The natural history of insomnia: predisposing, precipitating, coping, and perpetuating factors over the early developmental course of insomnia

Cognitive-behavioral treatment for insomnia and mindfulness-based stress reduction in nurses with insomnia: a non-inferiority internet delivered randomized controlled trial

Background

Insomnia is a highly prevalent sleep disorder frequently comorbid with mental health conditions in nurses. Despite the effectiveness of evidence-based cognitive behavioral therapy for insomnia (CBT-I), there is a critical need for alternative approaches. This study investigated whether internet-delivered mindfulness-based stress reduction (IMBSR) for insomnia could be an alternative to internet-delivered CBT-I (ICBT-I).

Objective

The hypothesis was that the IMBSR would be noninferior to the ICBT-I in reducing the severity of insomnia among nurses with insomnia. Additionally, it was expected that ICBT-I would produce a greater reduction in the severity of insomnia and depression than IMBSR.

Method

Among 240 screened nurses, 134 with insomnia were randomly allocated (IMBSR, n = 67; ICBT-I, n = 67). The assessment protocol comprised clinical interviews and self-reported outcome measures, including the Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), the 15-item Five Facet Mindfulness Questionnaire (FFMQ), and the Client Satisfaction Questionnaire (CSQ-I).

Results

The retention rate was 55% with 77.6% (n = 104) of participants completing the study. At post-intervention, the noninferiority analysis of the ISI score showed that the upper limit of the 95% confidence interval was 4.88 (P = 0.46), surpassing the pre-specified noninferiority margin of 4 points. Analysis of covariance revealed that the ICBT-I group had significantly lower ISI (Cohen's d = 1.37) and PHQ-9 (Cohen's d = 0.71) scores than did the IMBSR group. In contrast, the IMBSR group showed a statistically significant increase in the FFMQ-15 score (Cohen's d = 0.67). Within-group differences showed that both the IMBSR and ICBT-I were effective at reducing insomnia severity and depression severity and improving mindfulness.

Conclusion

Overall, nurses demonstrated high levels of satisfaction and adherence to both interventions. The IMBSR significantly reduced insomnia severity and depression, but the findings of this study do not provide strong evidence that the IMBSR is at least as effective as the ICBT-I in reducing insomnia symptoms among nurses with insomnia. The ICBT-I was found to be significantly superior to the IMBSR in reducing insomnia severity, making it a recommended treatment option for nurses with insomnia.

An online behavioral self-help intervention rapidly improves acute insomnia severity and subjective mood during the coronavirus disease-2019 pandemic: a stratified randomized controlled trial

STUDY OBJECTIVES

Stressful life events, such as the coronavirus disease-2019 (COVID-19) pandemic, can cause acute insomnia. Cognitive behavioral therapy for acute insomnia is effective but is both time and resource-intensive. This study investigated if an online behavioral self-help intervention, which has been successfully used alongside sleep restriction for acute insomnia, reduced insomnia severity and improved mood in acute insomnia. This study also assessed good sleepers to explore if a "sleep vaccination" approach was feasible.

METHODS

In this online stratified randomized controlled trial, 344 participants (103 good sleepers and 241 participants with DSM-5 acute insomnia) were randomized to receive the intervention/no intervention (good sleepers) or intervention/intervention after 28 days (poor sleepers). Insomnia severity was assessed using the ISI (primary outcome), and anxiety and depression using the GAD-7/PHQ-9 (secondary outcomes) at baseline, 1 week, 1 month, and 3-month follow-up.

RESULTS

In people with acute insomnia, relative to baseline, there were significant reductions in ISI (dz = 1.17), GAD-7 (dz = 0.70), and PHQ-9 (dz = 0.60) scores at 1-week follow-up. ISI, GAD-7, and PHQ-9 scores were significantly lower at all follow-up time points, relative to baseline. Subjective diary-derived sleep continuity was unaffected. No beneficial effects on sleep or mood were observed in good sleepers.

CONCLUSIONS

An online behavioral self-help intervention rapidly reduces acute insomnia severity (within 1 week), and benefits mood in people with acute insomnia. These beneficial effects are maintained up to 3 months later. Although the use of the intervention is feasible in good sleepers, their subjective sleep was unaffected.

CLINICAL TRIAL REGISTRATION

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic; prospectively registered at ISRCTN on 8 April 2020 (identifier: ISRCTN43900695).

The relationship between self-compassion, coping style, sleep quality, and depression among college students

Background

The prevalence of sleep quality problems and depression in the college student population has attracted widespread attention. However, the factors influencing this are still unclear. The objective of this study was to investigate the associations between self-compassion (S-C), sleep quality (SQ), and depression (DEP) among college students and examine the mediating effects of coping style (CS) between the variables.

Methods

A total of 1,038 Chinese university students were recruited for the study. The study used the Self-Compassion Scale (SCS), Simplified Coping Style Questionnaire (SCSQ), Depression Anxiety Stress Scale 21 (DASS-21), and Pittsburgh Sleep Quality Index (PSQI) to conduct the survey.

Results

The self-compassion and coping style showed significant negative correlations with sleep quality and depression. Coping style partially mediated the relationship between self-compassion and sleep quality. The coping style also fully mediated the relationship between self-compassion and depression.

Conclusion

This study reveals the associations between self-compassion and sleep quality and depression, and the mediating role of coping style among college students. This study provides valuable insights for improving sleep quality and alleviating depression problems among college students. It emphasizes the importance of self-compassion and positive coping style.

The relationships between insomnia, nightmares, and dreams: A systematic review

Insomnia and nightmares are both prevalent and debilitating sleep difficulties. The present systematic review aims to document the relationships between insomnia and nightmares in individuals without a concomitant psychopathology. The relationships between insomnia and dreams are also addressed. PsycINFO and Medline were searched for papers published in English or French from 1970 to March 2023. Sixty-seven articles were included for review. Most results support positive relationships between insomnia variables and nightmare variables in individuals with insomnia, individuals with nightmares, the general population, students, children and older adults, and military personnel and veterans. These positive relationships were also apparent in the context of the COVID-19 pandemic. Some psychological interventions, such as Imagery Rehearsal Therapy, might be effective in alleviating both nightmares and insomnia symptoms. Regarding the relationships between insomnia and dreams, compared with controls, the dreams of individuals with insomnia are characterized by more negative contents and affects. The results show that insomnia and nightmares are connected and may be mutually aggravating. A model is proposed to explain how insomnia might increase the likelihood of experiencing nightmares, and how nightmares can in turn lead to sleep loss and nonrestorative sleep.

Negative life events and sleep disturbance among adolescents: Intolerance of uncertainty as mediator and moderator

BACKGROUND

While negative life events (NLEs) have been linked to an increased risk of sleep disturbance among adolescents, the mechanisms of this impact still lack further examination. The current study aimed to explore whether intolerance of uncertainty (IU), a dispositional transdiagnostic vulnerability factor for psychopathology, could act as a mediator and/or moderator in the link from NLEs to sleep disturbance.

METHODS

A longitudinal nested subsample of 54,240 Chinese adolescents (aged 9-19) were surveyed at baseline (Timepoint 1) and six months later (Timepoint 2). They completed questionnaires to assess their IU, NLEs, sleep disturbance and sociodemographic characteristics. Mediation and moderation analyses were conducted to test our hypotheses.

RESULTS

Upon adjusting for covariates, IU was found to mediate the relationship between NLEs and residual changes in sleep disturbance over a six-month period, with the mediation effect accounting for 31.8%. Additionally, the moderating role of IU in this relationship was also identified, suggesting that a high level of IU exacerbated the effect of NLEs on sleep disturbance.

