The insomnia with short sleep duration phenotype: an update on it's importance for health and prevention

Subtypes of Insomnia Disorder Identified by Cortical Morphometric Similarity Network

Insomnia disorder (ID) is a highly heterogeneous psychiatric disease, and the use of neuroanatomical data to objectively define biological subtypes is essential. We aimed to examine the neuroanatomical subtypes of ID by morphometric similarity network (MSN) and the association between MSN changes and specific transcriptional expression patterns. We recruited 144 IDs and 124 healthy controls (HC). We performed heterogeneity through discriminant analysis (HYDRA) and identified subtypes within the MSN strength. Differences in MSN between subtypes and HC were compared, and clinical behavioral differences were compared between subtypes. In addition, we investigated the association between MSN changes and brain gene expression in different ID subtypes using partial least squares regression to assess genetic commonalities in psychiatric disorders and further performed functional enrichment analyses. Two distinct subtypes of ID were identified, each exhibiting different MSN changes compared to HC. Furthermore, subtype 1 is characterized by objective short sleep, impaired cognitive function, and some relationships with major depressive disorder and autism spectrum disorder (ASD). In contrast, subtype 2 has normal objective sleep duration but subjectively reports poor sleep and is only related to ASD. The pathogenesis of subtype 1 may be related to genes that regulate sleep rhythms and sleep-wake cycles. In contrast, subtype 2 is more due to adverse emotion perception and regulation. Overall, these findings provide insights into the neuroanatomical subtypes of ID, elucidating the relationships between structural and molecular aspects of the relevant subtypes.

Sleep quality and incident hypertension

INTRODUCTION AND OBJECTIVES

Poor sleep quality poses significant public health challenges worldwide. This study aimed to investigate the association between sleep quality and the risk of hypertension.

METHODS

The study analyzed 284 250 adults from the UK Biobank (UKB) and 6104 participants from the English Longitudinal Study of Ageing (ELSA) without hypertension at baseline. The exposure of interest was sleep quality, which was evaluated based on questionnaires. Participants were divided into 3 groups based on the assessment of sleep quality. Sleep duration was assessed by self-reported sleep hours by each participant. The primary endpoint was new onset hypertension.

RESULTS

In the UKB cohort, participants with poor sleep quality showed a significantly higher risk of hypertension than those with healthy sleep quality (HR, 1.277; 95%CI, 1.21-1.346]. The results from the ELSA cohort effectively validated those from the UKB cohort; participants with poor sleep quality had a notably heightened risk of hypertension (HR, 1.264; 95%CI, 1.02-1.566). Prolonging sleep duration was associated with a decrease in the risk of hypertension in individuals with intermediate or healthy sleep quality. Although several factors were independently associated with a lower risk of hypertension (P<.001), the association between sleep quality and an increased risk of hypertension remained significant regardless of genetic susceptibility to hypertension (P for interaction=.067).

CONCLUSIONS

Considering the genetic predisposition to hypertension, poor sleep quality is associated with an elevated risk of hypertension. In intermediate or healthy levels of sleep quality, prolonging sleep duration is linked to a reduced risk of hypertension.

The benefit of inhibitory control training for insomnia with short sleep duration phenotype: a pilot randomized trial

BACKGROUND

Two phenotypes of insomnia disorder (ID) have been identified based on objective total sleep duration (TST): one with short sleep duration (ISSD) and another with normal sleep duration (INSD). Recent proposals suggested that insomnia with objective short-sleep duration (TST < 7 h) is associated with impaired inhibitory function, leading to a dysregulation of cortical inhibition, which may underlie its prevalence. This study investigated the status of impaired response inhibition in these two phenotypes and examined the potential different effect of response inhibition training on these two phenotypes.

METHODS

Twenty-two healthy controls (HC) and eighty-one patients with ID were recruited, with IDs further categorized into ISSD and INSD (with TST ≥ 7 h). Clinical behavior measures, including the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pre-sleep Arousal Scale (PSAS), objective sleep characteristics assessed by all-night sleep electroencephalography, and the accuracy of NoGo trials in the Go/NoGo task were compared among the three groups. Subsequently, within each ID phenotype, participants were divided into training and blank control sub-groups. The two training sub-groups completed Adaptive Go/NoGo training task (Through adaptive difficulty adjustment, the task trains participants' inhibitory control) 15 times over 3 weeks, and all IDs were assessed using sleep-related subjective and objective measures and Go/NoGo task before and after the intervention.

RESULTS

ISSD patients exhibited significantly longer sleep latency (p = 0.003) compared to HC, while wakefulness duration (p = 0.004) and light sleep duration (p < 0.001) were shorter than INSD. No significant differences in objective sleep characteristics were observed between INSD and HC. Following adaptive training, the ISSD training sub-group showed decreased scores in PSQI (p = 0.039) and ISI (p = 0.053) compared to their blank control sub-group. In the INSD groups, both training and blank control sub-groups demonstrated reductions in PSQI (p < 0.001), ISI (p < 0.001), and the cognitive arousal sub-dimension of the PSAS scores (p = 0.003) in the post-session test.

CONCLUSIONS

Impaired response inhibition is a characteristic of ISSD, potentially indicating dysfunctional cortical inhibition, whereas INSD pathogenesis may be related to cognitive-emotional arousal. Response inhibition training effectively alleviates sleep problems in ISSD. These findings provide new insights for developing precise intervention strategies in ID.

TRIAL REGISTRATION

The study was prospectively registered on May 30, 2024, in Chinese Clinical Trials registry (ChiCTR2400085063).

The prevalence of sleep disturbance and its possible associated factors among iranian medical students: A cross-sectional study with a national meta-analysis

Background

The aim of this cross-sectional study was to investigate the prevalence of sleep disturbance and its possible associated factors among Iranian medical students. Additionally, a national meta-analysis was conducted to provide a comprehensive overview of sleep disturbance in this population.

Methods

A sample of medical students from Guilan University of Medical Sciences, Iran was included in the study. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep disturbance. Demographic and lifestyle factors, as well as academic performance, were collected through a self-administered questionnaire. The data collected from this study were combined with existing studies through a meta-analysis to estimate the overall prevalence of sleep disturbance among Iranian medical students using the random effects model.

Results

A total of 249 medical students participated in the study. The prevalence of sleep disturbance among Guilan University of Medical Sciences medical students was found to be 71.1%. A significant difference was observed in total PSQI means regarding medical students' residency (p < 0.001) and their duration of sleep in the last 24 h (p = 0.006). The national prevalence of sleep disturbances was 59% (95% CI: [51%-66%], I2 = 97%).

Conclusion

Sleep disturbance is highly prevalent among Iranian medical students, with various factors contributing to its occurrence. The findings of this study highlight the need for interventions and strategies to improve sleep quality and overall well-being among this population. The national meta-analysis provides valuable insights into the overall burden of sleep disturbance among Iranian medical students and can serve as a reference for future studies and public health initiatives targeting this issue.

Insomnia disorder is associated with 24-hour cortical hyperarousal

OBJECTIVE

Cortical hyperarousal has been proposed as a primary underlying mechanism for insomnia disorder. However, most evidence comes from nighttime sleep and whether patients with insomnia disorder have cortical hyperarousal through the 24-h sleep/wake cycle is not resolved.

METHODS

We included 49 patients with insomnia disorder and 49 age-and sex-matched normal sleepers. All participants underwent an over-night polysomnography followed by a Multiple Sleep Latency Test during daytime. Nighttime and daytime delta, theta, alpha, sigma and beta relative power at central electroencephalogram derivations during wakefulness and non-rapid eye movement (NREM) sleep were calculated. Insomnia disorder was defined based on the International Classification of Sleep Disorders Third Edition criteria. Insomnia with objective short sleep duration was defined as patients with insomnia who slept <7 h based on nighttime polysomnography recording.

RESULTS

Compared to normal sleepers, patients with insomnia disorder had significantly higher nighttime (P = 0.040) and daytime (P = 0.021) relative electroencephalogram power in beta during NREM sleep and marginally significantly lower relative electroencephalogram power in theta (P = 0.060) during nighttime wakefulness. Furthermore, linear trend association was observed across normal sleepers, and patients with insomnia who slept ≥7 h and insomnia who slept <7 h in relative electroencephalogram power in beta during nighttime and daytime NREM sleep, and relative electroencephalogram power in theta during nighttime wakefulness (all P for trend <0.05).

