The natural history of insomnia: evaluating illness severity from acute to chronic insomnia; is the first the worst?

STUDY OBJECTIVES

The 3P and 4P models represent illness severity over the course of insomnia disorder. The 3P model suggests that illness severity is worst during acute onset. The 4P model suggests that illness severity crescendos with chronicity. The present analysis from an archival dataset assesses illness severity with new onset illness (i.e. from good sleep [GS] to acute insomnia [AI] to chronic insomnia [CI]). Illness severity is quantified in terms of total wake time (TWT).

METHODS

GSs (N = 934) were followed up to 1 year with digital sleep diaries, and classified as GS, AI, or CI. Data for CIs were anchored to the first of 14 days with insomnia so that day-to-day TWT was represented prior to and following AI onset. A similar graphic (+/-acute onset) was constructed for number of days per week with insomnia. GS data were temporally matched to CI data. Segmented linear mixed regression models were applied to examine the change in slopes in the AI-to-CI period compared to GS-to-AI period.

RESULTS

Twenty-three individuals transitioned to AI and then CI. Average TWT rose during the first 2 weeks of AI onset (b = 1.8, SE = 0.57, p = 0.001) and was then stable for 3 months (b = -0.02, SE = 0.04, p = 0.53). Average number of affected days was stable from AI to CI (b = 0.0005, SE = 0.002, p = 0.81). That is, while there was week-to-week variability in the number of days affected, no linear trend was evident.

CONCLUSIONS

In our sample of CIs, primarily with middle insomnia, the average severity and number of affected days were worst with the onset of AI (worst is first) and stable thereafter.

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.

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

OBJECTIVE/BACKGROUND

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

PATIENTS/METHODS

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

RESULTS

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

CONCLUSIONS

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

The Assessment of Post-COVID Fatigue and Its Relationship to the Severity and Duration of Acute COVID Illness

Emerging data suggests that COVID-19 is associated with fatigue well beyond the acute illness period. The present analysis aimed to: (1) characterize the prevalence and incidence of high fatigue at baseline and follow-up; (2) examine the impact of COVID-19 diagnosis on fatigue level following acute illness; and (3) examine the impact of acute COVID-19 symptom severity and duration on fatigue at follow-up. Subjects (n = 1417; 81.0% female; 83.3% White; X¯age = 43.6 years) completed the PROMIS-Fatigue during the initial wave of the pandemic at baseline (April-June 2020) and 9-month follow-up (January-March 2021). A generalized linear model (binomial distribution) was used to examine whether COVID-19 positivity, severity, and duration were associated with higher fatigue level at follow-up. Prevalence of high fatigue at baseline was 21.88% and 22.16% at follow-up, with 8.12% new cases at follow-up. Testing positive for COVID-19 was significantly associated with higher fatigue at follow-up. COVID-19 symptom duration and severity were significantly associated with increased fatigue at follow-up. COVID-19 symptom duration and severity during acute illness may precipitate longer-term fatigue, which could have implications for treatment planning and future research. Future studies should further evaluate the relationship between symptom severity, duration, and fatigue.

Elevated estradiol during a hormone simulated pseudopregnancy decreases sleep and increases hypothalamic activation in female Syrian hamsters

Sleep disruptions are a common occurrence during the peripartum period. While physical and environmental factors associated with pregnancy and newborn care account for some sleep disruptions, there is evidence that peripartum fluctuations in estrogens may independently impact sleep. However, the impact of these large fluctuations in estrogens on peripartum sleep is unclear because it is difficult to tease apart the effects of estrogens on sleep from effects associated with the growth and development of the fetus or parental care. We therefore used a hormone-simulated pseudopregnancy (HSP) in female Syrian hamsters to test the hypothesis that pregnancy-like increases in estradiol decrease sleep in the absence of other factors. Adult female Syrian hamsters were ovariectomized and given daily hormone injections that simulate estradiol levels during early pregnancy, late pregnancy, and the postpartum period. Home cage video recordings were captured at seven timepoints and videos were analyzed for actigraphy. During "late pregnancy," total sleep time and sleep efficiency were decreased in hormone-treated animals during the white light period compared to pretest levels. Likewise, during "late pregnancy," locomotion was increased in the white light period for hormone-treated animals compared to pretest levels. These changes continued into the "postpartum period" for animals who continued to receive estradiol treatment, but not for animals who were withdrawn from estradiol. At the conclusion of the experiment, animals were euthanized and cFos expression was quantified in the ventral lateral preoptic area (VLPO) and lateral hypothalamus (LH). Animals who continued to receive high levels of estradiol during the "postpartum" period had significantly more cFos in the VLPO and LH than animals who were withdrawn from hormones or vehicle controls. Together, these data suggest that increased levels of estradiol during pregnancy are associated with sleep suppression, which may be mediated by increased activation of hypothalamic nuclei.

