) and pain-related disability.

METHODS

A prospective study of 10,847 participants in the Norwegian HUNT Study without chronic musculoskeletal pain at baseline in 2006-2008. We used a modified Poisson regression model to estimate adjusted risk ratios (RRs) with a 95% confidence interval (CI) for CWP and pain-related disability at follow-up in 2017-2019 associated with insomnia and number of nighttime insomnia symptoms at baseline. Chronic insomnia was defined according to the current classification system and grouped into three categories based on the number of reported nighttime symptoms (ie, difficulty initiating sleep, trouble maintaining sleep and early morning awakenings).

RESULTS

Compared to the reference group of people without insomnia, people with insomnia had RRs for CWP and pain-related disability of 1.64 (1.26-2.14) and 1.63 (1.37-1.94), respectively. When people with insomnia were categorized based on the number of nighttime symptoms, people who reported one, two, or three nighttime symptoms had RRs of CWP of 1.19 (95% CI 0.80-1.78), 1.78 (95 CI 1.13-2.80) and 3.08 (95% CI 1.93-4.92), respectively, compared to people without insomnia. The corresponding RRs for pain-related disability were 1.49 (95% CI 1.17-1.89), 1.46 (95% CI 2.04-2.05), and 2.46 (95% CI 1.76-3.42).

CONCLUSION

These findings indicate that people with insomnia characterized by symptoms in all phases of the sleep period have a substantially increased risk of CWP and pain-related disability.

Reciprocal relations between work stress and insomnia symptoms: A prospective study

Work stress and poor sleep are closely related in cross-sectional data, but evidence from prospective data is limited. We analysed how perceived stress and work stressors (work demands, decision authority and workplace social support) are related to key dimensions of insomnia over time, using structural equation modelling. Biennial measurements from a large sample of the working population in Sweden enabled us to analyse both the relationship from stress to sleep as well as that from sleep to stress. Overall, we found reciprocal relations between insomnia and all four stress measures. However, looking at the relation between each dimension of insomnia and each stress measure, there were some differences in direction of effects. In the direction from stress to sleep, all work stressors as well as perceived stress predicted both difficulties initiating sleep and difficulties maintaining sleep. The same was found for non-restorative sleep, with the exception for decision authority. In the opposite direction, difficulties maintaining sleep predicted increased levels of work demands and perceived stress. Difficulties initiating sleep stood out among the insomnia symptoms as not predicting any of the stress measures, while non-restorative sleep was the only symptom predicting all stress measures. The results advance the understanding of the stress-sleep relationship and indicate a potential vicious circle between insomnia and perceived stress as well as work stressors, suggesting that the workplace could be an arena for interventions to alleviate insomnia.

Therapeutic efficacy of zolpidem combined with cognitive-behavioral therapy on primary insomnia

BACKGROUND

In this study, we intend to assess the efficacy of zolpidem combined with cognitive-behavioral therapy (CBT) for patients with primary insomnia (PI).

METHODS

A predefined search strategy will be used to search for associated literature from inception to the July 1, 2019: PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, Google Scholar, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure with no language limitation. In addition, we will also retrieve reference lists of included studies and relevant reviews, as well as the conference proceedings. All randomized controlled trials related to the zolpidem and CBT for PI will be included. Two authors will perform study selection, data collection, and study quality, respectively. We will also apply RevMan 5.3 software for statistical analysis.

RESULTS

This study will provide a comprehensive overview of the available evidence of the benefits and safety of zolpidem and CBT for PI. Primary outcomes are sleep quality and severity of sleep disorders. Secondary outcomes consist of sleep-onset latency, total sleep duration, sleep efficiency, and frequency and adverse events.

CONCLUSION

The results of this study will inform clinical and policy decisions regarding the benefits and harm of zolpidem and CBT for patients with PI.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019142796.