CONCLUSION

Increased high-frequency electroencephalogram power during nighttime and daytime sleep suggests that insomnia is a disorder of 24-h cortical hyperarousal. Decreasing both nighttime and daytime cortical arousal levels should be our therapeutic target for insomnia.

The Association between Suicidal Ideation and Subtypes of Comorbid Insomnia Disorder in Apneic Individuals

Background/Objectives: Given the existence of higher suicidality in apneic individuals, this study aimed to determine the potential role played by subtypes of the comorbid insomnia disorder (CID) in the occurrence of suicidal ideation for this specific subpopulation. Methods: To perform our analyses, 1488 apneic individuals were retrospectively extracted from the Sleep Laboratory hospitalization register. Only apneic individuals with suicidal ideation highlighted during the psychiatric interview and/or with a score ≥1 on item G of the Beck Depression Inventory confirmed during the clinical interview were included in the group with suicidal ideation. The likelihood of suicidal ideation associated with CID subtypes was investigated using logistic regression analyses. Results: The prevalence of suicidal ideation was 9.3% in our sample of apneic individuals. After hierarchically introducing the significant confounders for adjustment, multivariate logistic regression analyses demonstrated that unlike short sleep duration alone and CID without short sleep duration, the likelihood of suicidal ideation was only higher for CID with short sleep duration in apneic individuals. Conclusions: Thus, we highlighted in this study that CID with short sleep duration could play a major role in higher suicidality for apneic individuals, which seems to require systematic screening and appropriate treatment of this comorbid sleep disorder to enable better management of suicidal risk in this specific subpopulation.

Functional MRI-based biomarkers of insomnia with objective short sleep duration phenotype

BACKGROUND

Insomnia disorder with objective short sleep duration (ISS) phenotype is a more serious biological subtype than insomnia with objective normal sleep duration (INS) phenotype, and the neuroimaging data is helpful to understand the pathophysiology of the ISS phenotype. This study was to compare the amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), and functional connectivity (FC) between the ISS phenotype and the INS phenotype.

METHODS

In this cross-sectional study, 55 patients with insomnia disorder were recruited, and 22 of them were defined as the ISS phenotype by the objective cardiopulmonary coupling (CPC) technique. The blood oxygen level-dependent (BOLD) sequences of all participants were obtained using the 3.0 T magnetic resonance imaging system. We analyzed and compared the ALFF, ReHo, and FC between the ISS phenotype and the INS phenotype. We also conducted Pearson's correlation analysis between significant neuroimaging biomarkers and the CPC parameters.

RESULTS

The differences were not significant in ALFF (PFWE-corr＞0.05) or ReHo (PFWE-corr＞0.05) between the ISS phenotype and the INS phenotype. For the FC analysis, the ISS phenotype had a Hub-node of the left inferior occipital gyrus (IOG.L), with significantly decreased connections (p＜0.001) in the bilateral occipital, parietal, and temporal regions. The significant FCs were closely related to sleep parameters.

CONCLUSION

The left inferior occipital gyrus (IOG.L), as a Hub-node with decreased functional connections, may be a potential fMRI-based biomarker of the ISS phenotype.

Daytime sleepiness in insomnia: Are we focusing on what truly matters?

Insomnia, the most prevalent sleep disorder, is commonly associated with other mental and somatic disorders, making it a significant health concern. It is characterized by nighttime symptoms and daytime dysfunction, with sleepiness being a potential criterion for the latter. Sleepiness is a normal physiological state that is typically experienced near usual bedtime, in normal circumstances. In insomnia, it seems somewhat logical the idea that there is significant daytime sleepiness. However, the topic has been the subject of various discussions in sleep medicine, with studies yielding contradictory and inconsistent results. In this article, we aim to critically examine daytime sleepiness in individuals with insomnia disorder and propose an alternative approach to addressing it, both in clinical practice and research settings. It is crucial to further investigate the role of daytime sleepiness in insomnia, particularly by focusing on sleepiness perception as a more relevant dimension to explore in majority of patients. It is plausible that certain insomnia phenotypes are objectively sleepy during the day, but more studies are necessary, particularly with well-defined clinical samples. The implications of assessing sleepiness perception in insomnia for clinical practice are discussed, and new avenues for research are suggested.

Association of comorbid obstructive sleep apnea and insomnia with risk of major adverse cardiovascular events in sleep medicine center patients

OBJECTIVES

To investigate the association between comorbid obstructive sleep apnea and insomnia and major adverse cardiovascular events, including myocardial infarction, unstable angina, congestive heart failure, and stroke, in adults with suspected sleep disorders who underwent sleep apnea testing.

METHODS

We conducted a retrospective analysis of electronic medical records data from patients with clinical encounters at sleep medicine centers to identify patients with comorbid obstructive sleep apnea and insomnia, obstructive sleep apnea only, insomnia only, and patients without a diagnosis of obstructive sleep apnea or insomnia (i.e., controls). Obstructive sleep apnea, insomnia, comorbidities, and new-onset major adverse cardiovascular events were ascertained by ICD-9-CM and ICD-10-CM codes. Multivariable adjusted Cox proportional regression models evaluated the risk of major adverse cardiovascular events over a 10-year follow-up period.

RESULTS

A total of 3951 patients, 226 controls, 2107 with obstructive sleep apnea only, 276 with insomnia only, and 1342 with comorbid obstructive sleep apnea and insomnia, were included in the analysis. Compared to controls, comorbid obstructive sleep apnea and insomnia were associated with a significantly higher risk of developing major adverse cardiovascular events (hazard ratio 3.60, 95 CI%: 2.33-5.91) in unadjusted analyses. The relationship between comorbid obstructive sleep apnea and insomnia and major adverse cardiovascular events remained after adjustment for demographic and behavioral factors, but not after further adjustment for comorbidities. The greatest risk of major adverse cardiovascular events was found among younger adults with comorbid obstructive sleep apnea and insomnia. Obstructive sleep apnea only was associated with greater risk of major adverse cardiovascular events in unadjusted analyses only (hazard ratio 2.77, 95% CI: 1.80-4.54). Insomnia only was not significantly associated with increased risk of major adverse cardiovascular events.

CONCLUSIONS

Comorbid obstructive sleep apnea and insomnia may be a high-risk group for major adverse cardiovascular events, particularly younger adults. Further research is needed to better understand the association between comorbid obstructive sleep apnea and insomnia and major adverse cardiovascular events risk.

Temporary relationship between sleep duration and depression and its impact on future risk of cardiovascular disease

BACKGROUND

Although sleep duration and depression were correlated, their temporal sequence and how the sequence influence on future risk of cardiovascular disease (CVD) remained undetermined. This study aimed to explore the temporal relationship between sleep duration and depression, and its association with future CVD risk.

METHODS

We included 10,629 middle-aged and elderly participants with repeated measurements of sleep duration and depressive symptoms (measured by Center for Epidemiological Studies-Depression scale [CESD]) at the first two visits from the China Health and Retirement Longitudinal Study. Cross-lagged analysis and mediation analysis were used to examine the temporal relationship between sleep duration and depression and its impact on future risk of CVD.

RESULTS

The adjusted cross-lagged path coefficient from baseline sleep duration to follow-up CES-D (β1 = -0.191; 95 % confidence interval [CI], -0.239 to -0.142) was significantly greatly than that from baseline CES-D to follow-up sleep duration (β2 = -0.031; 95 % CI, -0.031 to -0.024) (Pdifference < 0.0001). Similarly, the path coefficient from baseline sleep duration to annual changes in CES-D was significantly greater than that from baseline CES-D to annual changes in sleep duration (β1 = -0.093 versus β2 = -0.015, Pdifference < 0.0001). The path coefficient from baseline sleep duration to follow-up CES-D in CVD group was significantly greater than that in those without CVD (Pdifference of β1 = 0.0378). Furthermore, 27.93 % of the total association of sleep duration with CVD was mediated by depression symptoms.