CONCLUSIONS

In conclusion, our findings shed light on the dual roles of IU in the link from NLEs to sleep disturbance, holding significant practical implications for preventing and intervening in sleep disturbance among adolescents. To mitigate the risk of sleep disturbance among adolescents experiencing NLEs, timely assessments of IU and tailored interventions to enhance uncertainty tolerance are necessary.

Insomnia is more likely to persist than remit after a time of stress and uncertainty: a longitudinal cohort study examining trajectories and predictors of insomnia symptoms

STUDY OBJECTIVES

The study aimed to characterize insomnia symptom trajectories over 12 months during a time of stress and uncertainty, the coronavirus disease 2019 (COVID-19) pandemic. It also aimed to investigate sleep and psychological predictors of persistent insomnia symptoms.

METHODS

This longitudinal cohort study comprised 2069 participants with and without insomnia symptoms during the first year of the pandemic. Participants completed online surveys investigating sleep, insomnia, and mental health at four timepoints over 12 months (April 2020-May 2021). Additional trait-level cognitive/psychological questionnaires were administered at 3 months only.

RESULTS

Six distinct classes of insomnia symptoms emerged: (1) severe persistent insomnia symptoms (21.65%), (2) moderate persistent insomnia symptoms (32.62%), (3) persistent good sleep (32.82%), (4) severe insomnia symptoms at baseline but remitting over time (2.27%), (5) moderate insomnia symptoms at baseline but remitting over time (7.78%), and (6) good sleep at baseline but deteriorating into insomnia symptoms over time (2.85%). Persistent insomnia trajectories were predicted by high levels of sleep reactivity, sleep effort, pre-sleep cognitive arousal, and depressive symptoms at baseline. A combination of high sleep reactivity and sleep effort reduced the odds of insomnia remitting. Higher sleep reactivity also predicted the deterioration of good sleep into insomnia symptoms over 12 months. Lastly, intolerance of uncertainty emerged as the only trait-level cognitive/psychological predictor of insomnia trajectory classes.

CONCLUSIONS

Insomnia was more likely to persist than remit over the first year of the COVID-19 pandemic. Addressing sleep reactivity and sleep effort appears critical for reducing insomnia persistence rates after times of stress and uncertainty.

Associations between Sleep Disturbances, Personality Traits and Self-Regulation in a Sample of Healthy Adults

Background: Scientific evidence and everyday experience show that sleep disturbances and self-regulation as a proxy of stress reactivity are linked. Particular personality traits such as neuroticism, internalizing and externalizing problems are also associated with sleep disturbances. Here, we combined self-regulation and personality traits and associated these variables with subjective sleep disturbances. Methods: A total of 846 adults (mean age: 33.7 years; 78.7% females) completed questionnaires covering sleep disturbances, self-regulation and personality traits. Results: Higher scores for sleep disturbances were associated with higher scores for externalization, internalization, and instability and with lower scores for stability (all trait variables) and with poorer self-regulation (state variable). The regression model showed that higher scores for externalization and internalization (traits), and lower scores for self-regulation (state) predicted higher scores for sleep disturbance. Next, self-regulation had both a direct effect on sleep disturbance, and an indirect effect via personality traits. Conclusions: Sleep disturbances were related to both state (i.e., self-regulation) and trait (e.g., internalization and instability) dimensions. The current data analysis leapfrogs the state-trait dichotomy discussion and reconciles the state-and-trait approach in the prediction of poor sleep, though self-regulation appeared to have both direct and indirect effects on sleep disturbances.

Perpetuating and protective factors in insomnia across racial/ethnic groups of veterans

Few studies have examined racial/ethnic differences in rates and correlates of insomnia among veterans. This study compared rates of insomnia and interest in sleep treatment among veterans of diverse racial/ethnic backgrounds. Consistent with the 3P model, we tested racial discrimination as a predictor of insomnia, with post-traumatic stress disorder symptoms and romantic partners as perpetuating and protective moderators of this association, respectively. A total of 325 veterans (N = 236 veterans of colour; 12% Asian, 36% Black, 14% Hispanic/Latine) completed questionnaires online from remote locations. Descriptive statistics were used to compare patterns across racial/ethnic groups. Linear regression was used to test moderators of the association between racial discrimination and insomnia severity. Overall, 68% of participants screened positive for insomnia: 90% of Asian; 79% of Hispanic/Latine; 65% of Black; and 58% of White participants. Of those, 74% reported interest in sleep treatment, and 76% of those with partners reported interest in including their partner in treatment. Racial discrimination and post-traumatic stress disorder were correlated with more severe insomnia, while romantic partners were correlated with less severe insomnia. Only post-traumatic stress disorder moderated the association between racial discrimination and insomnia severity. Rates of insomnia were highest among Asian and Hispanic/Latine participants, yet these groups were among the least likely to express interest in sleep treatment. Racial discrimination may exacerbate insomnia symptoms among veterans, but only among those who do not already have disturbed sleep in the context of post-traumatic stress disorder. Romantic partners may serve as a protective factor in insomnia, but do not seem to mitigate the impact of racial discrimination.

The interaction between polygenic risk and environmental influences: A direct test of the 3P model of insomnia in adolescents

BACKGROUND

Stress is a universal phenomenon and one of the most common precipitants of insomnia. However, not everyone develops insomnia after experiencing a stressful life event. This study aims to test aspects of Spielman's '3P model of insomnia' (during adolescence) by exploring the extent to which: (a) insomnia symptoms are predicted by polygenic scores (PGS); (b) life events predict insomnia symptoms; (c) the interaction between PGS and life events contribute to the prediction of insomnia symptoms; (d) gene-environment interaction effects remain after controlling for sex.

METHODS

The sample comprised 4,629 twins aged 16 from the Twin Early Development Study who reported on their insomnia symptoms and life events. PGS for insomnia were calculated. In order to test the main hypothesis of this study (a significant interaction between PGS and negative life events), we fitted a series of mixed effect regressions.

RESULTS

The best fit was provided by the model including sex, PGS for insomnia, negative life events, and their interactions (AIC = 26,158.7). Our results show that the association between insomnia symptoms and negative life events is stronger for those with a higher genetic risk for insomnia.

CONCLUSIONS

This work sheds light on the complex relationship between genetic and environmental factors implicated for insomnia. This study has tested for the first time the interaction between genetic predisposition (PGS) for insomnia and environmental stressors (negative life events) in adolescents. This work represents a direct test of components of Spielman's 3P model for insomnia which is supported by our results.

Changes in sleep effort mediate insomnia severity in older adults following online cognitive behavioural therapy

BACKGROUND

To examine treatment mechanisms of digitally delivered cognitive behavioural therapy for insomnia (CBT-I), this study assessed the mediating effects of dysfunctional beliefs, hyperarousal, locus of control, self-efficacy, sleep effort, and safety behaviours on self-reported insomnia severity in older adults before and following the completion of a self-guided, online CBT-I program.

METHODS

The baseline and follow-up measurements were completed by 62 older adults (55 female, 89%). This was a two-condition within-participant design. Mediation analysis using a parallel mediation model was conducted using the MEMORE macro for repeated measure designs.

RESULTS

Out of all the included mediator variables, only a reduction in sleep effort scores (0.88; SE 0.51; 95% CI 0.001-2.00) significantly mediated changes in insomnia severity scores following the intervention. Insomnia severity scores significantly reduced following the intervention (Mpre  = 9.84, SD = 5.89, Mpost  = 6.87, SD = 4.90); t(61) = 5.19, P = <0.001; d = 0.55 95% CI 0.38-0.93.