On the relationship between EEG spectral analysis and pre-sleep cognitive arousal in insomnia disorder: towards an integrated model of cognitive and cortical arousal

According to the hyperarousal model, insomnia is characterised by increased arousal in the cortical, cognitive, and physiological domains. However, the interaction between these arousal domains is poorly understood. The present observational case-control study aimed to investigate cortical arousal during the night, pre-sleep cognitive arousal and the relationship between these two domains. A total of 109 patients with insomnia disorder (ID) and 109 age-and gender matched healthy controls were investigated on two sleep laboratory nights. Electroencephalographic (EEG) spectral power during non-rapid eye movement (NREM) and REM sleep was analysed as a measure of cortical arousal. In addition, patients completed the Pre-Sleep Arousal Scale (PSAS), which consists of two subscales, one for cognitive arousal (PSAS-CA) and one for self-reported somatic arousal (PSAS-SA). The relationship between the subscale scores and EEG spectral power was calculated by multi- and univariate analyses of variance. During NREM and REM sleep, patients with ID showed significantly increased spectral power in the EEG gamma band. In addition, patients with ID showed significantly increased scores on both subscales of the PSAS. The PSAS-CA score was significantly associated with increased NREM and REM gamma power, whereas PSAS-SA was associated with decreases in NREM and REM gamma power. Consistent with our hypothesis, patients with ID showed increased cortical and cognitive arousal. Moreover, there was an association between these two arousal domains, which may indicate that cortical arousal during the night is (at least in part) elicited by pre-sleep worry and rumination.

Sleep continuity, timing, quality, and disorder are associated with suicidal ideation and suicide attempts among college students

Objective: To evaluate sleep continuity, timing, quality, and disorder in relation to suicidal ideation and attempts among college students. Participants: Eight hundred eighty-five undergraduates aged 18-25 in the southwestern United States. Methods: Participants completed questionnaires on sleep, suicide risk, mental health, and substance use. Differences in sleep variables were compared by lifetime and recent suicidal ideation and suicide attempts using covariate-adjusted and stepwise regression models. Results: A total of 363 (41.0%) individuals reported lifetime suicidal ideation, of whom 172 (47.4%) reported suicidal ideation in the last 3 months and 97 (26.7%) had attempted suicide in their lifetime. Sleep disturbances were prevalent among those with lifetime suicidal ideation or a lifetime suicide attempt. Insomnia was identified as the best predictor of recent suicidal ideation, but this relationship did not survive adjustment for covariates. Conclusions: Sleep continuity, quality, and sleep disorders are broadly associated with suicidal thoughts and behaviors among college students.

Insomnia symptoms predict longer COVID-19 symptom duration

OBJECTIVE

/Background: The goal of the present study was to assess the prevalence and incidence of insomnia in the United States during the COVID-19 pandemic, and whether, among those that contracted COVID-19, insomnia predicted worse outcomes (e.g., symptoms of greater frequency, duration, or severity).

METHODS

A nationwide sample of 2980 adults living in the United States were surveyed online at two points during the COVID-19 pandemic (T1 = April-June 2020; T2 = January-March 2021). Insomnia symptoms were assessed at both time points using the Insomnia Severity Index (ISI). The T2 survey also asked questions regarding COVID-19 testing and symptoms.

RESULTS

The prevalence of insomnia (defined as ISI ≥15) was 15% at T1 and 13% at T2. The incidence rate of insomnia (i.e., new cases from T1 to T2) was 5.6%. Participants with insomnia were not more likely to contract COVID-19 relative to those participants without insomnia. Among those participants in our sample that contracted the virus during the study interval (n = 149), there were no significant group differences in COVID-19 symptom outcomes, with one exception, participants with insomnia were more likely to report a longer symptom duration (insomnia = 24.8 sick days, no insomnia = 16.1 sick days).

CONCLUSIONS

The present study suggests the prevalence of insomnia in the U.S. population remained high during the COVID-19 pandemic. The data also support that insomnia may be related to experiencing more chronic COVID-19 symptoms. These findings have more general implications for the role of sleep and insomnia on immune functioning.

Insomnia

Insomnia is highly prevalent in clinical practice, occurring in up to 50% of primary care patients. Insomnia can present independently or alongside other medical conditions or mental health disorders and is a risk factor for the development and exacerbation of these other disorders if not treated. In 2016, the American College of Physicians recommended that insomnia be specifically targeted for treatment. The recommended first-line treatment for insomnia, whether the underlying cause has been identified or not, is cognitive behavioural therapy for insomnia (CBT-I). Currently, there is no global consensus regarding which pharmacological treatment has the best efficacy or risk-benefit ratio. Both CBT-I and pharmacological intervention are thought to have similar acute effects, but only CBT-I has shown durable long-term effects after treatment discontinuation. Administering a combined treatment of CBT-I and medication could decrease the latency to treatment response, but might diminish the durability of the positive treatment effects of CBT-I.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

The natural history of insomnia: high sleep reactivity interacts with greater life stress to predict the onset of acute insomnia

STUDY OBJECTIVES

Prior research suggests that some individuals have a predisposition to experience insomnia following acute stressors (i.e. sleep reactivity). The present study was a proof of concept and specifically aimed to provide additional empirical evidence that the link between stressful life events and the onset of acute insomnia is moderated by sleep reactivity.

METHODS

About 1,225 adults with a history of good sleep (Mage = 53.2 years, 68% female, 83% white) were recruited nationwide for an online study on sleep health. Participants completed surveys to assess sleep reactivity (baseline), sleep patterns (daily sleep diary), and stressful life events (weekly survey). All daily and weekly measures were completed for a one-year period. Sleep diary data were used to identify sleep initiation/maintenance difficulties, including whether they met criteria for acute insomnia at any point during the one-year interval.

RESULTS

Participants with high sleep reactivity compared to low sleep reactivity were at 76% increased odds of developing acute insomnia during the one-year interval. In general, greater weekly stressful life events were associated with greater insomnia during the subsequent week. Those participants with high sleep reactivity demonstrated a stronger relationship between weekly stressful life events and insomnia, such that they reported the greatest levels of insomnia following weeks where they experienced a greater number of stressful life events.

CONCLUSIONS

These results further support the sleep reactivity model of insomnia, and specifically, provide evidence that sleep reactivity predicts the incidence of acute insomnia in a sample of participants with no history of insomnia.