CONCLUSIONS

The findings provide evidence that decrease in sleep duration probably precedes the increased in depressive symptoms, and depression partially mediated the pathway from sleep duration to incident CVD.

Sleep disorders in Parkinson's disease, an early and multiple problem

In Parkinson's disease (PD), it remains unclear whether sleep disorders including insomnia, REM sleep behavior disorder (RBD), excessive daytime sleepiness (EDS), restless legs syndrome (RLS) and sleep-disordered breathing (SDB), are isolated or combined, interact with each other and are associated with clinical factors. We sought to determine the prevalence and combinations of the main sleep disorders, and their clinical and polysomnographic associations in early stage PD. Sleep disorders were systematically diagnosed after medical interview and video-polysomnography in 162 participants with early stage PD and 58 healthy controls from the baseline of the longitudinal ICEBERG cohort. Demographic, clinical (motor, cognitive, autonomic, psychological and sensory tests), therapeutic and polysomnographic associations of sleep disorders were investigated. Sleep disorders were frequent (71%) and combined in half of the patients. The number of sleep disorders increased with disease duration and dysautonomia. Insomnia was the most common (41%), followed by definite RBD (25%), EDS (25%), and RLS (16%). These disorders were more frequent than in controls whereas SDB was rare, moderate and similar in both groups. In patients, insomnia (mainly difficulties maintaining sleep) was associated with female gender, shorter sleep time and RLS, but not with motor or psychological symptoms. RBD was associated with dysautonomia and advanced age, but not with motor and cognitive measures. EDS was associated with psychiatric and motor symptoms as well as the sedative effects of dopamine agonists but not with other sleep disturbances. Sleep disturbances are frequent and combined in early patients with PD. Their determinants and markers are more organic than psychological.

Reconsidering sleep perception in insomnia: from misperception to mismeasurement

So-called 'sleep misperception' refers to a phenomenon in which individuals have the impression of sleeping little or not at all despite normal objective measures of sleep. It is unknown whether this subjective-objective mismatch truly reflects an abnormal perception of sleep, or whether it results from the inability of standard sleep recording techniques to capture 'wake-like' brain activity patterns that could account for feeling awake during sleep. Here, we systematically reviewed studies reporting sleep macro- and microstructural, metabolic, and mental correlates of sleep (mis)perception. Our findings suggest that most individuals tend to accurately estimate their sleep duration measured with polysomnography (PSG). In good sleepers, feeling awake during sleep is the rule at sleep onset, remains frequent in the first non-rapid eye movement sleep cycle and almost never occurs in rapid eye movement (REM) sleep. In contrast, there are patients with insomnia who consistently underestimate their sleep duration, regardless of how long they sleep. Unlike good sleepers, they continue to feel awake after the first sleep cycle and importantly, during REM sleep. Their mental activity during sleep is also more thought-like. Initial studies based on standard PSG parameters largely failed to show consistent differences in sleep macrostructure between these patients and controls. However, recent studies assessing sleep with more refined techniques have revealed that these patients show metabolic and microstructural electroencephalography changes that likely reflect a shift towards greater cortical activation during sleep and correlate with feeling awake. We discuss the significance of these correlates and conclude with open questions and possible ways to address them.

Insomnia nosology: a systematic review and critical appraisal of historical diagnostic categories and current phenotypes

Insomnia nosology has significantly evolved since the Diagnostic and Statistical Manual (DSM)-III-R first distinguished between 'primary' and 'secondary' insomnia. Prior International Classification of Sleep Disorders (ICSD) nosology 'split' diagnostic phenotypes to address insomnia's heterogeneity and the DSM nosology 'lumped' them into primary insomnia, while both systems assumed causality for insomnia secondary to health conditions. In this systematic review, we discuss the historical phenotypes in prior insomnia nosology, present findings for currently proposed insomnia phenotypes based on more robust approaches, and critically appraise the most relevant ones. Electronic databases PsychINFO, PubMED, Web of Science, and references of eligible articles, were accessed to find diagnostic manuals, literature on insomnia phenotypes, including systematic reviews or meta-analysis, and assessments of the reliability or validity of insomnia diagnoses, identifying 184 articles. The data show that previous insomnia diagnoses lacked reliability and validity, leading current DSM-5-TR and ICSD-3 nosology to 'lump' phenotypes into a single diagnosis comorbid with health conditions. However, at least two new, robust insomnia phenotyping approaches were identified. One approach is multidimensional-multimethod and provides evidence for self-reported insomnia with objective short versus normal sleep duration linked to clinically relevant outcomes, while the other is multidimensional and provides evidence for two to five clusters (phenotypes) based on self-reported trait, state, and/or life-history data. Some approaches still need replication to better support whether their findings identify true phenotypes or simply different patterns of symptomatology. Regardless, these phenotyping efforts aim at improving insomnia nosology both as a classification system and as a mechanism to guide treatment.

The importance and limitations of polysomnography in insomnia disorder-a critical appraisal

The importance polysomnography (PSG) in the diagnosis and treatment process of insomnia disorder (ID) remains highly disputed. This review summarises the state of the science regarding PSG indications and findings in ID, and the indications to conduct PSG in ID as stated by relevant guidelines. It then highlights the most relevant questions regarding the topic, including the relevance of ID subtyping, to allow an individualised pharmacological or psychotherapeutic treatment approach.

Insomnia disorder with objective short sleep duration (ISS) phenotype and cognitive performance: a systematic review and meta-analysis

OBJECTIVE

Insomnia disorder with objective short sleep duration (ISS) has been considered as a biologically severe subtype. The aim of this meta-analysis was to reveal the association of the ISS phenotype and cognitive performance.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library for studies that observed an association of cognitive performance and insomnia with objective short sleep duration (ISS) phenotype. The "metafor" and "MAd" packages in R software (version 4.2.0) were used to calculate the unbiased standardized mean difference (Hedge's g), which was adjusted so that a negative value indicated worse cognitive performance.

RESULTS

The pooled analysis with 1339 participants revealed that the ISS phenotype was associated with overall cognitive impairments (Hedges' g = - 0.56 [- 0.89, - 0.23]), as well as specific cognitive domains including attention (Hedges' g = - 0.86 [- 1.25, - 0.47]), memory (Hedges' g = - 0.47 [- 0.82, - 0.12]), and executive function (Hedges' g = - 0.39 [- 0.76, - 0.02]). However, cognitive performance was not significantly different between insomnia disorder with objective normal sleep duration (INS) and good sleepers (p > .05).

CONCLUSION

Insomnia disorder with the ISS phenotype, but not the INS phenotype, was associated with cognitive impairments, suggesting the possible utility of treating the ISS phenotype to improve cognitive performance.

Postpartum Behavioral Sleep Intervention for Smoking Relapse Prevention: A Pilot Trial

OBJECTIVES

Rates of postpartum smoking relapse are high (70-90%) but standard relapse prevention interventions are not effective postpartum. This pilot study evaluated effects of a combined relapse prevention and sleep intervention on sleep and relapse to smoking.

METHODS

Twenty-eight postpartum mothers were assigned to the intervention group-combined relapse prevention and behavioral sleep intervention-or to the comparison group-relapse prevention alone. Questionnaires and actigraphy were completed at baseline (1-week postpartum), post-treatment (8-weeks postpartum), and follow-up (12-weeks postpartum). Sleep diaries were completed weekly for the first 8 weeks postpartum and once at 12 weeks postpartum. To corroborate abstinence, CO levels in expired air were measured weekly for the first 8 weeks postpartum and at follow-up. Timeline Followback (TLFB) and salivary cotinine analysis were conducted at baseline, post-treatment, and follow-up to assess for nicotine and other substance use (TLFB) and to further corroborate abstinence (salivary cotinine analysis).

RESULTS

The sleep intervention lengthened maternal nighttime actigraphic sleep by an average of 48 minutes nightly; lengthened the longest bout of consolidated actigraphic sleep by an average of 42 minutes nightly; increased actigraphic sleep efficiency into the healthy range (> 85%); and lowered subjective ratings of sleep disturbance (ps < .05). Findings were inconclusive regarding whether better sleep was associated with abstinence. Post Hoc analyses identified the presence of an additional support person in the home as well as social and emotional support as being positively correlated with smoking abstinence (p < .05; p < .01).