CONCLUSIONS

Sleep in older adults improved following digitally delivered CBT-I, and these changes were influenced by a reduction in sleep control efforts exerted by participants. These findings highlight possible treatment pathways of CBT-I. Further investigation of CBT-I as a strategy to prevent sleep problems is warranted.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN 12619001509156; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378451.

Sleepless behind bars: the connection between mental health, environment, and sleep among women in jail

Study Objectives

Given the barriers to good sleep in corrections facilities and the lack of research in this area, the current study aimed to characterize sleep quality and insomnia incidence in women in jail. Furthermore, we aimed to investigate the relation of sleep to depression, posttraumatic stress disorder (PTSD), and trauma exposure in incarcerated women. Lastly, we examined self-reports of environmental and individual factors that impaired sleeping in this population.

Methods

Participants included 176 women incarcerated in two jails in southeast Idaho. Participants were randomly selected to complete several self-report questionnaires, including the Pittsburgh Sleep Quality Index and the Insomnia Severity Index, verbally administered by interviewers.

Results

A majority of participants endorsed poor sleep quality (76%) and subthreshold or higher levels of insomnia (70%). Multiple regression analyses found that depressive symptoms and PTSD symptoms were both significantly related to insomnia and poor sleep quality. Excessive noise, poor bedding, and mental health were commonly cited factors that disrupted sleep.

Conclusions

These results are consistent with previous literature that has examined these outcomes in prison populations and incarcerated populations in other countries. Correctional facilities can consider altering environmental factors that impair sleep to not only promote better overall health but also as a way to address common manifestations of poor mental health in their inmate populations. Screening for and treating mental health problems, namely depression and PTSD, is another way these facilities can improve inmate health and promote better sleep.

Insomnia: A Current Review

Insomnia is a prevalent sleep disorder with pervasive effects on quality of life. The deleterious effects of insomnia are largely preventable with appropriate therapeutic interventions. Pharmacotherapy should be initiated in patients with inadequate response to CBT-I and tailored to comorbidities. Referral to a sleep medicine specialist should be considered in patients with a suboptimal response.

Animal models of human insomnia

Insomnia disorder (chronic sleep continuity disturbance) is a debilitating condition affecting 5%-10% of the adult population worldwide. To date, researchers have attempted to model insomnia in animals through breeding strategies that create pathologically short-sleeping individuals or with drugs and environmental contexts that directly impose sleeplessness. While these approaches have been invaluable for identifying insomnia susceptibility genes and mapping the neural networks that underpin sleep-wake regulation, they fail to capture concurrently several of the core clinical diagnostic features of insomnia disorder in humans, where sleep continuity disturbance is self-perpetuating, occurs despite adequate sleep opportunity, and is often not accompanied by significant changes in sleep duration or architecture. In the present review, we discuss these issues and then outline ways animal models can be used to develop approaches that are more ecologically valid in their recapitulation of chronic insomnia's natural aetiology and pathophysiology. Conditioning of self-generated sleep loss with these methods promises to create a better understanding of the neuroadaptations that maintain insomnia, including potentially within the infralimbic cortex, a substrate at the crossroads of threat habituation and sleep.

Epidemiology of insomnia disorder in older persons according to the Diagnostic and Statistical Manual of Mental Disorders: a systematic review and meta-analysis

PURPOSE

There is a scarcity of summarizing data on the epidemiology of insomnia in older persons, especially when diagnosed with international criteria. This study aimed to estimate the prevalence and correlates of insomnia disorder in older persons, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM).

METHODS

Through PubMed/MEDLINE, EMBASE, and Web of Science (WoS), we searched for relevant articles published before June 28, 2023. The risk of bias was weighed using the Joanna Briggs Institute's (JBI's) critical appraisal checklist for studies reporting prevalence data. For our analyses, we used a random-effect model, with subgroup analyses, meta-regression, and sensitivity analyses to explore potential sources of heterogeneity. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement.

RESULTS

We included 18,270 participants across 16 studies. The male/female ratio was 0.89 (12 studies), and the mean age varied from 65.9 to 83.1 years (8 studies). The pooled prevalence of insomnia was 19.6% (95% CI = [12.3%; 28.3%]), with substantial heterogeneity. This prevalence fluctuated according to the sample size, the minimal age for inclusion, and the study quality, considering that the risk of bias was moderate for most of studies. There was a publication bias, with a very low level of certainty. Insomnia disorder was associated with the female gender, depression, anxiety, and somatic illnesses notably cardiovascular, respiratory, and painful ones.

CONCLUSION

Nearly one in every five old individuals was considered to have insomnia disorder, which was associated with the gender and the existence of mental health and/or somatic conditions.

REGISTRATION

We registered the protocol in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number: CRD42022344675.

Hyperarousal in insomnia disorder: Current evidence and potential mechanisms

Insomnia disorder is among the most frequent mental disorders, making research on its aetiology and pathophysiology particularly important. A unifying element of many aetiological and pathophysiological models is that they support or even centre on the role of some form of hyperarousal. In this theoretical review, we aim to summarise the current evidence on hyperarousal in insomnia. Hyperarousal is discussed as a state of relatively increased arousal in physiological, cortical and cognitive-emotional domains. Regarding physiological hyperarousal, there is no conclusive evidence for the involvement of autonomous variables such as heart rate and heart rate variability, whereas recent evidence points to a pathophysiological role of neuroendocrine variables. In addition, current literature supports a central involvement of cortical arousal, that is, high-frequency electroencephalographic activity. An increasingly important focus in the literature is on the role of other microstructural sleep parameters, especially the existence of microarousals during sleep. Beyond that, a broad range of evidence exists supporting the role of cognitive-emotional hyperarousal in the form of insomnia-related thought and worries, and their concomitant emotional symptoms. Besides being a state marker of insomnia, hyperarousal is considered crucial for the predisposition to insomnia and for the development of comorbid mental disorders. Thus, beyond presenting evidence from cross-sectional studies on markers of hyperarousal in insomnia, hypotheses about the mechanisms of hyperarousal are presented. Nevertheless, longitudinal studies are needed to further elucidate the mechanism of hyperarousal throughout the course of the disorder, and future studies should also focus on similarities and differences in hyperarousal across different diagnostic entities.

Personality and insomnia: A systematic review and narrative synthesis

The inherent nature of personality serves as a predisposing, and possible maintaining, factor of insomnia. However, methodological differences limit the ability to draw causal conclusions regarding the specific traits involved in the aetiology of the disorder. This systematic review of the relationship between insomnia and personality provides a narrative synthesis of the literature to date. Here, we identified N = 76 studies meeting the inclusion/exclusion criteria. The outcomes reliably evidenced the experience of insomnia to be associated with personality traits that are typically considered to be negative or maladaptive in nature. More specifically, insomnia was related to neuroticism, introversion, perfectionistic doubts and concerns, elevated personal standards, negative affect, social inhibition and avoidance, hysteria, hypochondriasis, psychasthenia, impulsive behaviour, anger, hostility, and psychopathic tendencies, schizotypal and borderline traits, reduced conscientiousness and self-directedness, and negatively perceived perception of the self. Several studies examined the role that personality plays in predicting the treatment efficacy and adherence of CBTi. Moving forward, longitudinal research, methodological consistency, the mediating role of treatment outcomes and adherence, and clinical and population representative samples should be prioritised. Methodological strengths and limitations of the literature are discussed alongside the next steps that should be taken to advance our understanding of the literature.