Nocturnal Wakefulness and Suicide Risk in the Australian Population

Objective: Temporal patterns for suicide over a 24-hour period have shown mixed results among prior studies. However, analyses of 24-hour temporal patterns for wakeful actions including suicidal behavior should adjust for expected sleep requirements that inherently skew such activities to conventional wakeful times. This study analyzed the time-of-day for suicide cases from the Australian population for the year 2017, adjusting for expected sleep patterns. Identification of time-of-day trends using this methodology may reveal risk factors for suicide and potentially modifiable contributors. Methods: The Australian National Coronial Information System database was accessed, and data for completed suicide were extracted for the most recent completed year (2017). Time of suicide was allocated to one of four 6-hourly time bins across 24 hours, determined from time last seen alive and time found subsequently. Prevalence of suicide for each time bin was adjusted for the likelihood of being awake for each bin according to sleep-wake norms published from a large Australian community survey. Observed prevalence of suicide was compared to expected values predicted from likelihood of being awake across each time bin calculated as a standardized incidence ratio (SIR). Results: For the year 2017, there were 2,808 suicides, of which 1,417 were able to be allocated into one of four 6-hourly time bins. When compared to expected values, suicides were significantly more likely to occur in the overnight bin (2301-0500; SIR = 3.93, P < .001). Conclusions: Higher-than-expected rates of suicide overnight associated with nocturnal wakefulness may represent a modifiable risk factor for triggering suicide events.

Social Jetlag and Other Aspects of Sleep Are Linked to Non-Suicidal Self-Injury Among College Students

INTRODUCTION

Disrupted sleep is associated with non-suicidal self-injury (NSSI) in young adults, but many specific features of sleep continuity and timing have yet to be examined. Additionally, the psychological mechanisms linking sleep to NSSI are unclear. The present study evaluated 14 sleep variables as classifiers of lifetime or recent NSSI and examined potential confounding and mediating factors.

METHODS

A sample of 885 college students provided measures of sleep continuity (e.g., duration, timing, fragmentation), nightmares, insomnia, and perceived sleep control. Lifetime and past 3-month NSSI were measured using a self-report version of the Columbia Suicide Severity Ratings Scale. Bidirectional stepwise regression identified significant sleep classifiers and subsequent models examined their associations with NSSI after adjusting for covariates and through potential psychological mediators.

RESULTS

Only absolute social jetlag was associated with recent NSSI, even after adjusting for covariates, such that each additional hour difference between weekday and weekend sleep schedules was associated with a 17% greater risk of recent NSSI. Nightmares, weekend sleep efficiency, and perceived sleep control were associated with lifetime NSSI, although only weekend sleep efficiency remained associated after adjusting for covariates. Bootstrap mediations identified negative urgency as a partial mediator for recent and lifetime NSSI, and lack of premeditation and perceived burdensomeness as partial mediators for lifetime NSSI.

CONCLUSIONS

The timing and consistency of young adults' sleep schedules may be of greater importance to NSSI among college students than insomnia or insufficient sleep. Future studies of sleep and NSSI should include these measures as potential risk factors. HIGHLIGHTSDifferences between weekday/weekend sleep timing are linked to recent NSSI.Negative urgency partially mediates poor sleep on recent and lifetime NSSI.Sleep shares a multifaceted relationship with NSSI risk in college students.

The Mind After Midnight: Nocturnal Wakefulness, Behavioral Dysregulation, and Psychopathology

Sufficient sleep with minimal interruption during the circadian/biological night supports daytime cognition and emotional regulation. Conversely, disrupted sleep involving significant nocturnal wakefulness leads to cognitive and behavioral dysregulation. Most studies to-date have examined how fragmented or insufficient sleep affects next-day functioning, but recent work highlights changes in cognition and behavior that occur when someone is awake during the night. This review summarizes the evidence for day-night alterations in maladaptive behaviors, including suicide, violent crime, and substance use, and examines how mood, reward processing, and executive function differ during nocturnal wakefulness. Based on this evidence, we propose the Mind after Midnight hypothesis in which attentional biases, negative affect, altered reward processing, and prefrontal disinhibition interact to promote behavioral dysregulation and psychiatric disorders.

Pre-Sleep Cognitive Arousal Is Negatively Associated with Sleep Misperception in Healthy Sleepers during Habitual Environmental Noise Exposure: An Actigraphy Study

Specific noises (e.g., traffic or wind turbines) can disrupt sleep and potentially cause a mismatch between subjective sleep and objective sleep (i.e., “sleep misperception”). Some individuals are likely to be more vulnerable than others to noise-related sleep disturbances, potentially as a result of increased pre-sleep cognitive arousal. The aim of the present study was to examine the relationships between pre-sleep cognitive arousal and sleep misperception. Sixteen healthy sleepers participated in this naturalistic, observational study. Three nights of sleep were measured using actigraphy, and each 15-s epoch was classified as sleep or wake. Bedside noise was recorded, and each 15-s segment was classified as containing noise or no noise and matched to actigraphy. Participants completed measures of habitual pre-sleep cognitive and somatic arousal and noise sensitivity. Pre-sleep cognitive and somatic arousal levels were negatively associated with subjective−objective total sleep time discrepancy (p < 0.01). There was an association between sleep/wake and noise presence/absence in the first and last 90 min of sleep (p < 0.001). These results indicate that higher levels of habitual pre-sleep arousal are associated with a greater degree of sleep misperception, and even in healthy sleepers, objective sleep is vulnerable to habitual bedside noise.