CONCLUSIONS FOR PRACTICE

(1) Postpartum sleep can be improved with behavioral interventions in women with a history of smoking. (2) Social-emotional postpartum support is an important factor in preventing smoking relapse for these women.

Baseline sleep characteristics are associated with gains in sleep duration after cognitive behavioral therapy for insomnia

OBJECTIVE/BACKGROUND

Cognitive behavioural therapy for insomnia (CBT-I) substantially reduces total wake time (TWT) by the end of treatment. In contrast, total sleep time (TST) does not increase above baseline levels for most patients following 4-8 sessions of treatment. In the 6-12 months following CBT-I, without any further intervention, up to 64% of participants substantially increase their TST (by ≥ 30 min). The current study investigated which baseline characteristics are associated with increases in TST after CBT-I.

PATIENTS/METHODS

Data were analysed from a randomised controlled trial assessing acute and maintenance CBT-I (N = 80). Linear mixed models were conducted to assess the effect of baseline characteristics on changes in TST up to 24 months after CBT-I. Baseline characteristics included age, sex, marital status, sleep continuity (derived from sleep diaries and polysomnography studies), and mental health and quality of life questionnaires.

RESULTS

At baseline, self-reported sleep latency, wake after sleep onset, early morning awakenings, TWT, TST, and sleep efficiency were associated with the greatest changes in TST (p < .03 for interactions), such that patients who reported more wake/less sleep at baseline also reported the largest increases in TST. No other baseline variables were associated with changes in TST after CBT-I, including age, sex, and polysomnography-derived sleep continuity (p > .07 for interactions).

CONCLUSIONS

Patients with more severe self-reported sleep difficulties and lower sleep duration at baseline showed greater improvements in TST after CBT-I. Whether more patients could increase their TST, within the context of acute treatment or following treatment, warrants investigation.

Cognitive-behavioral therapy for insomnia with objective short sleep duration phenotype: A systematic review with meta-analysis

Cognitive-behavioral therapy for insomnia (CBT-I) has been recommended as the first-line therapy for this condition. However, insomnia disorder with objective short sleep duration (ISS) phenotype is a distinct subtype from insomnia with normal sleep duration (INS) phenotype, and it may have a differential therapeutic response. We searched PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov using the PICOS principle for studies that examined the efficacy of cognitive-behavioral therapy for those with the ISS phenotype versus the INS phenotype, and identified nine studies with 612 patients with insomnia disorder. This included 270 patients with the ISS phenotype and 342 patients with the INS phenotype. The main outcome was that CBT-I had a better efficacy for the INS phenotype compared with the ISS phenotype, with about 30% higher response and about 20% higher remission. Similar results were indicated in the secondary outcomes. The therapeutic response of the ISS phenotype was significantly different from that of the INS phenotype. In the future, research is needed to clarify how to optimally treat insomnia disorder with the ISS phenotype in prospective randomized clinical trials, and to understand whether decreasing physiologic arousal will be necessary to improve results.

Emerging applications of objective sleep assessments towards the improved management of insomnia

Self-reported sleep difficulties are the primary concern associated with diagnosis and treatment of chronic insomnia. This said, in-home sleep monitoring technology in combination with self-reported sleep outcomes may usefully assist with the management of insomnia. The rapid acceleration in consumer sleep technology capabilities together with their growing use by consumers means that the implementation of clinically useful techniques to more precisely diagnose and better treat insomnia are now possible. This review describes emerging techniques which may facilitate better identification and management of insomnia through objective sleep monitoring. Diagnostic techniques covered include insomnia phenotyping, better detection of comorbid sleep disorders, and identification of patients potentially at greatest risk of adverse outcomes. Treatment techniques reviewed include the administration of therapies (e.g., Intensive Sleep Retraining, digital treatment programs), methods to assess and improve treatment adherence, and sleep feedback to address concerns about sleep and sleep loss. Gaps in sleep device capabilities are also discussed, such as the practical assessment of circadian rhythms. Proof-of-concept studies remain needed to test these sleep monitoring-supported techniques in insomnia patient populations, with the goal to progress towards more precise diagnoses and efficacious treatments for individuals with insomnia.

Sleep and Circadian Disturbance in Cardiovascular Risk

PURPOSE OF REVIEW

We discuss the relationship between sleep and circadian factors with cardiovascular disease (CVD) risk, including physiologic, behavioral, and psychological mechanisms along this pathway.

RECENT FINDINGS

The relationship between short and long sleep duration, as well as insomnia, with CVD risk is well-established. Recent work has highlighted how other sleep factors, such as sleep regularity (i.e., consistency of sleep timing), multidimensional sleep health, and circadian factors like chronotype and social jetlag, relate to CVD risk. Sleep-focused interventions (e.g., cognitive behavioral therapy for insomnia and sleep extension) may be effective to reduce CVD risk and disease burden. Sleep is increasingly recognized as an integral component of cardiovascular health. This was underscored by the recent inclusion of sleep duration as a health behavior in the American Heart Association's Life's Essential 8 for defining optimal cardiovascular health.

Prevalence of insomnia and hypnotic use in Norwegian patients visiting their general practitioner

BACKGROUND

Sleep problems are common in the general population, but there are few studies on the prevalence of sleep problems and hypnotic use among patients in general practice.

OBJECTIVES

To estimate the prevalence of insomnia (based on the Diagnostic and Statistical Manual of Mental Disorders [DSM], version 5), self-reported sleep problems and hypnotic use among patients in general practice, and explore whether the prevalence depended on patient characteristics.

METHODS

A cross-sectional study with questionnaire data collected by 114 final-year medical students while deployed in different general practices in Norway during 2020. A total of 1,848 consecutive and unselected patients (response rate 85.2%) visiting their general practitioners (GPs) completed a one-page questionnaire, that included the validated Bergen Insomnia Scale (BIS), questions on for how long they have had a sleep problem, hypnotic use, and background characteristics. Associations were estimated using a modified Poisson regression model.

RESULTS

The prevalence of chronic insomnia according to BIS was 48.3%, while 46.9% reported chronic sleep problems (sleep problems of ≥3 months) and 17.8% reported hypnotic use. Females, patients with low compared with higher education, and patients who slept shorter or longer than 7-8 h, had higher risk of chronic insomnia disorder (CID), chronic self-reported sleep problems (CSP), and hypnotic use. The oldest age group (≥65 years) had lower risk of chronic insomnia compared with the youngest (18-34) but twice the probability of hypnotic use.

CONCLUSIONS

CID, CSP, and hypnotic use were prevalent among patients visiting their GP. Insomnia can be effectively treated and deserves more attention among GPs.

Sleep Quality and Insomnia Severity among Italian University Students: A Latent Profile Analysis

Insomnia is a widespread sleep disorder associated with physical and mental health conditions. Although the heterogeneity of insomnia presentations has been acknowledged, research investigating clinically meaningful insomnia subtypes is still ongoing. This study aimed at exploring insomnia subtypes according to widely-used measures of symptoms severity and sleep quality among Italian university students using a latent profile analysis. Data were collected from 490 students reporting relevant insomnia symptoms through an online cross-sectional survey comprising the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, the 21-item Depression Anxiety Stress Scale, and the Short Form-12. Latent profile analysis identified five insomnia subtypes. The severe insomnia (8.8%) group showed the highest insomnia severity, with diverse complaints concerning sleep quality and daytime functioning. Moderate insomnia with sleep duration complaints (8.4%) and moderate insomnia with medication use (15.9%) subgroups were characterized by middle range insomnia severity, with problems of sleep continuity and sleep medication use, respectively. Subthreshold insomnia with sleep latency complaints (20.4%) and subthreshold insomnia (46.5%) groups showed attenuated insomnia symptoms. Higher psychological complaints and worse quality of life were associated with greater sleep complaints. Overall, these findings highlight the relevance of sleep quality domains in identifying insomnia subtypes and might help optimize insomnia treatments.

Does total sleep time substantially increase after cognitive behavioral therapy for insomnia?