Interacting Influences of Sleep, Pain, and Analgesic Medications on Sleep Studies in Rodents

This overview provides a brief summary of the complex interactions that link sleep, pain, and analgesic medications. Sleep scientists and clinicians are well aware of these relationships and understand that maintaining healthy pain-free subjects in a stable environment is essential to generating interpretable data and valid conclusions. However, these concepts and the data that support bidirectional interactions between sleep and pain may be less known to those who are not sleep scientists yet need such information to protect and advance both animal wellbeing and research validity (for example, veterinarians, IACUC members). Abundant human evidence supports the disruptive effect of pain and the modulatory effects of analgesic drugs on sleep; however, analgesic drugs can alter both sleep and the electroencephalogram, which is the primary objective measure for identifying sleep and evaluating sleep properties in both humans and animals. Consideration of the modulatory and interactive relationships of sleep, pain, and analgesic medications is essential to designing and conducting valid and reproducible sleep research using animal subjects.

Effectiveness of Chinese herbal medicine for patients with primary insomnia: A PRISMA-compliant meta-analysis

BACKGROUND

Traditional medicine is widely used for patients with primary insomnia, but the studies showed inconsistent results. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the effectiveness of Chinese herbal medicine (CHM) versus placebo for primary insomnia patients.

METHODS

The electronic databases including PubMed, EmBase, Cochrane library, and China National Knowledge Infrastructure were searched to identify the RCTs published from inception till July 2018. The summary weighted mean difference (WMD) with its 95% confidence interval (CI) for Pittsburgh sleep quality index (PSQI), sleep onset latency, total sleep duration, Athens insomnia scale (AIS), and sleep efficiency were calculated using random-effects model.

RESULTS

Fifteen RCTs comprising 1500 patients were finally included in the meta-analysis. Overall, patients who received CHM had lower levels of PSQI (WMD: -2.36; 95% CI: -4.02 to -0.70; P = .005), sleep onset latency (WMD: -11.54; 95% CI: -20.55 to -2.54; P = .012), and AIS (WMD: -0.59; 95% CI: -0.97 to -0.22; P = .002) as compared with placebo. Moreover, the summary WMDs of CHM versus placebo were associated with higher total sleep duration (WMD: 0.79; 95% CI: 0.56-1.02; P < .001), and sleep efficiency (WMD: 9.72; 95% CI: 6.49-12.96; P < .001). The treatment effect on PSQI might be affected by publication year, sample size, mean age, percentage male, diagnostic tool, duration of insomnia, treatment duration, and study quality.

CONCLUSION

The findings of this meta-analysis indicated that CHM could significantly improve the symptoms of insomnia than placebo for patients with primary insomnia.

Associations of presence or absence of exercise and/or physical activity with non-restorative sleep by gender and age: a cross-sectional study

OBJECTIVES

Non-restorative sleep (NRS) is related to qualitative aspects of sleep. The associations of NRS with exercise (EX; a planned and purposeful activity) and physical activity (PA; daily bodily movement) by gender and age have not yet been clarified. We investigated the associations of EX and/or PA with NRS by gender and age.

DESIGN

A cross-sectional study.

SETTING

The data on gender, age, presence of NRS and engagement in EX and/or PA were obtained from database and questionnaire of specified medical check-ups in FY 2013 in Japan. The analysis was conducted in 2017.

PARTICIPANTS

The subjects comprised 90 122 residents (38 603 males and 51 519 females), aged 40-74 years, who had completed the specified medical check-ups.

OUTCOME MEASURE

The presence of NRS was assessed using a question asking whether or not the subjects usually got enough sleep. NRS was considered to be present when the subjects answered 'No'. Binary logistic regression analysis was used to assess the associations of presence or absence of EX and/or PA with NRS. The OR and 95% CI of NRS prevalence were calculated and compared between those engaged in both EX and PA and the others.

RESULTS

Except for 40s and 70s among males and 40s and 50s among females, the absence of EX or PA was associated with higher ORs of NRS than referent. ORs were more than twice compared with the referents in males in their 50s (OR 2.030(95% CI 1.675 to 2.459)) and 60s (OR 2.148(95% CI 1.970 to 2.343)) and females in their 60s (OR 2.142(95% CI 1.994 to 2.302)) when they engaged in neither EX nor PA.