We know CBT-I works, now what?

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be efficacious and now is considered the first-line treatment for insomnia for both uncomplicated insomnia and insomnia that occurs comorbidly with other chronic disorders (comorbid insomnia). The purposes of this review are to provide a comprehensive summary of the efficacy data (for example, efficacy overall and by clinical and demographic considerations and by CBT-I formulation) and to discuss the future of CBT-I (for example, what next steps should be taken in terms of research, dissemination, implementation, and practice).

Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a multi-component treatment for insomnia that targets difficulties with initiating and/or maintaining sleep and is delivered over the course of six to eight sessions. The primary focus of CBT-I is to address the perpetuating factors (according to the three-factor model of insomnia) that contribute to the development of chronic insomnia. Chronic insomnia is the most prevalent sleep disorder, occurring in approximately 6-10% of the population, and is a risk factor for multiple medical and psychiatric disorders. Despite its prevalence and morbidity, the widespread dissemination of CBT-I is not commensurate with insomnia's overall public health impact. This is particularly surprising given its large evidence base and recent recommendation as the first line intervention for insomnia. The primary goal of this article is to provide a primer or brief introduction to CBT-I that is intended to be accessible to all clinicians and researchers, including non-sleep experts. Core components of CBT-I (i.e., Sleep Restriction Therapy, Stimulus Control Therapy, Sleep Hygiene, and Cognitive Therapy), relapse prevention strategies, multicultural considerations, adjuvants to traditional interventions, treatment adherence issues, efficacy, and further training options are described. A session-by-session outline is also provided.

Insomnia Severity and Degree of Dysfunction: What Is to Be Learned When These Domains are Discordant?

OBJECTIVE/BACKGROUND

Illness severity and resultant dysfunction are often linearly related and tightly coupled (concordant). Some percentage of individuals, however, exhibit discordant associations (high illness severity and low dysfunction [HL] or low illness severity and high dysfunction [LH]). In the present study, a sample of subjects with insomnia complaints were evaluated to determine what percentage of subjects exhibited discordant associations.

PARTICIPANTS

Archival data were drawn from a community-based sample (n = 4,680; 61.8% female; Ages 18-105).

METHODS

Median splits were calculated for illness severity and daytime dysfunction and each individual was typed as High (H) or Low (L) for the concordant (HH and LL) and discordant domains (HL and LH).

RESULTS

Given this typology, 61% were classified as concordant and 39% were classified as discordant. Of these, 38% were sub-typed as HH, 23% as LL, 26% as LH, and 13% as HL.

CONCLUSIONS

We propose that some of the discordance may be ascribable to a mismatch between sleep need and sleep ability. Those "who need a lot, may suffer a lot, in the face of only a little (LH)", whereas those "who need a little, may suffer only a little, in the face of a lot (HL)".

Durability of treatment response to zolpidem using a partial reinforcement regimen: does this strategy require priming?

BACKGROUND

Previous research has shown that after one month of full dose nightly treatment with zolpidem (priming), subjects with chronic insomnia (CI) switched to intermittent dosing with medication and placebos were able to maintain their treatment responses. This approach to maintenance therapy is referred to as partial reinforcement. The present study sought to assess whether priming is required for partial reinforcement or whether intermittent dosing with placebos (50% placebos and 50% active medication) can, by itself, be used for both acute and extended treatment.

METHOD

55 CI subjects underwent a baseline evaluation (Phase-1) and then were randomized to one of two conditions in Phase-2 of the study: one month of (1) nightly medication use with standard-dose zolpidem (QHS [n = 39]) or (2) intermittent dosing with standard-dose zolpidem and placebos (IDwP [n = 16]). In Phase-3 (three months), the QHS group was re-randomized to either continued QHS full dose treatment (FD/FD) or to IDwP dose treatment (FD/VD). Treatment response rates and Total Wake Time (TWT = [SL + WASO + EMA]) were assessed during each phase of the study.

RESULTS

In Phase-2, 77% (QHS) and 50% (IDwP) subjects exhibited treatment responses (p = 0.09) where the average change in TWT was similar. In Phase-3, 73% (FD/FD), 57% (FD/VD), and 88% (VD/VD) of subjects exhibited continued treatment responses (p = 0.22) where the average improvement in TWT continued with FD/FD and remained stable for FD/VD and VD/VD (p < 0.01).

CONCLUSION

These results suggest that intermittent dosing with placebos can maintain effects but do not allow for the additional clinical gains afforded by continuous treatment.

Measuring the Effects of Social Isolation and Dissatisfaction on Depressive Symptoms during the COVID-19 Pandemic: The Moderating Role of Sleep and Physical Activity

Social distancing was universally implemented to reduce the spread of the COVID-19 virus. Long-term social distancing can lead to increased feelings of social isolation or dissatisfaction with one's daily interpersonal interactions, which can subsequently result in reduced psychological health (e.g., greater depression). The present study quantified this association, and the extent to which it was moderated by measures of sleep and physical activity, by surveying 3658 adults (mean age = 46.0 years) from across the United States. Participants answered questions related to their social experiences, sleep, physical activity, and depressive symptoms during the early stages of the pandemic (March-June 2020). Results showed that social isolation and social dissatisfaction were associated with greater depressive symptoms. As predicted, self-reported sleep quality and physical activity moderated these associations, such that lower sleep quality and physical activity exacerbated their effect on depressive symptoms.