STUDY OBJECTIVES

In most standardized approaches to cognitive behavioral therapy for insomnia, it is commonly the case that total wake time is reduced substantially during sleep restriction, but self-reported total sleep time (TST) is minimally affected. By follow-up, however, TST increases by almost 1 hour on average. A secondary analysis was undertaken to assess what percentage of participants meet or appreciably exceed baseline TST after cognitive behavioral therapy for insomnia.

METHODS

Data were drawn from a randomized controlled trial assessing acute and maintenance therapies for chronic insomnia (n = 80). The present analyses assessed the percentage of participants that 1) reached (≥ 0 minute increase) and 2) appreciably exceeded (≥ 30 minutes increase) baseline TST as assessed via daily sleep diaries at posttreatment and 3, 6, 12, and 24 months following treatment.

RESULTS

By the end of acute treatment, 45% of participants reached or exceeded baseline TST. By 24 months follow-up, this percentage had increased to 86%. Only 17% of participants achieved a 30-minute increase in TST by the end of acute treatment, and this proportion only increased to 58% over time.

CONCLUSIONS

These findings suggest that cognitive behavioral therapy for insomnia in its current form does not appreciably increase self-reported TST in a significant proportion of patients with insomnia. Whether participants would benefit from further increases in TST warrants investigation. The further titration of sleep opportunity may be useful to accelerate increases in TST, to extend the effect to a larger subset of patients, and/or to increase the magnitude of the TST gain.

CITATION

Scott H, Cheung JMY, Muench A, et al. Does total sleep time substantially increase after cognitive behavioral therapy for insomnia? J Clin Sleep Med. 2022;18(7):1823-1829.

Association of insomnia phenotypes based on polysomnography-measured sleep duration with suicidal ideation and attempts

OBJECTIVE

To assess the association of insomnia phenotypes, being insomnia with short sleep duration (ISSD) and insomnia with normal sleep duration (INSD), with suicidality in a randomly selected population-based sample.

METHODS

Data were analyzed from the Penn State Adult Cohort. Participants (N = 1741, 52.5 years, 57.4% female) were randomly recruited from the general population between January 1990 through March 1999 and mortality data were available through December 2018. Insomnia symptoms were defined as self-reports of moderate-to-severe difficulties initiating or maintaining sleep, early morning awakening and non-restorative sleep, or having chronic insomnia (n = 719). Short sleep duration was defined as <6 hours of in-lab polysomnography-measured sleep duration (n = 879). Suicidality (SAI; n = 102) was ascertained by a lifetime history of suicidal ideation (SI; n = 84), suicide attempts (SA; n = 48) or death by suicide (DBS; n = 10).

RESULTS

Compared to normal sleepers who slept ≥6 hours, participants with ISSD and INSD were associated with 1.72-fold and 2.22-fold increased odds of SAI, respectively; these associations were significant for SI, with 2.09-fold and 2.24-fold increased odds, respectively, but not for SA, after adjusting for physical and mental health comorbidities. ISSD and INSD differed in SAI age of onset and hospitalizations after SA.

CONCLUSIONS

The results of this cohort study suggest that both INSD and ISSD phenotypes are associated with increased suicidal ideation, while the INSD phenotype has an earlier age of onset and is more likely to experience hospitalizations after attempting suicide. These results highlight the importance of targeting insomnia symptoms to help prevent suicide.

Insomnia symptom severity and cognitive performance: Moderating role of APOE genotype

INTRODUCTION

We evaluated whether insomnia symptom severity was associated with cognitive function, and whether this relationship was modified by biomarkers associated with Alzheimer's disease risk.

METHODS

We examined insomnia symptoms and neuropsychological performance 3.4 years later in 511 dementia-free Framingham Heart Study participants (62.65 ± 8.7 years, 50.9% male). Additionally, we explored insomnia symptoms combined with self-reported short habitual sleep duration and effect modification by apolipoprotein E (APOE) ε4 allele status.

RESULTS

More severe insomnia symptoms were associated with lower performance on global cognition, and immediate and delayed Logical Memory recall, especially when insomnia symptoms were combined with short sleep duration. The association between insomnia symptoms and poorer memory recall was more pronounced in APOE ε4 allele carriers.

DISCUSSION

Insomnia symptom severity was associated with worse subsequent global cognitive and memory performance, which was especially apparent in APOE ε4 allele carriers, suggesting that poor sleep might be particularly detrimental when the brain is already vulnerable to neurodegeneration.

Self-Awareness of Sleep Apnea Symptoms Among Middle-Aged and Elderly People in Taiwan

In recent years, the proportion of middle-aged and elderly people in Taiwan has gradually increased and has already surpassed that of advanced countries such as Europe, the United States and Japan, therefore, the health of middle-aged and elderly people is a topic that needs attention. This is because physical deterioration or illness can lead to a decline in quality of life and create a medical burden on the individual and society. This study investigated the common symptoms of sleep apnea in middle-aged and elderly people (over 40 years old), and developed a self-test subjective perception model, using "daytime sleepiness" and "sleep quality" as influencing factors, and "attention" as mediating variables to verify the effect with sleep apnea symptoms. An online electronic questionnaire was conducted and distributed through social media and groups of friends in Taiwan. A total of 541 valid questionnaires were collected and analyzed in three stages: Descriptive Analysis, Measurement Model Validation, and Structural Equation Model. The research processes of the study showed that the sample fitted the normal distribution and the measurement model conformed with convergent reliability and discriminant validity. The research results were found that "sleep quality" had a significant negative effect on sleep apnea symptoms. "Daytime sleepiness" had a positive effect on sleep apnea symptoms. "Daytime sleepiness" had a negative effect on sleep apnea symptoms through the "attention" mediator. Finally, through the questionnaire, we hope to make the middle-aged people aware of themselves, so that they can seek early medical treatment if there are signs and symptoms of sleep apnea symptoms.

Emotion coping strategies and dysfunctional sleep-related beliefs are associated with objective sleep problems in young adults with insomnia

BACKGROUND

Though insomnia is associated with affected emotion regulation and dysfunctional ideas about sleep, little is known about the relation of these problems with objective sleep disruption. We aimed to explore this relationship in young adults with and without insomnia.

METHODS

Twenty young adults with diagnosed insomnia disorder (aged 27.7 ± 8.6 years) and twenty age-matched individuals without insomnia (26.7 ± 7.0 years) completed questionnaires, measuring sleep-related thoughts and emotions and emotion regulation. Objective sleep measurements were collected through 10-days actigraphy as a representative sample of nights, and analyzed for sleep onset latency, sleep efficiency total sleep time. T-tests and multivariate analyses of variance (MANOVA) were conducted for sample characterization and analysis of the association of sleep-related thoughts and emotions and emotion regulation with objective sleep data.

RESULTS

As expected, young people showed more dysfunctional sleep-related thoughts and emotions (all ps ≤ 0.025) and dysfunctional emotion regulation strategies (all ps ≤ 0.040). Surprisingly, MANOVA results showed that only emotion coping strategies after a stressful event (p = 0.017) and dysfunctional beliefs about sleep (p = 0.012), but not other factors of arousal or sleep reactivity, were associated with overall worse sleep, especially sleep onset latency (all ps ≤ 0.012) and sleep efficiency (all ps ≤ 0.010).

CONCLUSIONS

Maladaptive emotion coping strategies after a stressful event and dysfunctional sleep-related beliefs and attitudes affect objective sleep onset latency and sleep efficiency in young adults, highlighting the importance of targeting these features in the prevention and treatment of chronic insomnia and improving actual sleep quality.