CONCLUSIONS

Healthcare providers must take into account the similarities and differences in the associations of EX and/or PA with NRS by gender and age when they support people with NRS.

Sleep and Self-Rated Health in an Aging Workforce

The labor force participation rate for adults aged 55 years and older has increased nearly 10% over the past two and a half decades. As workers age, they frequently experience increased chronic health conditions and impaired sleep, which may negatively influence their self-rated health (SRH) and work performance. This study aimed to examine the associations between nonrestorative sleep (NRS) and work performance (i.e., difficulty concentrating or having lower productivity at work) and associations between demographic and sleep characteristics with SRH in middle-aged workers. We conducted a secondary data analysis among working middle-aged adults 50 to 65 years of age ( N = 392) from the 2008 Sleep in America Poll. Respondents frequently reported impaired sleep such as frequent insomnia symptoms, NRS, and short sleep duration. Nonrestorative sleep was associated with decreased work performance such as trouble organizing work, doing work over due to mistakes, and lower productivity. Nonrestorative sleep and short sleep duration were significantly associated with lower SRH. Strategies for the early detection of impaired sleep and implementation of interventions to improve sleep may improve SRH and work performance in working middle-aged adults.

Impact of migraine on the clinical presentation of insomnia: a population-based study

BACKGROUND

Insomnia and migraine are closely related; insomnia aggravates migraine symptoms. This study was conducted to investigate the impact of migraine on the clinical presentation of insomnia symptoms.

METHODS

The data of the Korean Headache-Sleep Study (KHSS) were used in the present study. The KHSS is a nation-wide cross-sectional population-based survey regarding headache and sleep in Korean adults aged 19 to 69 years. If a participant's Insomnia Severity Index (ISI) score ≥ 10, she/he was classified as having insomnia. The clinical presentation of insomnia symptoms was assessed using total and subcomponent scores of the ISI.

RESULTS

Of 2695 participants, 290 (10.8%) and 143 (5.3%) individuals were assigned as having insomnia and migraine, respectively. The proportions of migraine (12.8% vs. 4.4%, p <  0.001) and non-migraine headache (59.0% vs. 39.9%, p <  0.001) were higher among individuals with insomnia compared to those without insomnia. Among participants with insomnia, total ISI scores were not significantly different among participants with migraine, non-migraine, and non-headache [median and interquartile range: 13.0 (11.0-17.5) vs. 13.0 (11.0-17.5) vs. 12.0 (11.0-16.0), p = 0.245]. ISI scores for noticeability of sleep problems to others were significantly higher among participants with migraine [3.0 (2.0-4.0) vs. 2.0 (2.0-3.0), p = 0.011] and non-migraine headache [3.0 (2.0-4.0) vs. 2.0 (2.0-3.0), p = 0.001] compared to those without headache history. Other ISI subcomponent scores did not significantly differ between headache status groups.

CONCLUSIONS

Participants with insomnia had an increased risk of migraine and non-migraine headache compared to those without insomnia. Among participants with insomnia, overall insomnia severity was not significantly influenced by the headache status.

New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation

In mammals, a central circadian clock, located in the suprachiasmatic nuclei (SCN) of the hypothalamus, tunes the innate circadian physiological rhythms to the ambient 24 h light-dark cycle to invigorate and optimize the internal temporal order. The SCN-activated, light-inhibited production of melatonin conveys the message of darkness to the clock and induces night-state physiological functions, for example, sleep/wake blood pressure and metabolism. Clinically meaningful effects of melatonin treatment have been demonstrated in placebo-controlled trials in humans, particularly in disorders associated with diminished or misaligned melatonin rhythms, for example, circadian rhythm-related sleep disorders, jet lag and shift work, insomnia in children with neurodevelopmental disorders, poor (non-restorative) sleep quality, non-dipping nocturnal blood pressure (nocturnal hypertension) and Alzheimer's disease (AD). The diminished production of melatonin at the very early stages of AD, the role of melatonin in the restorative value of sleep (perceived sleep quality) and its sleep-anticipating effects resulting in attenuated activation of certain brain networks are gaining a new perspective as the role of poor sleep quality in the build-up of β amyloid, particularly in the precuneus, is unravelled. As a result of the recently discovered relationship between circadian clock, sleep and neurodegeneration, new prospects of using melatonin for early intervention, to promote healthy physical and mental ageing, are of prime interest in view of the emerging link to the aetiology of Alzheimer's disease. LINKED ARTICLES: This article is part of a themed section on Recent Developments in Research of Melatonin and its Potential Therapeutic Applications. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.16/issuetoc.