Nocturnal and Morning Wakefulness Are Differentially Associated With Suicidal Ideation in a Nationally Representative Sample

Objective: Prior studies indicate nocturnal wakefulness is associated with suicide, while morning wakefulness is linked to reduced suicidal ideation. These relationships, however, may be confounded by sociodemographic factors. Therefore, this study investigated whether timing of wakefulness was associated with suicidal ideation in a nationally representative sample.

Methods: Data were collected from the US National Health and Nutrition Examination Survey for the years 2015 to 2018, resulting in a final sample of 10,166 participants (51.1% female) with complete data available on suicidal ideation status, time to bed, and time out of bed. Population-weighted logistic regression models estimated the associations between time spent out of bed (ie, being awake) and suicidal ideation.

Results: A total of 385 survey participants (47.5% female) reported suicidal ideation in the past 2 weeks for a population-weighted prevalence of 3.37% (95% CI, 2.85%-3.87%). Wakefulness between 11:00 pm and 5:00 am was associated with suicidal ideation (OR = 1.16; 95% CI, 1.08-1.24 per hour), even after adjustment for sociodemographic factors and symptoms of sleep disorders, but not after adjustment for the severity of depression symptoms. Conversely, wakefulness between 5:00 am and 11:00 am was associated with reduced odds of suicidal ideation (OR = 0.77; 95% CI, 0.70-0.85 per hour) in all models.

Conclusions: Individuals who spent more time awake at night were more likely to have recent suicidal ideation, while the opposite was true for those with more time spent awake in the morning. Moreover, these associations were independent of sociodemographic factors and thus not confounded by varying rates of suicidal ideation in different populations.

Self-reported poor quality of sleep in solid organ transplant: A systematic review

BACKGROUND

High quality sleep of sufficient duration is vital to overall health and wellbeing. Self-reported poor quality of sleep, sleep reported as irregular in timing, marked by frequent awakenings, or shortened in duration, is common across the solid-organ transplant trajectory.

AIM

This Systematic Review aimed to summarize available literature on rates of self-reported poor quality of sleep among solid organ transplant candidates and recipients.

METHODS

A systematic search of published literature was conducted in PubMed/MEDLINE, Embase, Web of Science, CINHAL, and PsychInfo databases with no date restrictions. Original articles in the English language describing self-reported quality of sleep using standardized questionnaires in adults either waitlisted for, or who received a solid organ transplant (heart, lung, kidney, liver, pancreas, or multi-solid organ) were included.

RESULTS

Of a potential 2054 articles identified, 44 were included (63.6% renal transplant, 20.5% liver transplant, 11.4% lung transplant, and 4.5% included multiple organ transplant populations), with the majority (68.2%) focusing only on post-transplant populations. No included articles focused solely on heart or pancreas transplant populations. On average, the transplant population with the greatest improvement in quality of sleep (reported as poor sleep quality, insomnia, sleep disturbance, or sleep dissatisfaction) from transplant candidacy to post-transplantation were renal transplant (from 53.5% pre, to 38.9% post) followed by liver transplant patients (from 52.8% pre, to 46.3% post), while lung transplant patients remained similar pre- to post-transplantation (55.6% pre, to 52% post). Poor quality of sleep was frequently associated with anxiety and depression, poorer quality of life, restless legs syndrome, and higher comorbidity.

CONCLUSIONS

Reports of poor quality of sleep are highly prevalent across all solid-organ transplant populations, both pre- and post-transplantation. Future studies should assess quality of sleep longitudinally throughout all phases of the transplantation trajectory, with more research focusing on how to optimize sleep in solid organ transplant populations.

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

While there is an extensive literature on predisposing, precipitating, coping, and perpetuating factors in those with chronic insomnia, very little work has been undertaken to evaluate these factors over the early developmental course of insomnia. The present aim was to determine whether several hypothesized factors in each domain (predisposing, precipitating, coping, and perpetuating), assessed during an episode of acute insomnia (AI), are related to its persistence or remission to normal sleep. Participants comprised n = 140 people with AI and n = 737 normal sleepers (NS) recruited from the general public. Participants completed measures assessing predisposing characteristics (personality traits, arousal predisposition, and insomnia vulnerability), precipitating events and outcomes (life events, perceived stress, anxiety, and depression), coping styles (thought control strategies and coping styles), and perpetuating factors (sleep preoccupation, pre-sleep arousal, dysfunctional beliefs, and fatigue). Additionally, insomnia status (from AI at baseline to its persistence or natural remission [NR]) was assessed 1 month later (n = 129). Baseline differences between NS and individuals with AI were observed in each domain with increasing age, lower openness to experience and conscientiousness, higher insomnia severity, levels of anxiety, and affective sleep preoccupation significantly predicting AI status. Further, a previous episode of insomnia, higher depression scores, and affective sleep preoccupation scores significantly predicted its persistence, as opposed to its NR. Results are discussed with reference to the conceptualization of insomnia and how the findings may influence the design of preventative interventions to circumvent the transition from acute to chronic insomnia.

When reason sleeps: attempted suicide during the circadian night

None

Disrupted sleep and nocturnal wakefulness are evidence-based risk factors for suicidal thoughts and behaviors. We present a suicide attempt following a rapid increase in nocturnal wakefulness. This case illustrates how nocturnal wakefulness may drive suicide risk through circadian misalignment.

Suicidal ideation is associated with nighttime wakefulness in a community sample

STUDY OBJECTIVES

Nocturnal wakefulness is a risk factor for suicide and suicidal ideation in clinical populations. However, these results have not been demonstrated in general community samples or compared to sleep duration or sleep quality. The present study explored how the timing of wakefulness was associated with suicidal ideation for weekdays and weekends.