The sleep response to stress: how sleep reactivity can help us prevent insomnia and promote resilience to trauma

Sleep reactivity is a predisposition to sleep disturbance during environmental perturbations, pharmacological challenges, or stressful life events. Consequently, individuals with highly reactive sleep systems are prone to insomnia disorder after a stressor, engendering risk of psychopathology and potentially impeding recovery from traumatic stress. Thus, there is tremendous value in ameliorating sleep reactivity to foster a sleep system that is robust to stress exposure, ultimately preventing insomnia and its downstream consequences. We reviewed prospective evidence for sleep reactivity as a predisposition to insomnia since our last review on the topic in 2017. We also reviewed studies investigating pre-trauma sleep reactivity as a predictor of adverse post-traumatic sequelae, and clinical trials that reported the effect of behavioural treatments for insomnia on mitigating sleep reactivity. Most studies measured sleep reactivity via self-report using the Ford Insomnia Response to Stress Test (FIRST), demonstrating high scores on this scale reliably indicate a sleep system with a lower capacity to tolerate stress. Nascent evidence suggests elevated sleep reactivity prior to trauma increases the risk of negative posttraumatic outcomes, namely acute stress disorder, depression, and post-traumatic stress disorder. Lastly, sleep reactivity appears most responsive to behavioural insomnia interventions when delivered early during the acute phase of insomnia. Overall, the literature strongly supports sleep reactivity as a premorbid vulnerability to incident acute insomnia disorder when faced with an array of biopsychosocial stressors. The FIRST identifies individuals at risk of insomnia a priori, thereby guiding early interventions toward this vulnerable population to prevent insomnia and promote resilience to adversity.

Sleep Pathologies and Eating Disorders: A Crossroad for Neurology, Psychiatry and Nutrition

The intricate connection between eating behaviors and sleep habits is often overlooked in clinical practice, despite their profound interdependence. Sleep plays a key role in modulating psychological, hormonal and metabolic balance and exerting an influence on food choices. Conversely, various eating disorders may affect sleep continuity, sometimes promoting the development of sleep pathologies. Neurologists, nutritionists and psychiatrists tend to focus on these issues separately, resulting in a failure to recognize the full extent of the clinical conditions. This detrimental separation can lead to underestimation, misdiagnosis and inappropriate therapeutic interventions. In this review, we aim to provide a comprehensive understanding of the tangled relationship between sleep, sleep pathologies and eating disorders, by incorporating the perspective of sleep experts, psychologists and psychiatrists. Our goal is to identify a practical crossroad integrating the expertise of all the involved specialists.

Pharmacists' perspectives and attitudes towards the 2021 down-scheduling of melatonin in Australia using the Theoretical Domains Framework: a mixed-methods study

BACKGROUND

In Australia, prescription melatonin became a 'Pharmacist Only Medicine' for people over 55 with insomnia from June 2021. However, little is known about pharmacists' views on melatonin down-scheduling and perceived impacts on practice.

AIM

To explore Australian community pharmacists' views on and attitudes towards the down-scheduling of melatonin.

METHOD

A convenience sample of community pharmacists and pharmacy interns were recruited. Participants completed a survey capturing demographic and professional practice details, and rated their knowledge, beliefs and attitudes towards melatonin. This was followed by an online semi-structured interview. Interviews were guided by a schedule of questions developed using the Theoretical Domains Framework and explored the perceived role of melatonin, preparation/response to down-scheduling, practice changes and patient interactions. Interviews continued until data saturation and were digitally recorded, transcribed verbatim and analysed using the Framework Approach.

RESULTS

Twenty-four interviews were conducted with community pharmacists (n = 19) and intern pharmacists (n = 5), all practicing in metropolitan areas. Pharmacists/intern pharmacists welcomed the increased accessibility of melatonin for patients. However, pharmacists perceived a disconnect between the guidelines, supply protocols and pack sizes with practice, making it difficult to monitor patient use of melatonin. The miscommunication of eligibility also contributed to patient-pharmacist tension when supply was denied. Importantly, most participants indicated their interest in upskilling their knowledge in melatonin use in sleep, specifically formulation differences and dosage titration.

CONCLUSION

While pharmacists welcomed the down-scheduling of melatonin, several challenges were noted, contributing to pharmacist-patient tensions in practice. Findings highlight the need to refine and unify melatonin supply protocols and amend pack sizes to reflect guideline recommendations as well as better educating the public about the risk-benefits of melatonin.

Long-term use of benzodiazepines in chronic insomnia: a European perspective

Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.

Comparative impact of yoga and ayurveda practice in insomnia: A randomized controlled trial

BACKGROUND

Insomnia is connected with a lifted hazard for neurocognitive dysfunction and psychiatric disarranges. Clinical observations of psychosomatic patients indicate that their distorted somatopsychic functioning necessitates their practice of yoga-like therapy. Sleep and its modifications and management have also been explained well in ayurveda. This study aimed to compare the effectiveness of Yoga and Nasya Karma on the sleep quality, stress, cognitive function, and quality of life of people suffering from acute insomnia.

MATERIAL AND METHODS

It was an open-label, randomized controlled trial. A total of 120 participants were randomly (computer-generated randomization) equally allocated to three groups, yoga group (G-1), ayurveda group (G-2), and control group (G-3). All the groups were assessed on the first day before the start of the yoga regime and the 48^th day. Participants in the study were included in the age group of 18 to 45 years, fulfilling DSM-V criteria for insomnia, physically fit for the yoga module, and Nasya procedure. Outcomes were measured by the Pittsburgh Sleep Quality Index (PSQI) questionnaire, Perceived Stress Scale (PSS), cognitive failure questionnaire, and WHO Quality of Life Scale-Brief (WHOQOL-Brief). Proportions and frequencies were described for categorical variables and compared using the Chi-square test. ANOVA (one-way) and post hoc analysis, Bonferroni test, were performed for multiple comparisons in groups at a significance level of P < 0.05 using SPSS (23 version).

RESULTS

A total of 112 participants were analyzed as per protocol analysis. All groups have observed significant mean differences for stress (<0.05) and sleep quality (<0.05). All five aspects of quality of life - general health (<0.05), physical health (<0.01), psychological health (<0.05), social health (<0.05), and environmental health (<0.05) - had a significant mean difference in all three groups. All three aspects of cognitive failure, forgetfulness (<0.05), distractibility (<0.05), and false triggers (<0.01) had a significant mean difference in scores for all three groups.

CONCLUSION

Yoga practice was effective, followed by ayurveda and the control group in reducing stress and improving sleep, cognitive function, and quality of life.

Beyond Stress: Altered Sleep-Wake Patterns are a Key Behavioral Risk Factor for Acute Insomnia During Times of Crisis

BACKGROUND

Stress is a common precipitant of acute insomnia; however, reducing stress during times of crisis is challenging. This study aimed to determine which modifiable factors, beyond stress, were associated with acute insomnia during a major crisis, the COVID-19 pandemic.

PARTICIPANTS/METHODS

A global online survey assessed sleep/circadian, stress, mental health, and lifestyle factors between April-May 2020. Logistic regression models analyzed data from 1319 participants (578 acute insomnia, 731 good sleepers), adjusted for demographic differences.

RESULTS

Perceived stress was a significant predictor of acute insomnia during the pandemic (OR 1.23, 95% CI1.19-1.27). After adjusting for stress, individuals who altered their sleep-wake patterns (OR 3.36, CI 2.00-5.67) or increased technology use before bed (OR 3.13, CI 1.13-8.65) were at increased risk of acute insomnia. Other sleep factors associated with acute insomnia included changes in dreams/nightmares (OR 2.08, CI 1.32-3.27), increased sleep effort (OR 1.99, CI1.71-2.31) and cognitive pre-sleep arousal (OR 1.18, CI 1.11-1.24). For pandemic factors, worry about contracting COVID-19 (OR 3.08, CI 1.18-8.07) and stringent government COVID-19 restrictions (OR 1.12, CI =1.07-1.18) were associated with acute insomnia. Anxiety (OR 1.02, CI 1.01-1.05) and depressive (OR 1.29, CI 1.22-1.37) symptoms were also risk factors. A final hierarchical regression model revealed that after accounting for stress, altered sleep-wake patterns were a key behavioral predictor of acute insomnia (OR 2.60, CI 1.68-5.81).