Sleep Characteristics in Mothers of Children With Developmental Disabilities

Impaired sleep can contribute to conditions such as cardiometabolic disorders, depression, and decreased immune function. Mothers of children with developmental disabilities (DDs) may be at greater risk for impaired sleep due to the sleep problems of their children. This cross-sectional study described the self-reported sleep characteristics of mothers of children (ages 6-12) with DDs by using a sleep diary and the Pittsburgh Sleep Quality Index (PSQI) as quantitative and qualitative measures of sleep in these mothers. The Consensus Sleep Diary was modified to ascertain how the child's sleep and needs for care during the night impacted the mother's sleep. The results showed that mothers had short sleep duration (nearly 40% slept <7 hours per night), woke up an average of 2.2 times per night (most commonly due to caregiving needs of children), and had poor sleep quality (mean PSQI global score of 7.9 [SD=4.8]). The sleep problems of children with DDs may influence mothers' sleep.

The Effect of Sleep Disorders, Sedating Medications, and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis

Cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) is an effortful process requiring engagement in cognitive restructuring. Sleep disorders may lead to avoidance of effortful tasks and cognitive performance deficits. We explored whether sleep disorders, as assessed by polysomnography, were consistently associated with treatment response in combination with other factors. This study included 32 U.S. veterans who were examined both before and after CPT for combat-related PTSD. We employed a novel, case-comparative technique, fuzzy set qualitative comparative analysis (fsQCA), to identify combinations of fuzzy and crisp factors (recipes) that achieve a clinically significant outcome. Approximately one-quarter of cases experiencing clinically significant change were either (a) Vietnam era veterans without sedating medications, moderate sleep disordered breathing, and severe depression; or (b) non-Vietnam era veterans with sedating medications and without severe periodic limb movements (or significant periodic limb movement arousals). Recipes involving the absence of the relevant sleep disorder were associated with the highest coverage values. These results using fsQCA (a) provide valuable information about the heterogeneity of CPT response and (b) suggest that sleep disorders are important factors to consider in theoretical discussions of who responds to CPT for PTSD.

When a gold standard isn't so golden: Lack of prediction of subjective sleep quality from sleep polysomnography

BACKGROUND

Reports of subjective sleep quality are frequently collected in research and clinical practice. It is unclear, however, how well polysomnographic measures of sleep correlate with subjective reports of prior-night sleep quality in elderly men and women. Furthermore, the relative importance of various polysomnographic, demographic and clinical characteristics in predicting subjective sleep quality is not known. We sought to determine the correlates of subjective sleep quality in older adults using more recently developed machine learning algorithms that are suitable for selecting and ranking important variables.

METHODS

Community-dwelling older men (n=1024) and women (n=459), a subset of those participating in the Osteoporotic Fractures in Men study and the Study of Osteoporotic Fractures study, respectively, completed a single night of at-home polysomnographic recording of sleep followed by a set of morning questions concerning the prior night's sleep quality. Questionnaires concerning demographics and psychological characteristics were also collected prior to the overnight recording and entered into multivariable models. Two machine learning algorithms, lasso penalized regression and random forests, determined variable selection and the ordering of variable importance separately for men and women.

RESULTS

Thirty-eight sleep, demographic and clinical correlates of sleep quality were considered. Together, these multivariable models explained only 11-17% of the variance in predicting subjective sleep quality. Objective sleep efficiency emerged as the strongest correlate of subjective sleep quality across all models, and across both sexes. Greater total sleep time and sleep stage transitions were also significant objective correlates of subjective sleep quality. The amount of slow wave sleep obtained was not determined to be important.