Presleep Arousal and Sleep in Early Childhood

Research suggests that arousal during the transition to sleep-presleep arousal-is associated with sleep disturbances. Although a robust literature has examined the role of presleep arousal in conferring risk for sleep disturbances in adults, substantially less research has examined the developmental origins of presleep arousal in early childhood. The authors examined presleep arousal using parent report and psychophysiological measures in a sample of preschoolers to explore the association between different measures of presleep arousal, and to examine how nightly presleep arousal is associated with sleep. Participants included 29 children assessed at 54 months of age. Presleep arousal was measured using parent reports of child arousal each night at bedtime and using a wearable device that took minute-by-minute recordings of heart rate, peripheral skin temperature, and electrodermal activity each night during the child's bedtime routine. This yielded a dataset with 4,550 min of ambulatory recordings across an average of 3.52 nights per child (SD = 1.84 nights per child; range = 1-8 nights). Sleep was estimated using actigraphy. Findings demonstrated an association between parent-reported and psychophysiological arousal, including heart rate, peripheral skin temperature, and skin conductance responses during the child's bedtime routine. Both the parent report and psychophysiological measures of presleep arousal showed some associations with poorer sleep, with the most robust associations occurring between presleep arousal and sleep onset latency. Behavioral and biological measures of hyperarousal at bedtime are associated with poorer sleep in young children. Findings provide early evidence of the utility of wearable devices for assessing individual differences in presleep arousal in early childhood.

Cognitive deficit is correlated with sleep stability in insomnia: A cardiopulmonary coupling study

OBJECTIVES

To assess the correlation of cognitive function with sleep stability and depressive-anxious symptoms in insomnia patients.

METHODS

Twenty-two insomnia patients with cognitive impairment (insomnia-CI), 21 insomnia patients with normal cognition (insomnia-CN), and 15 matched healthy control subjects (HCs) were enrolled and completed neuropsychological tests, the Hamilton Depression and Anxiety Scales (HAMD and HAMA), the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index (PSQI),the Insomnia Severity Index (ISI), and the cardiopulmonary coupling (CPC) examination. Ratios of high-frequency coupling (HFC), low-frequency coupling (LFC), and very low-frequency coupling (VLFC) measured by CPC analysis represent stable sleep, unstable sleep, and wake/rapid eye movement (REM) sleep, respectively.

RESULTS

The HAMD, HAMA, PSQI, and ISI scores were higher in the insomnia-CN patients than in the HCs (all p < .01). However, no differences were found in the HFC, LFC, and VLFC ratio between the HCs and insomnia-CN groups. Compared with the insomnia-CN patients, insomnia-CI patients exhibited higher scores on the HAMD, HAMA (all p < .01), and PSQI (p < .05), performed worse on the Auditory Verbal Learning Test, Trial Making Test B, and Stroop Test B (all p < .01), had a lower HFC ratio, and had a higher LFC ratio in the CPC analysis (all p < .01). Furthermore, in the insomnia patients, poorer cognition was correlated with a decreased HFC ratio and an increased VLFC ratio (r = .356, p = .019; r = -.339, p =.026, respectively) and increased HAMD and HAMA scores (r = -.507, p < .001; r = -.561, p < .001, respectively); a higher VLFC ratio was correlated with an increased ISI score (r = .346, p = .023).

CONCLUSIONS

Cognitive deterioration in insomnia patients was associated with a decreased stable sleep ratio, an increased wake/REM sleep ratio and more severe symptoms of depression and anxiety. CPC analysis can reflect the severity of insomnia.

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health

STUDY OBJECTIVES

Insomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking.

METHODS

We analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems.

RESULTS

Participants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15-3.66 and OR = 2.18, 95% CL = 1.07-4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01-3.75 and OR = 2.33, 95% CL = 1.07-5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30-1.76 and OR = 0.75, 95% CL = 0.21-2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42-2.74 and OR = 0.76, 95% CL = 0.16-3.57, respectively).

CONCLUSIONS

Insomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.

Arousability as a trait predisposition to insomnia: multidimensional structure and clinical utility of the Spanish and English versions of the Arousal Predisposition Scale

OBJECTIVES

Traits related to a hyper-reactive arousal system (arousability) and weakened sleep system (sleep reactivity) are considered predisposing factors for insomnia of potential clinical utility. However, research examining the psychometric properties (ie, reliability and validity) of the Arousal Predisposition Scale (APS) and its clinical utility (ie, cut-off scores) among population-based and clinical samples is very limited.

METHODS

A total of 500 adults (41.8% female, 39.1 ± 15.9 years) from the general population in Spain and 217 adults (64.5% female, 46.0 ± 16.1 years) from a clinical sample in the United States completed the APS, as well as measures of sleep reactivity, insomnia severity, anxiety, depression, and stress. Structural equation modeling was used to conduct confirmatory factor analysis (CFA) of the APS. Correlation and receiver operating characteristic (ROC) analyses were used to determine convergent and predictive validity of the APS and its factors.

RESULTS

The CFAs supported two dimensions of emotional reactivity (APS-ER, 9 items) and trait anxiety (APS-TA, 3 items) in both independent samples. APS-ER was associated with sleep reactivity and performed better than APS-TA when predicting clinically significant sleep reactivity and similarly when predicting clinically significant insomnia severity.

CONCLUSIONS

Our findings support the specificity of emotional reactivity and sleep reactivity as trait predispositions to insomnia, while trait anxiety is a predisposing factor for the comorbidity of insomnia with state anxiety rather than a specific diathesis for insomnia. These data provide further support for the diathesis-stress model of insomnia and, as a transdiagnostic process, its potential etiological link with psychopathology.

The association of insomnia disorder characterised by objective short sleep duration with hypertension, diabetes and body mass index: A systematic review and meta-analysis

Insomnia disorder with objective short sleep duration (less than 6 h of objective sleep or sleep efficiency less than 85%) has been considered as a biologically severe subtype of insomnia associated with a higher risk of cardiometabolic disease morbidity. This systematic review and meta-analysis firstly compared insomnia disorder with objective short and normal sleep duration, and subsequently, objective short sleep duration with and without insomnia disorder, and their associations with hypertension, type 2 diabetes and body mass index. A systematic search of five databases yielded 2345 non-duplicated articles, of which 11 individual studies were used for the qualitative review and 10 individual studies for the meta-analysis. The sample size varied from 30 to 4994 participants. A higher risk of hypertension (RR 1.54, 95% CI: [1.30; 1.82] p < 0.0001) and type 2 diabetes (RR 1.63 [1.37; 1.94], p < 0.0001) was associated with insomnia disorder with objective short sleep compared to normal sleep duration, but not for body mass index. Comparisons between insomnia disorder with objective short sleep and objective short sleep without insomnia disorder showed no significant differences. However, the majority of these studies were cross-sectional, and there is a need for more cohort study data.

Cannabis use and sleep: Expectations, outcomes, and the role of age

STUDY OBJECTIVES

Determine relationship between cannabis use with 1) expectations of cannabis being a sleep aid, 2) subjective sleep outcomes, and 3) the influence of age on these relationships.

METHODS

In 152 moderate cannabis users with a wide age range (67% female, mean age = 31.45, SD = 12.96, age range = 21-70; mean days of cannabis use in prior two weeks = 5.54, SD = 5.25) we examined the influence of cannabis use history and behaviors on expectations of cannabis being a sleep aid and sleep outcomes via the Pittsburgh Sleep Quality Index (PSQI). Moderation analysis examined the role of age in the relationship between cannabis use and sleep outcomes.

RESULTS

Endorsing current cannabis use and more days of cannabis use were associated with increased expectations that cannabis use improves sleep (all β > 0.03, p < 0.04). Frequency of recent use and reported average THC or CBD concentration were largely not associated with sleep outcomes. However, endorsing current cannabis use was associated with worse subjective sleep quality (β = 1.34, p = 0.02) and increased frequency of consuming edibles was associated with worse subjective sleep efficiency (β = 0.03, p = 0.04), lower sleep duration (β = 0.03, p = 0.01), and higher global PSQI scores (worse overall sleep) (β = 0.10, p = 0.01). Additionally, age had a moderating influence on the relationship between increased self-reported concentration of CBD and both better sleep duration and sleep quality (both p < 0.03). While the main effects of cannabis use on sleep outcomes did not survive multiple comparisons correction test (all p adj > 0.34), the adjusted p values for the main effects of cannabis behaviors/history on expectations of cannabis as a sleep aid (p adj = 0.07-0.09) and the main effects of CBD concentration on sleep duration (p adj = 0.08), as well as the interaction terms of CBD and age for that model (p adj = 0.07), were trending.