CONCLUSION

Beyond stress, altered sleep-wake patterns are a key risk factor for acute insomnia. Modifiable behaviors such as maintaining regular sleep-wake patterns appear vital for sleeping well in times of crisis.

Subjective versus objective sleep outcomes in older adults with and without uncoupled sleep following online cognitive behavioural therapy for insomnia

BACKGROUND

Uncoupled sleep is a phenomenon characterised by a disconnect between sleep pattern and sleep complaint. This study examined the impact of uncoupled sleep on dysfunctional sleep beliefs and objective and subjective sleep outcomes in community-dwelling older adults following digitally delivered Cognitive Behavioural Therapy for Insomnia (CBT-I) to assess how these groups respond to CBT-I.

METHODS

Objective sleep was measured using wrist actigraphy, subjective sleep quality via sleep diaries and the Pittsburgh Sleep Quality Index (PSQI). Dysfunctional sleep beliefs were assessed by the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16). All measurements were taken prior to and following a 4-week online CBT-I program. Linear mixed model and generalised linear mixed model analyses were conducted to examine objective and subjective sleep onset latency, total sleep time, wake after sleep onset and number of awakenings as well as PSQI and DBAS-16 scores, respectively.

RESULTS

Out of 80 enrolled participants, 62 participants (55 females, 89%; 16 complaining good sleepers, 26 complaining poor sleepers, 11 non-complaining good sleepers, and nine non-complaining poor sleepers) completed the study. CBT-I reduced dysfunctional sleep beliefs across all sleeper classifications. Objective and self-reported changes in sleep parameters were demonstrated in complaining poor sleepers without uncoupled sleep. Complaining good sleepers with uncoupled sleep only reported a decrease in the number of subjective sleep awakenings. There were no changes in sleep outcomes in non-complaining good and non-complaining poor sleepers.

CONCLUSIONS

Online CBT-I was effective in improving the sleep outcomes of individuals who had both subjective and objective poor sleep. However, as the online CBT-I reduced dysfunctional sleep beliefs in all sleep groups, further examination of dysfunctional sleep beliefs and whether they mediate the outcomes of digital CBT-I in older adults will need to be conducted.

Effectiveness of one-week internet-delivered cognitive behavioral therapy for insomnia to prevent progression from acute to chronic insomnia: A two-arm, multi-center, randomized controlled trial

Acute insomnia is common and a substantial proportion of people with acute insomnia (i.e. 3 days to 3 months) transit into chronic insomnia (i.e. 3 months or longer). Therefore, early intervention for acute insomnia is vital to prevent chronicity. Previous trials with small sample sizes have shown that brief versions of both individual and group-based face-to-face cognitive behavioral therapy for insomnia (CBT-I) can improve insomnia symptoms among those with acute insomnia. However, it is unknown whether one-week internet-delivered cognitive behavioral therapy for insomnia (CBT-I) is effective in treating acute insomnia. This was a randomized controlled trial and 192 participants were randomly assigned to the CBT-I group (n = 95) or control group (n = 97). The primary outcome was the incidence of chronic insomnia, determined via a structured diagnostic questionnaire for insomnia disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Secondary outcomes were Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), Epworth Sleepiness Scale (ESS), Pre-sleep Arousal Scale (PSAS), Ford Insomnia Response to Stress Test (FIRST), Sleep Hygiene and Practices Scale (SHPS), Hospital Anxiety and Depression Scale (HADS), and Short-Form 12-Item Health Survey version 2 (SF-12v2). At week 12, the incidence of chronic insomnia was significantly lower in the CBT-I group compared with control group (33.3% [27/81] vs. 65.8% [52/79]). Participants in the CBT-I group achieved significantly more improvements in ISI, ESS, PSAS, FIRST, SHPS, HADS-Depression, and the mental component summary and physical component summary of SF-12v2 than control group, but not DBAS and HADS-Anxiety. This one-week internet-delivered CBT-I program is an effective tool to prevent the chronicity of acute insomnia.

Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Prognostic and Treatment-Predictive Factors

Understanding which factors predict the outcome of internet-based cognitive behavioral therapy for insomnia (iCBT-I) may help to tailor this intervention to the patient's needs. We have conducted a secondary analysis of a randomized, controlled trial comparing a multicomponent iCBT-I (MCT) and an online sleep restriction therapy (SRT) for 83 chronic insomnia patients. The difference in the Insomnia Severity Index from pre- to post-treatment and from pre-treatment to follow-up at 6 months after treatment was the dependent variable. Prognostic and treatment-predictive factors assessed at baseline were analyzed with multiple linear regression. The shorter duration of insomnia, female gender, high health-related quality of life, and the higher total number of clicks had prognostic value for a better outcome. Other factors were found to be prognostic for outcome at the follow-up assessment: treatment with benzodiazepines, sleep quality, and personal significance of sleep problems. A high level of dysfunctional beliefs and attitudes about sleep (DBAS) was a moderator for better effects in the MCT at post-treatment assessment. Various prognostic factors (e.g., duration of insomnia, gender, or quality of life) may influence the success of treatment. The DBAS scale may be recommended to select patients for MCT rather than SRT.

Current models of insomnia disorder: a theoretical review on the potential role of the orexinergic pathway with implications for insomnia treatment

Insomnia disorder is considered as a stress-related disorder associated with hyperarousal, stress and emotion dysregulation and the instability of the 'flip-flop' switch system. The orexinergic system is well known for its key role in sleep and arousal processes but also in the allostatic system regulating stress and emotions and may thus be of major interest for insomnia and its treatment. Accordingly, we discuss the potential role of orexins on sleep processes, brain systems modulating stress and emotions with potential implications for insomnia pathophysiology. We reviewed available data on the effect of dual orexin receptor antagonists (DORAs) on sleep and brain systems modulating stress/emotions with implications for insomnia treatment. We present our findings as a narrative review. Few data in animals and humans have reported that disrupted sleep and insomnia may be related to the overactivation of orexinergic system, while some more consistent data in humans and animals reported the overactivation of orexins in response to acute stress and in stress-related disorders. Taken together these findings may let us hypothesise that an orexins overactivation may be associated with stress-related hyperarousal and the hyperactivation of arousal-promoting systems in insomnia. On the other hand, it is possible that by rebalancing orexins with DORAs we may regulate both sleep and allostatic systems, in turn, contributing to a 'switch off' of hyperarousal in insomnia. Nevertheless, more studies are needed to clarify the role of the orexin system in insomnia and to evaluate the effects of DORAs on sleep, stress and emotions regulating systems.

Stress and the hypothalamic-pituitary-adrenal axis: How can the COVID-19 pandemic inform our understanding and treatment of acute insomnia?