CONCLUSIONS

Overall, the commonly obtained measures of polysomnographically-defined sleep contributed little to subjective ratings of prior-night sleep quality. Though they explained relatively little of the variance, sleep efficiency, total sleep time and sleep stage transitions were among the most important objective correlates.

Sleep Difficulties and Insomnia Symptoms in Norwegian Musicians Compared to the General Population and Workforce

Sleep problems are reported as common among performing artists and musicians. However, epidemiological research comparing musicians to different groups of the general population is lacking. For this study, 4,168 members of the Norwegian Musician's Union were invited to an online survey regarding work and health. Of the 2,121 (51%) respondents, 1,607 were active performing musicians. We measured prevalence of insomnia symptoms using the Bergen Insomnia Scale (BIS), and compared this sample to a representative sample of the general Norwegian population (n = 2,645). Overall, musicians had higher prevalence of insomnia symptoms compared to the general population (Prevalence Difference 6.9, 95% Confidence Interval 3.9-10.0). Item response analysis showed that this difference was mainly explained by nonrestorative sleep and dissatisfaction with sleep among musicians. An additional analysis, comparing musicians to the general Norwegian workforce (n = 8,518) on sleep difficulties, confirmed this tendency (Prevalence Difference 6.2, 95% Confidence Interval 4.3-8.1). Musicians performing classical, contemporary, rock, and country music reported the highest prevalence of insomnia, and these genres might be of special interest when developing preventative measures, treatment strategies, and further research on sleep difficulties among musicians.

Effectiveness and safety of moxibustion for primary insomnia: a systematic review and meta-analysis

BACKGROUND

Primary insomnia is a widespread and refractory disease. Moxibustion therapy for insomnia shows some advantages compared with conventional therapies. This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the effectiveness and safety of moxibustion therapy for insomnia.

METHODS

We conducted a comprehensive literature review of the CENTRAL, PubMed, EMBASE, Web of science, CNKI, VIP, and Wanfang Data databases from their inception to July 2015 for RCTs that compared moxibustion with western medications, oral Chinese medicine, or other methods of traditional Chinese medicine (TCM) in patients with primary insomnia. The primary outcome measure was effective rate and secondary outcome measure was adverse events. Data collection and analysis included risk of bias evaluation, meta-analysis, sensitivity analysis, publication bias and adverse events analysis according to corresponding criteria.

RESULTS

The study included 22 RCTs (1,971 patients). The quality of the studies was low. The overall meta-analysis demonstrated that moxibustion was more effective for insomnia than western medications, oral Chinese medicine and other TCM therapies (RR = 1.17, 95 % CI 1.12 to 1.23, P < 0.00001). Subgroup analyses demonstrated that moxibustion was more effective for insomnia than western medications (RR = 1.16, 95 % CI 1.09 to 1.24, P < 0.00001), oral Chinese medicine (RR = 1.11, 95 % CI 1.04 to 1.18, P = 0.002), and other TCM therapies (RR = 1.22, 95 % CI 1.15 to 1.30, P < 0.00001). There were no serious adverse effects associated with moxibustion therapy for insomnia, and the rate of adverse events was low.

CONCLUSION

It is difficult to get the conclusion regarding the effectiveness and safety of moxibustion for primary insomnia due to insufficient evidence, such as the high risk of bias in the included studies, small sample sizes, and few reports on adverse effects. Moxibustion should be considered as a novel therapeutic option for insomnia, and more rigorous clinical trials of moxibustion therapy for insomnia are needed to assess its effects.

Insomnia Symptoms Are Not Associated with Dyslipidemia: A Population-Based Study

STUDY OBJECTIVES

The purpose of this study was to examine whether or not insomnia symptoms were associated with measured dyslipidemia.