CONCLUSION

Cannabis users have increased expectations of cannabis being a sleep aid, but few associations existed between cannabis use and sleep outcomes. The two exceptions were endorsing any cannabis use and frequency of edible use. Additionally, age may be an important moderator of the potential positive influence CBD concentration can have on sleep.

Clinical Significance and Cut-Off Scores for the Pre-Sleep Arousal Scale in Chronic Insomnia Disorder: A Replication in a Clinical Sample

Background: In contrast to pre-sleep cognitive arousal, self-reported pre-sleep somatic arousal is a rather elusive construct for which little validity has been provided. Thus, the clinical significance of somatic symptoms during the pre-sleep period remains unknown. Participants: 248 patients (45.0 ± 16.7 years old, 65.3% female) with a diagnosis of chronic insomnia disorder, out of 388 consecutive patients evaluated at the Behavioral Sleep Medicine (BSM) program of Penn State Hershey Sleep Research & Treatment Center. Methods: Participants completed the Pre-sleep Arousal Scale assessing cognitive (PSAS-C) and somatic (PSAS-S) arousal as well as the Insomnia Severity Index (ISI), Ford Insomnia Response to Stress Test (FIRST), Arousal Predisposition Scale (APS), and Depression Anxiety Stress Scale (DASS). Multivariable stepwise regression assessed which clinical factors were independently associated with greater PSAS-C and PSAS-S scores. Receiver operating characteristic analysis determined the predictive value for identifying sleep reactivity (FIRST≥18) and clinical anxiety (DASS-A ≥ 10) and clinically useful cutoff scores. Results: The strongest correlates of PSAS-S were DASS-A (β = 0.64) and chronic pain (β = 0.11), while those of PSAS-C were FIRST (β = 0.29) and a history of stroke (β = 0.10). A PSAS-S score of 14.8 (AUC = 0.87, 95%CI = 0.83-0.91) and a PSAS-C score of 24.5 (AUC = 0.82, 95%CI = 0.76-0.88) showed the best balance in specificity and sensitivity to identify clinical anxiety and sleep reactivity, respectively. Conclusions: Self-reported pre-sleep somatic symptoms are a marker of comorbid anxiety and, potentially chronic pain, impacting nighttime sleep. The optimal cutoff scores of 14 and 20 proposed herein can help clinicians with case formulation, with tailoring BSM treatments and their targets.

Automated feature extraction from population wearable device data identified novel loci associated with sleep and circadian rhythms

Wearable devices have been increasingly used in research to provide continuous physical activity monitoring, but how to effectively extract features remains challenging for researchers. To analyze the generated actigraphy data in large-scale population studies, we developed computationally efficient methods to derive sleep and activity features through a Hidden Markov Model-based sleep/wake identification algorithm, and circadian rhythm features through a Penalized Multi-band Learning approach adapted from machine learning. Unsupervised feature extraction is useful when labeled data are unavailable, especially in large-scale population studies. We applied these two methods to the UK Biobank wearable device data and used the derived sleep and circadian features as phenotypes in genome-wide association studies. We identified 53 genetic loci with p<5×10-8 including genes known to be associated with sleep disorders and circadian rhythms as well as novel loci associated with Body Mass Index, mental diseases and neurological disorders, which suggest shared genetic factors of sleep and circadian rhythms with physical and mental health. Further cross-tissue enrichment analysis highlights the important role of the central nervous system and the shared genetic architecture with metabolism-related traits and the metabolic system. Our study demonstrates the effectiveness of our unsupervised methods for wearable device data when additional training data cannot be easily acquired, and our study further expands the application of wearable devices in population studies and genetic studies to provide novel biological insights.

Is single acupoint Sanyinjiao (SP 6) effective in managing insomnia? A systematic review of randomized controlled trials

Insomnia is a symptom of physical or mental disorder and refers to decreased sleep time and potentially low quality. There is evidence showing that acupuncture could enhance management of insomnia, and Sanyinjiao (SP 6) is one of the promising acupoints. This review aimed to evaluate the effectiveness of stimulating single acupoint SP 6 in managing insomnia. The study was registered under PROSPERO CRD42019140855. English and Chinese databases were searched for randomized controlled trials on single acupoint SP 6 stimulation in management of insomnia. Quality of methodology was assessed by two authors independently using the Cochrane Risk of Bias Tool, and reporting quality was assessed by the STRICTA checklist. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI), and secondary outcomes were improvement in clinical effect and sleep duration assessed by polysomnogram (PSG). The extracted data were pooled and meta-analyzed with RevMan 5.3 software. Four trials involving 288 participants were included in this review. The findings showed that SP 6 stimulation could improve sleep quality (MD -0.30, 95% CI [-0.52, -0.08]), lengthen deep sleep duration (MD 80.46, 95% CI [56.47, 104.45]), rapid eye movement (REM) duration (MD 91.53, 95% CI [68.41, 114.65]), and increase improvement in clinical effect. Quality of reporting and methodology was limited in all included trials. Some limited evidence showed that single acupoint stimulation of SP 6 could improve sleep quality, lengthen deep sleep and REM duration of patients with insomnia. However, the findings in this review should be interpreted with caution due to methodological limitations.

Onset of regular cannabis use and young adult insomnia: an analysis of shared genetic liability

STUDY OBJECTIVES

Estimate the genetic and environmental influences on the relationship between onset of regular cannabis use and young adult insomnia.

METHODS

In a population-based twin cohort of 1882 twins (56% female, mean age = 22.99, SD = 2.97) we explored the genetic/environmental etiology of the relationship between onset of regular cannabis use and insomnia-related outcomes via multivariate twin models.

RESULTS

Controlling for sex, current depression symptoms, and prior diagnosis of an anxiety or depression disorder, adult twins who reported early onset for regular cannabis use (age 17 or younger) were more likely to have insomnia (β = 0.07, p = 0.024) and insomnia with short sleep on weekdays (β = 0.08, p = 0.003) as young adults. We found significant genetic contributions for the onset of regular cannabis use (a2 = 76%, p < 0.001), insomnia (a2 = 44%, p < 0.001), and insomnia with short sleep on weekdays (a2 = 37%, p < 0.001). We found significant genetic correlations between onset of regular use and both insomnia (rA = 0.20, p = 0.047) and insomnia with short sleep on weekdays (rA = 0.25, p = 0.008) but no significant environmental associations between these traits.

CONCLUSIONS

We found common genetic liabilities for early onset of regular cannabis use and insomnia, implying pleiotropic influences of genes on both traits.

Objective sleep disturbance is associated with poor response to cognitive and behavioral treatments for insomnia in postmenopausal women

STUDY OBJECTIVES

To determine whether insomnia patients with objective sleep disturbance are less responsive to cognitive and behavioral treatments than those without objective sleep disturbance, characterize effects of insomnia therapy on objective sleep, and determine whether reductions in nocturnal cognitive arousal correspond to changes in objective sleep.

METHODS

Secondary analysis of a single-site, randomized controlled trial. 113 postmenopausal women (56.40 ± 5.34 years) with menopause-related insomnia disorder were randomized to three treatment conditions: cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy (SRT), or sleep education control. Primary outcomes were the Insomnia Severity Index (ISI) and polysomnography (PSG) sleep parameters and were collected at pretreatment, posttreatment, and six-month follow-up.

RESULTS

Patients with lower pretreatment PSG sleep efficiency had lower rates of insomnia remission after active treatment relative to those with higher sleep efficiency (37.8% vs 61.8%). Neither CBTI and SRT produced clinically meaningful effects on PSG sleep. Exploratory analyses revealed that reductions in nocturnal cognitive arousal were associated with decreases in PSG sleep latency, but not wake after sleep onset.

CONCLUSIONS

Our findings support an emerging literature suggesting that insomnia patients with objective sleep disturbance may have blunted response to insomnia therapy. Research is needed to enhance treatments to better improve insomnia in patients with objective sleep disturbance. A lack of observed CBTI and SRT effects on PSG sleep suggests that these therapies may be presently ill-designed to improve objective sleep. Nocturnal cognitive arousal may represent an entry point to improve objective sleep latency in insomnia. NAME: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov. Registration: NCT01933295.