Stress and sleep are very closely linked, and stressful life events can trigger acute insomnia. The ongoing COVID-19 pandemic is highly likely to represent one such stressful life event. Indeed, a wide range of cross-sectional studies demonstrate that the pandemic is associated with poor sleep and sleep disturbances. Given the high economic and health burden of insomnia disorder, strategies that can prevent and treat acute insomnia, and also prevent the transition from acute insomnia to insomnia disorder, are necessary. This narrative review outlines why the COVID-19 pandemic is a stressful life event, and why activation of the hypothalamic-pituitary-adrenal axis, as a biological marker of psychological stress, is likely to result in acute insomnia. Further, this review outlines how sleep disturbances might arise as a result of the COVID-19 pandemic, and why simultaneous hypothalamic-pituitary-adrenal axis measurement can inform the pathogenesis of acute insomnia. In particular, we focus on the cortisol awakening response as a marker of hypothalamic-pituitary-adrenal axis function, as cortisol is the end-product of the hypothalamic-pituitary-adrenal axis. From a research perspective, future opportunities include identifying individuals, or particular occupational or societal groups (e.g. frontline health staff), who are at high risk of developing acute insomnia, and intervening. From an acute insomnia treatment perspective, priorities include testing large-scale online behavioural interventions; examining if reducing the impact of stress is effective and, finally, assessing whether "sleep vaccination" can maintain good sleep health by preventing the occurrence of acute insomnia, by preventing the transition from acute insomnia to insomnia disorder.

Insomnia is a key risk factor for persistent anxiety and depressive symptoms: A 12-month longitudinal cohort study during the COVID-19 pandemic

BACKGROUND

Insomnia is a risk factor for affective disorders. This study examined whether individuals with insomnia symptoms early in the pandemic, either pre-existing or new-onset, were more vulnerable to anxiety and depressive symptoms over time than those who maintained normal sleep. Additionally, sleep-related factors such as pre-sleep arousal were assessed for their influence on clinically significant anxiety and depression risk.

METHODS

Using a global online survey with 3-, 6-, and 12-month follow-ups between April 2020 and May 2021, data from 2069 participants (M = 46.16 ± 13.42 years; 75.3 % female) with pre-existing, new-onset, or no insomnia symptoms was examined using mixed-effects and logistic regression models.

RESULTS

New-onset and pre-existing insomnia predicted persistent anxiety and depressive symptoms longitudinally (p's < 0.001), over other known risk factors, including age, sex, and previous psychiatric diagnoses. Anxiety and depressive symptoms in both insomnia groups remained above clinically significant thresholds at most time points, whereas normal sleepers remained subclinical. Pre-sleep arousal was found to increase the risk of clinically significant anxiety (OR = 1.05) and depressive symptoms (OR = 1.09) at 12-months. Sleep effort contributed to anxiety (OR = 1.06), whereas dysfunctional sleep-related beliefs and attitudes predicted clinically significant depression (OR = 1.22).

LIMITATIONS

Insomnia group categorization was based on self-report at baseline supported by a validated measure. High participant attrition was observed at 3-months (53 %; n = 971), but retention remained steady till 12-months (63 %, n = 779).

CONCLUSIONS

Insomnia is a modifiable risk factor for persistent anxiety and depressive symptoms that needs to be addressed in mental healthcare. Additionally, pre-sleep arousal may be an important transdiagnostic process linking insomnia with affective disorders.

The Effect of Chinese Agarwood Essential Oil with Cyclodextrin Inclusion against PCPA-Induced Insomnia Rats

OBJECTIVE

To study the extraction process of agarwood active ingredients (AA) and investigate the safety and effectiveness of AA in the treatment of insomnia rats by nasal administration.

METHOD

A β-cyclodextrin (β-CD) inclusion compound (a-β-CD) was prepared from agarwood essential oil (AEO), and the preparation process was optimized and characterized. The safety of AA in nasal mucosa was evaluated through Bufo gargarizans maxillary mucosa and rat nasal mucosa models. Insomnia animal models were replicated by injecting p-chlorophenylalanine (PCPA), conducting behavioral tests, and detecting the expression levels of monoamine neurotransmitters (NE and 5-HT) and amino acids (GABA/Glu) in the rat hypothalamus.

RESULTS

The optimum inclusion process conditions of β-CD were as follows: the feeding ratio was 0.35:1.40 (g:g), the inclusion temperature was 45 °C, the inclusion time was 2 h, and the ICY% and IEO% were 53.78 ± 2.33% and 62.51 ± 3.21%, respectively. The inclusion ratio, temperature, and time are the three factors that have significant effects on the ICY% and IEO% of a-β-CD. AA presented little damage to the nasal mucosa. AA increased the sleep rate, shortened the sleep latency, and prolonged the sleep time of the rats. The behavioral test results showed that AA could ameliorate depression in insomnia rats to a certain extent. The effect on the expression of monoamine neurotransmitters and amino acids in the hypothalamus of rats showed that AA could significantly reduce NE levels and increase the 5-HT level and GABA/Glu ratio in the hypothalamus of insomnia rats.

CONCLUSION

The preparation of a-β-CD from AEO can reduce its irritation, improve its stability, increase its curative effect, and facilitate its storage and transport. AA have certain therapeutic effects on insomnia. The mechanism of their effect on rat sleep may involve regulating the expression levels of monoamine neurotransmitters and amino acids in the hypothalamus.

The Role of Sleep Effort as a Mediator Between Anxiety and Depression

Depression, anxiety, and insomnia are all conditions that share a complex bidirectional relationship. Sleep effort is a construct with cognitive and behavioral components that perpetuates insomnia. Although many studies have examined the associations between these three variables, no studies have yet examined sleep effort as a mediating variable between anxiety and depression and vice versa. Online versions of the Hospital Anxiety and Depression Scale and the Glasgow Sleep Effort Scale were administered to a sample of 1927 higher education students aged 18-40 years (75.9% women and 76% from 18 to 23 years old). As part of the survey, participants also completed a sociodemographic questionnaire. Mediation analysis indicated that sleep effort mediates the relationship between depression and anxiety, when the former was the predictor and the latter was the criterion. Moreover, sleep effort also mediated the relationship between anxiety and depression when the former was the predictor and the latter was the criterion, albeit in a lesser extent. Sleep effort appears to play a bidirectional mediational role between depression and anxiety, being a potential target for intervention.

Internet delivered, non-inferiority, two-arm, assessor-blinded intervention comparing mindfulness-based stress reduction and cognitive-behavioral treatment for insomnia: a protocol study for a randomized controlled trial for nursing staff with insomnia

BACKGROUND

Insomnia and poor sleep quality are highly prevalent conditions related to coronavirus disease 2019 (COVID-19) complications among clinical nurses. Although cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment, CBT-I suffers from several major drawbacks. This study investigates whether the application of the internet-delivered mindfulness-based stress reduction (iMBSR) intervention will produce effects that are non-inferior to the internet-delivered CBT-I (iCBT-I) intervention in reducing the severity of insomnia in clinical nurses with insomnia at the end of the study.

METHODS

This study protocol presents an internet-delivered, parallel-groups, assessor-blinded, two-arm, non-inferiority randomized controlled trial. The primary outcome is sleep quality, assessed by the Insomnia Severity Index. Secondary outcomes include depression, dysfunctional beliefs, five facets of mindfulness, and client satisfaction.

CONCLUSION

It is expected that this study may address several gaps in the literature. The non-inferiority study design is a novel approach to evaluating whether a standardized, complementary treatment (i.e., MBSR) is as practical as a gold standard treatment rather than its potential benefits. This approach may lead to expanded evidence-based practice and improve patient access to effective treatments.

TRIAL REGISTRATION

Trial registration number: ISRCTN36198096 . Registered on 24th May 2022.