METHODS

This was a population-based multiyear cross-sectional study, using data from 2005-2008 United States National Health and Nutrition Examination Surveys. Survey participants ages 20 y and older self-reported the frequency of difficulty falling asleep, prolonged nocturnal awakening, and undesired early morning awakening over the preceding month. One-time venipuncture was performed and a low-density lipoprotein cholesterol (LDL-C) of ≥ 160 mg/ dL, triglycerides of ≥ 200 mg/dL, and a high-density lipoprotein cholesterol (HDL-C) of < 40 mg/dL denoted dyslipidemia. Descriptive statistics and multiple logistic regression were used.

RESULTS

Data on LDL-C, triglycerides, and HDL-C was available for 4,635, 4,757, and 9,798 individuals, respectively. There were no significant associations between having any insomnia symptom at least five times in the past month and high LDL-C (odds ratio [OR] 1.20, 95% confidence interval [CI] 0.92-1.55) or low HDL-C (OR 0.92, 95% CI 0.82-1.04) in unadjusted analyses, or with high triglycerides after adjusting for covariates (OR 1.03, 95% CI 0.78-1.37). Recipients of sleeping pills who also had insomnia symptoms had significantly increased adjusted odds of elevated LDL-C (OR 2.18, 95% CI 1.14-4.15).

CONCLUSIONS

Insomnia symptoms were generally not associated with dyslipidemia, but receipt of sleeping pills in the setting of insomnia was associated with elevated LDL-C. Further research is needed to confirm a possible link between sleeping pill use and dyslipidemia and to delineate if an association with atherosclerosis exists with specific types of sleeping pills or with all sedative medications more broadly.

Chronic fatigue syndrome and sleep disorders: clinical associations and diagnostic difficulties

INTRODUCTION

Chronic fatigue syndrome (CFS) is characterised by the presence of intractable fatigue and non-restorative sleep, symptoms which are also very prevalent in multiple diseases and appear as side effects of different drugs. Numerous studies have shown a high prevalence of sleep disorders in patients with CFS. However, non-restorative sleep and fatigue are frequently symptoms of the sleep disorders themselves, so primary sleep disorders have to be ruled out in many cases of CFS.

DEVELOPMENT

This review was performed using a structured search of the MeSH terms ([Sleep]+[Chronic fatigue syndrome]) in the PubMed database.

CONCLUSION

Identifying primary sleep disorders in patients meeting diagnostic criteria for CFS will allow for a more comprehensive treatment approach involving new diagnostic and therapeutic strategies that may improve quality of life for these patients.

Neural Reward Processing Mediates the Relationship between Insomnia Symptoms and Depression in Adolescence

STUDY OBJECTIVES

Emerging evidence suggests that insomnia may disrupt reward-related brain function-a potentially important factor in the development of depressive disorder. Adolescence may be a period during which such disruption is especially problematic given the rise in the incidence of insomnia and ongoing development of neural systems that support reward processing. The present study uses longitudinal data to test the hypothesis that disruption of neural reward processing is a mechanism by which insomnia symptoms-including nocturnal insomnia symptoms (NIS) and nonrestorative sleep (NRS)-contribute to depressive symptoms in adolescent girls.

METHOD

Participants were 123 adolescent girls and their caregivers from an ongoing longitudinal study of precursors to depression across adolescent development. NIS and NRS were assessed annually from ages 9 to 13 years. Girls completed a monetary reward task during a functional MRI scan at age 16 years. Depressive symptoms were assessed at ages 16 and 17 years. Multivariable regression tested the prospective associations between NIS and NRS, neural response during reward anticipation, and the mean number of depressive symptoms (omitting sleep problems).

RESULTS

NRS, but not NIS, during early adolescence was positively associated with late adolescent dorsal medial prefrontal cortex (dmPFC) response to reward anticipation and depressive symptoms. DMPFC response mediated the relationship between early adolescent NRS and late adolescent depressive symptoms.

CONCLUSIONS

These results suggest that NRS may contribute to depression by disrupting reward processing via altered activity in a region of prefrontal cortex involved in affective control. The results also support the mechanistic differentiation of NIS and NRS.