METHODS

Data were collected from 888 adults aged 22-60 as part of the Sleep and Healthy Activity, Diet, Environment, and Socialization study. Suicidal ideation was measured by the Patient Health Questionnaire-9, while timing of wakefulness was estimated from the Sleep Timing Questionnaire. Binomial logistic regressions estimated the association between nocturnal (11 pm-5 am) and morning (5 am-11 am) wakefulness and suicidal ideation.

RESULTS

Nocturnal wakefulness was positively associated with suicidal ideation on weekdays (OR: 1.44 [1.28-1.64] per hour awake between 11:00 pm and 05:00 am, p < 0.0001) and weekends (OR: 1.22 [1.08-1.39], p = 0.0018). Morning wakefulness was negatively associated with suicidal ideation on weekdays (OR: 0.82 [0.72-0.92] per hour awake between 05:00 am and 11:00 am, p = 0.0008) and weekends (OR: 0.84 [0.75-0.94], p = 0.0035). These associations remained significant when adjusting for sociodemographic factors. Additionally, nocturnal wakefulness on weekdays was associated with suicidal ideation when accounting for insomnia, sleep duration, sleep quality, and chronotype (OR 1.25 [1.09-1.44] per hour awake, p = 0.002).

CONCLUSION

Wakefulness at night was consistently associated with suicidal ideation. Additionally, morning wakefulness was negatively associated with suicidal ideation in some models. Although these findings are drawn from a non-clinical sample, larger longitudinal studies in the general population are needed to confirm these results.

The natural history of insomnia: Does sleep extension differentiate between those that do and do not develop chronic insomnia?

According to the "3P model" of insomnia, the variable that mediates the transition from acute insomnia (AI) to chronic insomnia is "sleep extension" (the behavioural tendency to expand sleep opportunity to compensate for sleep loss). In the present analysis, we sought to evaluate how time in bed (TIB) varies relative to the new onset of AI and chronic insomnia. A total of 1,248 subjects were recruited as good sleepers (GS). Subjects were monitored over 1 year with sleep diaries. State transitions were defined, a priori, for AI, recovered from AI (AI-REC), and for chronic insomnia (AI-CI). Two additional groupings were added based on profiles that were unanticipated: subjects that exhibited persistent poor sleep following AI (AI-PPS [those that neither recovered or developed chronic insomnia]) and subjects that recovered from chronic insomnia (CI-REC). All the groups (GS, AI-REC, AI-CI, AI-PPS and CI-REC) were evaluated for TIB differences with longitudinal mixed effects models. Post hoc analyses for the percentage of the groups that were typed as TIB "restrictors, maintainers, and expanders" were conducted using longitudinal mixed effects models and contingency analyses. Significant differences for pre-post AI TIB were not detected for the insomnia groups. Trends were apparent for the AI-CI group, which suggested that minor increases in TIB occurred weeks before the declared onset of AI. Additionally, it was found that a significantly larger percentage of AI-CI subjects engaged in sleep extension (as compared to GS). The present data suggest that transition from AI to chronic insomnia does not appear to be initiated by sleep extension and the transition may occur before the elapse of 3 months of ≥3 nights of sleep continuity disturbance. Given these findings, it may be that the mismatch between sleep ability and sleep opportunity is perpetuated over time given the failure to "naturally" engage in sleep restriction (as opposed to sleep extension).

A Drosophila model of sleep restriction therapy for insomnia

Insomnia is the most common sleep disorder among adults, especially affecting individuals of advanced age or with neurodegenerative disease. Insomnia is also a common comorbidity across psychiatric disorders. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia; a key component of this intervention is restriction of sleep opportunity, which optimizes matching of sleep ability and opportunity, leading to enhanced sleep drive. Despite the well-documented efficacy of CBT-I, little is known regarding how CBT-I works at a cellular and molecular level to improve sleep, due in large part to an absence of experimentally-tractable animals models of this intervention. Here, guided by human behavioral sleep therapies, we developed a Drosophila model for sleep restriction therapy (SRT) of insomnia. We demonstrate that restriction of sleep opportunity through manipulation of environmental cues improves sleep efficiency in multiple short-sleeping Drosophila mutants. The response to sleep opportunity restriction requires ongoing environmental inputs, but is independent of the molecular circadian clock. We apply this sleep opportunity restriction paradigm to aging and Alzheimer's disease fly models, and find that sleep impairments in these models are reversible with sleep restriction, with associated improvement in reproductive fitness and extended lifespan. This work establishes a model to investigate the neurobiological basis of CBT-I, and provides a platform that can be exploited toward novel treatment targets for insomnia.

Association Between Pretreatment Sleep Disturbance and Radiation Therapy-Induced Pain in 573 Women With Breast Cancer

CONTEXT

Pain can be a debilitating side effect of radiation therapy (RT). Data from the general population have shown that sleep disturbance can influence pain incidence and severity; however, less is known about this relationship in patients with breast cancer receiving RT.

OBJECTIVES

This secondary analysis examined the association of pretreatment moderate/severe levels of sleep disturbance with subsequent RT-induced pain after adjusting for pre-RT pain.

METHODS

We report on 573 female patients with breast cancer undergoing RT from a previously completed Phase II clinical trial for radiation dermatitis. Sleep disturbance, total pain, and pain subdomains-sensory pain, affective pain, and perceived pain intensity were assessed at pre-RT and post-RT. At pre-RT, patients were dichotomized into two groups: those with moderate/severe sleep disturbance (N = 85) vs. those with no/mild sleep disturbance (control; N = 488).