Functional connectivity correlates of attentional networks in insomnia disorder: A pilot study

Insomnia disorder has been associated with poor executive functioning. Functional imaging studies of executive functioning in insomnia are scarce and inconclusive. Because the Attentional Network Test relies on well-defined cortical networks and sensitively distinguishes different aspects of executive function, it might reveal brain functional alterations in relatively small samples of patients. The current pilot study assessed functional connectivity during the Attentional Network Test performed using magnetic resonance imaging in 12 participants with insomnia and 13 self-defined good sleepers. ANCOVAs were used to evaluate group differences in performance and functional connectivity in the regions of interest representing the attentional networks (i.e. alerting, orienting and executive control) at p < 0.05, uncorrected. During the orienting part, participants with insomnia showed weaker connectivity of the precentral gyrus with the superior parietal lobe (false discovery rate-corrected), while they showed stronger connectivity between premotor and visual regions. Individual differences in connectivity between premotor and visual regions correlated inversely with reaction time. Reaction times suggested more efficient executive control in participants with insomnia compared with good sleepers. During the executive control part, participants with insomnia showed stronger connectivity of thalamic parts of the arousal circuit with the middle frontal and the occipital gyri. Conversely, connectivity between the inferior and superior frontal gyri was weaker. Participants with insomnia seem to recruit more cortical resources in visuo-motor regions to orient attention than good sleepers do, and seem to have enhanced executive control that relates to stronger connectivity of arousal-related thalamic areas. This latter result should be treated with caution and requires confirmation.

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.

Bottom-Up and Cognitive Top-Down Emotion Regulation: Experiential Emotion Regulation and Cognitive Reappraisal on Stress Relief and Follow-Up Sleep Physiology

Emotional stress throughout the day is known to affect objective sleep physiology and subjective sleep quality. In the interplay between emotions and sleep, emotion regulation plays a critical role in the recovery from stressful, emotional events and subsequent sleep. While the effects of top-down emotion regulation strategies such as cognitive reappraisal on sleep have been studied before, the impact of bottom-up emotion regulation strategies such as experiential emotion regulation is understudied. Cognitive reappraisal reflects the cognitive reinterpretation of the meaning of a stressful event, while experiential emotion regulation involves an active, non-intervening, accepting, open and welcoming approach of acknowledging awareness of raw sensory affective experiences or 'experiential awareness' in a first phase and expression in a second phase. The present study aims to investigate the effects of experiential emotion regulation and cognitive reappraisal on the recovery from pre-sleep emotional stress measured by (1) negative affect and (2) sleep structure. Sleep of forty-three healthy Dutch-speaking participants (22 females, 21 males) has been assessed using EEG polysomnography. Stress was triggered using a pre-sleep emotional failure induction, after which emotion regulation by experiential emotion regulation versus cognitive reappraisal versus control was induced twice. The control condition consisted of the reallocation of attention towards the neutral aspects of the emotional event. The results indicated that recovery from negative affect of the failure experience after single or repeated deployment of experiential emotion regulation and cognitive reappraisal was not significantly different from the control condition. Moreover, after repeated deployment, sleep physiology did not significantly differ between experiential emotion regulation, cognitive reappraisal, and the control condition in the impact of the regulation of the failure experience. The implications of the distinctive impact of experiential emotion regulation and cognitive reappraisal on both the pre-sleep emotional experience and follow-up sleep physiology are discussed.

Prevalence and factors associated with insomnia symptoms in adolescents and young adults with cancer during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic has been particularly distressing for adolescents and young adults (AYAs) diagnosed with cancer. High levels of distress are associated with sleep disturbances. This study examined the prevalence of insomnia symptoms in AYAs during the COVID-19 pandemic and identified factors related to greater insomnia severity.

DESIGN, SETTING, AND PARTICIPANTS

An online survey was administered to Canadian AYAs (N = 805) diagnosed with cancer between 15 and 39 years from January to February 2021.

MEASUREMENTS

The primary measure was the Insomnia Severity Index (ISI). Univariable and multivariable binomial logistic regression examined demographic, clinical, and psychological factors associated with significant insomnia symptoms (ISI score ≥12).

RESULTS

Three hundred twelve (38.8%) participants reported insomnia symptoms. In the multivariable model, severe psychological distress (ie, depression and anxiety; adjusted odds ratio (AOR) = 28.75, p ≤.001), having a pre-existing mental health condition (AOR = 1.92, p = .03), worsened mental health during the pandemic (AOR = 1.73, p = .02), finished cancer treatment ≥1 year ago (AOR = 1.72, p = .03), and experiencing no changes to schooling during the COVID-19 pandemic (AOR = 2.18, p = .004) were associated with significant insomnia symptoms. Standardized coefficients also indicated that worrying about possible disruptions to cancer care and being a homemaker/caretaker contributed to insomnia symptoms.

CONCLUSIONS

Nearly 40% of AYAs with cancer reported insomnia symptoms during the COVID-19 pandemic. Insomnia was associated with potentially modifiable factors such as psychological distress, highlighting possible targets for intervention.

Tailored individual Yoga practice improves sleep quality, fatigue, anxiety, and depression in chronic insomnia disorder

BACKGROUND

Chronic insomnia disorder (CI) is a prevalent sleep disorder that can lead to disturbed daytime functioning and is closely associated with anxiety and depression. First-choice treatment is cognitive behavioral therapy (CBT-I). Other mind-body interventions, such as Tai-chi and Yoga, have demonstrated subjective improvements in sleep quality. The purpose of this study was to assess the efficacy of Yoga for improvement of subjective and objective sleep quality as well as measures of anxiety, depression, sleepiness, and fatigue in patients with CI.

METHODS

Adults with CI were prospectively included in this single group pre-post study. Baseline assessments included home polysomnography (PSG), 7-day actigraphy, and questionnaires (Pittsburgh Sleep Quality Index questionnaire (PSQI), Hospital Anxiety Depression scale (HADS), Epworth Sleepiness Scale (ESS), Pichot fatigue scale (PS)). Patients practiced Viniyoga, an individualised Yoga practice with daily self-administered exercises, for 14 weeks. Assessments were repeated at the end of Yoga practice.

RESULTS

Twenty-one patients completed the study. Objective sleep measurements revealed no change in PSG parameters after Yoga practice, but a decrease in arousals on actigraphy (p < 0.001). Subjective symptoms improved for all questionnaires (PSQI, p < 0.001; HAD-A, p = 0.020, HAD-D, p = 0.001, ESS, p = 0.041, PS, p = 0.010). In univariate correlations, decrease in PSQI was associated with increase in sleep stage N3 (p < 0.001) on PSG.

CONCLUSIONS

We have demonstrated a positive impact of individualized Yoga practice on subjective parameters related to sleep and daytime symptoms in CI, resulting in fewer arousals on actigraphy. Yoga could be proposed as a potentially useful alternative to CBT-I in CI, as it is easy to practice autonomously over the long-term. However, given the design of the present study, future prospective controlled studies should first confirm our results.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03314441 , date of registration: 19/10/2017.

Prevalence and Correlates of Insomnia Symptoms in Older Chinese Adults During the COVID-19 Outbreak: A Classification Tree Analysis

OBJECTIVE

To examine prevalence and correlates of insomnia symptoms in older Chinese adults (OCAs) during the COVID-19 outbreak.

BACKGROUND

During the COVID-19 pandemic, insomnia is a major health concern of elderly individuals, but its subtypes have not been investigated.

METHODS

Altogether, 590 OCAs (50+ years) were recruited via snowball sampling during the COVID-19 outbreak. Standardized self-report questions were used to assess the presence of difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), and early morning awakening (EMA). Classification tree analysis (CTA) was used to identify correlates of insomnia.