Auricular acupuncture with seed or pellet attachments for primary insomnia: a systematic review and meta-analysis

BACKGROUND

Primary insomnia is a common health issue in the modern world. We conducted a systematic review of the auricular therapy, aiming to evaluate whether there are advantages of auricular acupuncture with seed or pellet attachments for the treatment of primary insomnia.

METHODS

A search of relevant literatures was performed on major medical databases, including Medline, Embase, CENTRAL, CBM, CNKI, VIP, Wanfang Data and so on. Risk of bias evaluation, meta-analysis, sensitivity analysis and evidence rating of all extracted information were conducted also.

RESULTS

A total of 1381 records were identified, with 15 studies deemed eligible for the present review. Meta-analyses were conducted in two comparisons separately: participants received auricular acupuncture were more likely to make an improvement in clinical effective rate (RR = 1.40, 95% CI 1.07 to 1.83), sleep duration (MD = 56.46, 95% CI 45.61 to 67.31), sleep efficiency(MD = 12.86, 95% CI 9.67 to 16.06), global score on PSQI (MD = -3.41, 95% CI -3.93 to -2.89), number of awakenings( MD = -3.27, 95% CI -6.30 to -0.25) and sleep onset latency(MD = -10.35, 95% CI -14.37 to -6.33) when compared to sham auricular acupuncture or placebo; while in auricular acupuncture VS medications comparison, a better effective rate (RR = 1.24, 95% CI 1.15 to 1.34), better sleep efficiency(MD = 21.44, 95% CI 16.30 to 26.58), lower PSQI score (MD = -3.62, 95% CI -4.59 to -2.65) and less adverse effect (RR = 0.11, 95% CI 0.04 to 0.26) can be seen also in auricular acupuncture group. Although these results suggested benefits of auricular acupuncture, the overall quality of evidence rated by the GRADE system was low.

CONCLUSION

Statistical analyses of the outcomes revealed a positive effect of auricular acupuncture for primary insomnia. Nonetheless, considering the poor methodological quality, insufficient sample size and possible publication bias, current evidence is not yet adequate to provide a strong support for the use of auricular acupuncture in the treatment of primary insomnia. More strictly designed clinical studies will be needed to obtain a more explicit conclusion.

The nature of stable insomnia phenotypes

STUDY OBJECTIVES

We examined the 1-y stability of four insomnia symptom profiles: sleep onset insomnia; sleep maintenance insomnia; combined onset and maintenance insomnia; and neither criterion (i.e., insomnia cases that do not meet quantitative thresholds for onset or maintenance problems). Insomnia cases that exhibited the same symptom profile over a 1-y period were considered to be phenotypes, and were compared in terms of clinical and demographic characteristics.

DESIGN

Longitudinal.

SETTING

Urban, community-based.

PARTICIPANTS

Nine hundred fifty-four adults with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition based current insomnia (46.6 ± 12.6 y; 69.4% female).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

At baseline, participants were divided into four symptom profile groups based on quantitative criteria. Follow-up assessment 1 y later revealed that approximately 60% of participants retained the same symptom profile, and were hence judged to be phenotypes. Stability varied significantly by phenotype, such that sleep onset insomnia (SOI) was the least stable (42%), whereas combined insomnia (CI) was the most stable (69%). Baseline symptom groups (cross-sectionally defined) differed significantly across various clinical indices, including daytime impairment, depression, and anxiety. Importantly, however, a comparison of stable phenotypes (longitudinally defined) did not reveal any differences in impairment or comorbid psychopathology. Another interesting finding was that whereas all other insomnia phenotypes showed evidence of an elevated wake drive both at night and during the day, the 'neither criterion' phenotype did not; this latter phenotype exhibited significantly higher daytime sleepiness despite subthreshold onset and maintenance difficulties.

CONCLUSIONS

By adopting a stringent, stability-based definition, this study offers timely and important data on the longitudinal trajectory of specific insomnia phenotypes. With the exception of daytime sleepiness, few clinical differences are apparent across stable phenotypes.