RESULTS

At pre-RT, women with moderate/severe sleep disturbance were younger, less likely to be married, more likely to have had mastectomy and chemotherapy, and more likely to have depression/anxiety disorder and fatigue than the control group (all Ps < 0.05). Generalized estimating equations model, after controlling for pre-RT pain and other covariates (e.g., trial treatment condition and covariates that were significantly correlated with post-RT pain), showed that women with moderate/severe sleep disturbance at pre-RT vs. control group had significantly higher mean post-RT total pain as well as sensory, affective, and perceived pain (effect size = 0.62, 0.60, 0.69, and 0.52, respectively; all Ps < 0.05).

CONCLUSION

These findings suggest that moderate/severe disturbed sleep before RT is associated with increased pain from pre-to-post-RT in patients with breast cancer.

Why Treat Insomnia?

"Why treat insomnia?" This question grows out of the perspective that insomnia is a symptom that should only receive targeted treatment when temporary relief is needed or until more comprehensive gains may be achieved with therapy for the parent or precipitating medical or psychiatric disorders. This perspective, however, is untenable given recent data regarding the prevalence, course, consequences, and costs of insomnia. Further, the emerging data that the treatment of insomnia may promote better medical and mental health (alone or in combination with other therapies) strongly suggests that the question is no longer "why treat insomnia," but rather "when isn't insomnia treatment indicated?" This perspective was recently catalyzed with the American College of Physicians' recommendation that chronic insomnia should be treated and that the first line treatment should be cognitive-behavioral therapy for insomnia (CBT-I).

Insomnia Symptoms and Suicide-Related Ideation in U.S. Army Service Members

Background: Insomnia has been identified as a key risk factor for suicide, though most studies have been limited to global measures of these constructs. The aim of the present study was to evaluate the link between insomnia symptoms and five different aspects of suicide-related ideation. Participants: 1,160 active U.S. Army service members (719 male; M_age = 31.2; SD_age = 8.62). Methods: As part of an archival analysis, retrospectively assessed insomnia, depression, anxiety symptoms, as well as suicide-related ideation, were evaluated. Suicide-related ideation was assessed in terms of: thoughts of death, thoughts of suicide, suicidal plan, suicidal intent, and suicidal communication. Results: Subjects with clinically significant insomnia symptoms were 3.5 times more likely to report any suicide-related ideation, and approximately 3 times more likely to report thoughts of death and thoughts of suicide. More frequent nocturnal awakenings (i.e., waking up three or more times during a single night) were associated with a greater likelihood of reporting thoughts of death or suicide, whereas greater middle insomnia (i.e., waking up and having difficulty getting back to sleep) was associated with lower odds of experiencing thoughts of suicide, suicidal plan, and suicidal intent. Conclusions: A more refined delineation of insomnia and suicide-related ideation may serve to clarify the nature of the association, and potentially offer some clues as to the underlying mechanisms. With regard to potential clinical implications, the results support that careful assessment of insomnia symptoms, suicide-related ideation, and their respective subtypes, is important and may influence how we estimate risk for suicide.

Onset insomnia and insufficient sleep duration are associated with suicide ideation in university students and athletes

BACKGROUND

Previous work has shown that poor sleep is a prospective risk factor for suicide in clinical populations and might contribute to risk in the general population. The present study evaluated whether sleep distress, onset insomnia, and insufficient sleep are associated with suicide ideation in university students and athletes participating in the 2011-2014 National College Health Assessment (NCHA; n = 113,185).

METHODS

In the NCHA survey, students self-reported the presence or absence of suicide ideation within the past 12 months. SLEEP DISTRESS was assessed with an item indicating that "sleep difficulties" were "particularly traumatic or difficult to handle." ONSET INSOMNIA was assessed as at least 3 nights per week where survey participants reported an "extremely hard time falling asleep." INSUFFICIENT SLEEP was operationalized as the number of days per week where the participants felt they did not get "enough sleep to feel rested." All variables were yes/no except INSUFFICIENT SLEEP, which was categorized as 0-1 (reference), 2-3, 4-5, or 6-7 nights. Binary logistic regression analyses examined suicide ideation as the outcome and sleep variable as a predictor, adjusted for age, sex, year in school, recent depressed mood, and survey year. Associations within student-athletes were likewise assessed.

RESULTS

7.4% of students reported suicide ideation within the past 12 months. In adjusted models, this was significantly associated with SLEEP DISTRESS (OR = 3.01, 95% CI [2.86, 3.16], p < 0.0001), ONSET INSOMNIA (OR = 1.95, 95% CI [1.86, 2.04], p < 0.0001), as well as INSUFFICIENT SLEEP (4-5 nights, OR = 1.41, 95% CI [1.28, 1.56], p < 0.0001; 6-7 nights, OR = 1.92, 95% CI [1.74, 2.13], p < 0.0001). Although suicide ideation was less common among athletes, ORs were similar for athletes for all sleep variables of interest.

CONCLUSION

Sleep distress, onset insomnia, and insufficient sleep were all strongly related to suicide ideation among university students. These relationships were the same among collegiate athletes, even though this group reported less overall suicide ideation. Our findings suggest that university students may benefit from educational materials linking sleep disruption to maladaptive thinking and suicide ideation.

The Natural History of Insomnia: the incidence of acute insomnia and subsequent progression to chronic insomnia or recovery in good sleeper subjects

STUDY OBJECTIVES

The primary aim of the present study was to estimate the incidence per annum of acute insomnia and to what extent those that develop acute insomnia recover good sleep or develop chronic insomnia. Unlike prior studies, a dense-sampling approach was used here (i.e. daily diaries) and this allowed for a more precise detection of acute insomnia and the follow-on states (the transitions to either recovery or chronic insomnia).