A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women

OBJECTIVE

Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven care, a critical need exists to increase its accessibility. This RCT examined the efficacy internet-based digital CBTI in pregnant women with insomnia.

METHODS

Single-site RCT. A total of 91 pregnant women (29.03 ± 4.16 years) nearing/entering the third trimester who screened positive for clinical insomnia on the Insomnia Severity Index (ISI) were randomized to digital CBTI or digital sleep education control. The ISI, Pittsburgh Sleep Quality Index (PSQI), Edinburgh Postnatal Depression Scale (EPDS), and Pre-Sleep Arousal Scale's Cognitive factor (PSAS-C) served as study outcomes, which were collected before treatment and after treatment during pregnancy, then six weeks after childbirth.

RESULTS

From pre to posttreatment, CBTI patients reported reductions in ISI (-4.91 points, p < 0.001) and PSQI (-2.98 points, p < 0.001) and increases in nightly sleep duration by 32 min (p = 0.008). Sleep symptoms did not change during pregnancy in the control group. After childbirth, CBTI patients, relative to controls, slept longer by 40 min per night (p = 0.01) and reported better sleep maintenance. No pre or postnatal treatment effects on depression or cognitive arousal were observed.

CONCLUSIONS

Digital CBTI improves sleep quality and sleep duration during pregnancy and after childbirth. To better optimize outcomes, CBTI should be tailored to meet the changing needs of women as the progress through pregnancy and early parenting. NAME: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum Depression. URL: clinicaltrials.gov. Registration: NCT03596879.

Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment

OBJECTIVE

Sleep problems are transdiagnostic symptoms that confer significant risk for suicidal thoughts and behaviors (STBs) in adults. However, less is known about the sleep-STB association in adolescence-a developmental period when rates of STBs increase drastically, and sleep problems may be particularly pernicious. This article provides a systematic review of research on the sleep-STB association in youth, an overview of changes in sleep regulation during adolescence that may make sleep problems particularly detrimental for youth, and a discussion of the clinical implications of the sleep-STB association for hospitalized youth.

METHOD

The systematic review included all longitudinal studies in which sleep problems were examined as prospective predictors of STBs in adolescents (aged 10-24 years). The search was conducted on December 1, 2017 using PsychINFO, PubMed, and Web of Science databases.

RESULTS

Ten studies qualified for inclusion in this review. Of these, seven studies found at least one type of sleep problem significantly predicted a STB outcome.

CONCLUSIONS

Although findings are mixed, growing research suggests that sleep problems may be a unique risk factor for STBs in youth. Sleep problems may be particularly important intervention target because they are easily assessed across healthcare settings and are amenable to treatment.

Insomnia Patients With Subjective Short Total Sleep Time Have a Boosted Response to Cognitive Behavioral Therapy for Insomnia Despite Residual Symptoms

Background: Two distinct insomnia disorder (ID) phenotypes have been proposed, distinguished on the basis of an objective total sleep time less or more than 6 hr. In particular, it has been recently reported that patients with objective short sleep duration have a blunted response to cognitive behavioral therapy for insomnia (CBT-I). The aim of this study was to investigate the differences of CBT-I response in two groups of ID patients subdivided according to total sleep time. Methods: Two hundred forty-six ID patients were subdivided into two groups, depending on their reported total sleep time (TST) assessed by sleep diaries. Patients with a TST greater than 6 hr were classified as "normal sleepers" (NS), while those with a total sleep time less than 6 hr were classified as "short sleepers" (SS). Results: The delta between Insomnia Severity Index scores and sleep efficiency at the beginning as compared to the end of the treatment was significantly higher for SS in comparison to NS, even if they still exhibit more insomnia symptoms. No difference was found between groups in terms of remitters; however, more responders were observed in the SS group in comparison to the NS group. Conclusions: Our results demonstrate that ID patients with reported short total sleep time had a beneficial response to CBT-I of greater magnitude in comparison to NS. However, these patients may still experience the presence of residual insomnia symptoms after treatment.

Somatic symptoms are associated with Insomnia disorder but not Obstructive Sleep Apnoea or Hypersomnolence in traumatic brain injury

BACKGROUND

Previous studies examining insomnia in populations with traumatic brain injury (TBI) have not distinguished between transient insomnia symptoms and insomnia disorder and associations have been confounded by other highly prevalent sleep disorders post-TBI.

OBJECTIVE

To investigate the associations between affective symptoms and somatoform symptoms in patients with TBI and insomnia, sleep apnoea and hypersomnolence.

METHODS

Twenty-four participants from a multidisciplinary brain injury rehabilitation service with TBI were assessed for insomnia disorder, using Diagnostic and Statistical Manual Fifth Edition (DSM-5) criteria. Associations with affective and somatic symptoms were assessed, using the DASS-21 and PHQ-15 respectively. The same cohort was divided for Obstructive Sleep Apnoea (OSA) and hypersomnolence and analysed for the same outcomes. Associations were assessed using Pearson's correlation and a logistic binary regression model was developed to predict insomnia in patients with brain injury.

RESULTS

The insomnia disorder group (n = 11) had significantly higher rates somatoform symptoms (p < 0.05), compared to those without insomnia disorder (n = 13). These factors were not significantly associated with OSA or hypersomnolence. Pain was significantly associated with insomnia disorder.

CONCLUSIONS

Insomnia disorder, not OSA or hypersomnolence, may be related to the presence of somatoform symptoms in people with TBI. Addressing insomnia disorder may potentially improve recovery.

Sleep and cardiovascular disease: Emerging opportunities for psychology

Sleep disturbances and disorders have been implicated in cardiovascular morbidity and mortality. Converging evidence suggests that psychosocial factors that confer risk or resilience to cardiovascular disease (CVD) are also related to sleep. Profound differences in sleep among racial/ethnic minorities compared with non-Hispanic Whites in the United States suggest that sleep, and its interplay with psychosocial factors, may contribute to observed disparities in CVD and in health and functioning more broadly. Less understood is the extent to which sleep and psychosocial factors interact to influence the pathophysiology and clinical course of CVD. This article reviews observational and experimental evidence linking short sleep duration and insomnia, both modifiable sleep disturbances, to CVD, including key physiological mechanisms. Also reviewed is evidence of significant interrelationships among sleep, race/ethnicity, and psychosocial factors known to confer risk or resilience to CVD, including depression, psychological stress, and close interpersonal relationships. It is proposed that a transdisciplinary research framework that integrates knowledge, methods, and measures from the fields of psychology and sleep research may be used to catalyze advances in the prevention and treatment of CVD. Also discussed are promising new directions, expected challenges, and the importance of training in transdisciplinary science and research approaches. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Insomnia-related Memory Impairment in Individuals With Very Complex Chronic Pain

OBJECTIVE

To investigate the specific effect of insomnia on neuropsychological functioning in patients with very complex chronic pain.

BACKGROUND

Individuals with insomnia disorder or chronic pain often experience cognitive deficits, with both conditions appearing to correlate with impairments in neuropsychological functions. As insomnia often occurs comorbid with chronic pain, distinguishing the differential effects of these two syndromes on an individual's neuropsychological functioning can be challenging. Comorbid depressive symptoms in these individuals, which may also affect cognitive function, may further obscure the associations between chronic pain, insomnia, and the neuropsychological profile.

METHODS

The neuropsychological function of 22 individuals with very complex chronic pain was assessed using specialized tests examining aspects of memory and executive functioning. The severity of insomnia, depression, and anxiety was measured using questionnaires, and pain levels were assessed using a visual analog scale. Pain medications were transformed to the morphine-equivalent daily dose.

RESULTS

Insomnia severity was found to predict memory function, accounting for 32.4% of the variance: A 1 SD increase in insomnia severity decreased memory function by 0.57 SD. The negative correlation between insomnia and memory was significant even after controlling for pain level, morphine-equivalent daily dose, and comorbid levels of anxiety and depression.

CONCLUSIONS

Insomnia severity independently predicted memory function in patients with very complex chronic pain, even after controlling for other factors known to impair cognitive function. Insomnia may possibly explain some of the cognitive impairments related to chronic pain; thus, screening for, and treating, sleep disturbances may be a central aspect of chronic pain rehabilitation.