RESULTS

The one-month prevalence (95% confidence interval) of any subtype of insomnia symptoms was 23.4% (20.0-26.8%), with DIS, DMS, and EMA being 15.4% (12.5-18.3%), 17.1% (14.1-20.2%), and 11.2% (8.64-13.7%), respectively. Worry about being infected with COVID-19 emerged as the most salient correlate of insomnia (P < .001); compared to participants who were not worried about being infected, those who were worried and very worried were 3.2-fold (24.3% vs 7.5%) and 5.5-fold (24.3% vs 7.5%) more likely to have insomnia, respectively. Among participants in the "very worried" branch, those residing in Wuhan were 1.8-fold more likely to have insomnia than those residing in other places (50.0% vs 27.5%, P = .011). Among participants in the "worried" branch, unemployed persons were 2.0-fold more likely to have insomnia than employed persons (37.0% vs 18.1%, P < .001).

CONCLUSIONS

Insomnia symptoms were prevalent among OCAs during the COVID-19 outbreak. Selective intervention programs targeting elderly individuals who are worried about being infected, living in the epicenter of COVID-19, and unemployed might be effective.

Factors associated with insomnia among frontline nurses during COVID-19: a cross-sectional survey study

BACKGROUND

Research predominantly suggests that nurses are at high risk of developing psychopathology. The empirical data show that the occurrence rate of problem-related sleep quality among clinical nurses is high. Therefore, this study was conducted to address the lack of information on the relationship between the coronavirus disease 2019 (COVID-19) pandemic and insomnia.

METHODS

A convenience sample of nurses (n = 680) completed an online survey that included the Insomnia severity index, the COVID-19-related psychological distress scale, the general health questionnaire, neuroticism, dysfunctional beliefs, attitudes about sleep scale, and difficulties in emotion regulation scale.

RESULTS

The results showed that 35.8% (n = 253) of nurses were classified as individuals with moderate to severe clinical insomnia. The results showed that the psychological distress generated by COVID-19 predicted insomnia (β = .47, SE = 0.02, P < .001, t = 13.27, 95% CI 0.31-0.46). Additionally, the association is mediated by psychopathology vulnerabilities, emotion dysregulation, dysfunctional beliefs about sleep, and neuroticism. Moreover, female nurses exhibited higher levels of insomnia (Cohen's d = .37), neuroticism (Cohen's d = 30), psychopathology vulnerability (Cohen's d = .26), and COVID-19-related psychological distress (Cohen's d = .23).

CONCLUSION

The present study's findings help to explain how pandemic consequences can be associated with insomnia. Additionally, the findings make a significant contribution to better understanding the role of neuroticism, emotion dysregulation, beliefs, and psychopathology vulnerability in the development of insomnia among nurses. The findings suggest the potential influence of cognitive behavioral therapy for insomnia (CBT-I) and transdiagnostic integrated therapies that could be incorporated into therapeutic programs designed to develop as a way of inhibiting or preventing insomnia among clinical nurses.

Trajectories of Insomnia in Adults After Traumatic Brain Injury

IMPORTANCE

Insomnia is common after traumatic brain injury (TBI) and contributes to morbidity and long-term sequelae.

OBJECTIVE

To identify unique trajectories of insomnia in the 12 months after TBI.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective cohort study, latent class mixed models (LCMMs) were used to model insomnia trajectories over time and to classify participants into distinct profile groups. Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a longitudinal, multisite, observational study, were uploaded to the Federal Interagency Traumatic Brain Injury Repository (FITBIR) database. Participants were enrolled at 1 of 18 participating level I trauma centers and enrolled within 24 hours of TBI injury. Additional data were obtained directly from the TRACK-TBI investigators that will be uploaded to FITBIR in the future. Data were collected from February 26, 2014, to August 8, 2018, and analyzed from July 1, 2020, to November 15, 2021.

EXPOSURES

Traumatic brain injury.

MAIN OUTCOMES AND MEASURES

Insomnia Severity Index assessed serially at 2 weeks and 3, 6, and 12 months thereafter.

RESULTS

The final sample included 2022 participants (1377 [68.1%] men; mean [SD] age, 40.1 [17.2] years) from the FITBIR database and the TRACK-TBI study. The data were best fit by a 5-class LCMM. Of these participants, 1245 (61.6%) reported persistent mild insomnia symptoms (class 1); 627 (31.0%) initially reported mild insomnia symptoms that resolved over time (class 2); 91 (4.5%) reported persistent severe insomnia symptoms (class 3); 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months (class 4); and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months (class 5). In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex (odds ratio [OR], 1.65 [95% CI, 1.02-2.66]), Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1.

CONCLUSIONS AND RELEVANCE

These results suggest important heterogeneity in the course of insomnia after TBI in adults. More work is needed to identify outcomes associated with these insomnia trajectory class subgroups and to identify optimal subgroup-specific treatment approaches.

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic in self-reported good and poor sleepers (Sleep COVID-19): study protocol for a randomised controlled trial

Background

Theoretical models of insomnia suggest that stressful life events, such as the COVID-19 pandemic, can cause acute insomnia (short-term disruptions to sleep). Early interventions may prevent short-term sleep problems from progressing to insomnia disorder. Although cognitive behavioural therapy for insomnia (CBT-I) is effective in treating insomnia disorder, this can be time and resource-intensive. Further, online interventions can be used to deliver treatment to a large number of individuals. The objective of this study is to investigate if an online behavioural intervention, in the form of a leaflet, which has been successfully used alongside CBT-I for acute insomnia, can reduce symptoms of acute insomnia in poor sleepers.

Methods

A total of 124 self-reported good and poor sleepers will be enrolled in an online stratified randomised controlled trial. After baseline assessments (T1), participants will complete a 1-week pre-intervention sleep monitoring period (T2) where they will complete daily sleep-diaries. Poor sleepers (n = 62) will be randomly allocated to an invention or wait-list group, where they will receive the intervention (T3), or will do so after a 28-day delay. Good sleepers (n = 62) will be randomly assigned to an intervention or no intervention group. All participants will complete a 1-week post intervention sleep monitoring period using daily sleep diaries (T4). Participants will be followed up at 1 week (T5), 1 month (T6) and 3 months (T7) post intervention. The primary outcome measure will be insomnia severity, measured using the Insomnia Severity Index. Secondary outcome measures will include subjective mood and subjective sleep continuity, measured using sleep diaries. Data will be analysed using an intention-to-treat approach.

Discussion

It is expected that this online intervention will reduce symptoms of acute insomnia in self-reported short-term poor sleepers, and will also prevent the transition to poor sleep in good sleepers. We expect that this will demonstrate the feasibility of online interventions for the treatment and prevention of acute insomnia. Specific advantages of online approaches include the low cost, ease of administration and increased availability of treatment, relative to face-to-face therapy.

Trial registration

ISRCTN43900695 (Prospectively registered 8th of April 2020).

A systematic review and meta-analysis of poor sleep, insomnia symptoms and stress in undergraduate students

University students experience high prevalence of mental health problems and exacerbation of mental health difficulties, including sleep disturbances and stress during their studies. Stress and poor sleep quality and/or insomnia are interlinked outcomes for this population. The aim was to conduct a systematic review, and meta-analyses, of the relationships between sleep quality and/or insomnia with stress in students. Full-text articles of studies exploring the associations of stress with poor sleep quality and/or insomnia in undergraduate students using validated tools and published in peer-reviewed journals were eligible for inclusion. Thirty-four studies, resulting in 37 effect sizes, included and all were suitable for meta-analysis. The weighted pooled effect size between sleep quality and stress was for 0.39 (25 studies, n = 10,065), whereas a slightly higher pooled association of 0.41 was demonstrated for insomnia and stress (12 studies, n = 5564.5). Pooled associations show moderate effects for associations between sleep quality, insomnia and stress in undergraduate students. High heterogeneity in meta-analyses was found, suggesting the findings should be considered cautiously. Future research should focus on longitudinal studies exploring sleep difficulties across the academic year, whilst university services should consider psychoeducation for stress and sleep in university students, especially during transition to university.