METHODS

Good sleeper subjects (n = 1,248; 67% female) that were at least 35 years old participated in this prospective study on the natural history of insomnia. Subjects were recruited nationwide and completed online assessments for 1 year. The online measures consisted primarily of daily sleep diaries, as well as weekly/bi-weekly and monthly measures of sleep, stress, and psychological and physical health.

RESULTS

The 1-year incidence rate of acute insomnia was 27.0% (n = 337). The incidence rate of chronic insomnia was 1.8% (n = 23). Of those that developed acute insomnia, 72.4% (n = 244) went on to recover good sleep. 19.3% (n = 65) of the acute insomnia sample continued to experience persistent poor sleep, but did not meet criteria for chronic insomnia.

CONCLUSIONS

The incidence rate of acute insomnia (3 or more nights a week for between 2 and 12 weeks) is remarkably high. This said, most incident cases resolve within a few days to weeks. Incident chronic insomnia only occurs in about 2 in 100 individuals.

0120 Association Between Sleep Duration and Daytime Memory and Cognition Depends on Sleep Quality: Data from the 2017 Israel Social Survey

Introduction

This study examines the relationship between sleep duration, sleep disturbance, and cognitive problems in a representative sample of the Israeli population.

Methods

7,230 Israelis responded to an Israeli Bureau of Statistics population-based survey of households from the year 2017. All variables were self-reported. Outcome of interest was difficulty with memory/concentration (none, mild, or severe). Predictors included previous month sleep duration (&lt;=5hrs, 6hrs, 7hrs [reference], 8hrs, or &gt;=9hrs) and sleep disturbance (none [reference], mild [1/week], moderate [2–3/week], or severe [&gt;3/week]). Covariates included age, sex, ethnic group, and financial status. Multinomial logistic regressions evaluated the relationships between variables, and post-hoc testing identified relationships within specific subgroups.

Results

72.9% denied cognitive problems, 22.2% reported mild problems, and 4.9% severe problems. In adjusted analyses, Sleep &lt;=5hrs and &gt;=9hrs were associated with mild (RRR=1.39, p&lt;0.0005), (RRR=1.46, p=0.004) and severe (RRR=2.75, p&lt;0.0005), (RRR=3.24, p&lt;0.0005) cognitive problems, respectively. Mild, moderate, and severe sleep difficulties were associated with mild cognitive problems (RRR=2.09, p&lt;0.0005), (RRR=2.22, p&lt;0.0005), (RRR=2.44, p&lt;0.0005), and severe cognitive problems (RRR=1.77, p=0.001), (RRR=3.04, p&lt;0.0005), (RRR=4.22, p&lt;0.0005), respectively. There was an interaction between sleep duration and sleep difficulties (p&lt;0.05). Among those denying sleep difficulties, only &gt;=9hrs of sleep was associated with cognitive problems. Among those with mild, moderate, and severe sleep difficulties, both short and long sleep were associated with cognitive problems.

Conclusion

In an Israeli population sample, both sleep duration and quality were associated with cognitive problems. Among those with sleep difficulties, short and long sleep duration were associated with cognitive problems, but among those denying sleep difficulties, only long sleep was associated with cognitive problems. These results suggest that the impact of sleep loss on real-world cognition may also rely on the presence of poor sleep quality.

Support

Dr. Grandner is supported by R01MD011600

1096 Morning Wakefulness is Associated with Reduced Suicidal Ideation in a Nationally-Representative US Sample

Introduction

Nocturnal wakefulness is a unique risk factor for suicidal ideation in clinical as well as community samples. Preliminary data suggest that morning wakefulness may also be a protective factor against such thinking. However, these associations have not been explored in a nationally-representative dataset.

Methods

Data were collected from the 2015-2016 wave of the National Health and Nutrition Examination Survey. Participants reported typical bedtimes and waketimes. From these values, wakefulness during the night (00:00 to 05:59), morning (06:00 to 11:59), afternoon (12:00 to 17:59), and evening (18:00 to 23:59) was determined. Suicidal ideation was assessed by a question about “thoughts that you would be better off dead, or thoughts of hurting yourself in some way.” Ordinal logistic regression estimated the association between the number of hours awake at particular times of day and the frequency of suicidal ideation. Additional analyses adjusted for demographic factors and depressed mood.

Results

Out of 5133 respondents with available data, 125 reported suicidal ideation several days a week, 36 reported suicidal ideation more than half the days, and 29 reported suicidal ideation nearly every day. When controlling for demographics, morning wakefulness was associated with reduced frequency of suicidal ideation (OR: 0.69, 95% CI: [0.59,0.8]). Controlling for depressed mood attenuated, but did not eliminate, this association. Nocturnal wakefulness was not associated with suicidal ideation in this sample.

Conclusion

Using data from a nationally representative sample, morning wakefulness was associated with less frequent suicidal ideation. However, previous findings regarding nocturnal wakefulness were not replicated. The limited number of individuals in the sample endorsing both suicidal ideation and nighttime wakefulness may have insufficient power to detect an association.

Support

Dr. Grandner is supported by R01MD011600.

0152 Insomnia Severity and Daytime Complaints: What is to be Learned When These Domains are Discordant?

Introduction

If illness severity and daytime dysfunction are construed as categorical entities, it is possible to conceptualize the relationship between these variables in terms of a 2x2 matrix where the resultant cells represent a concordant dimension (quadrants 2 & 4 [high-high and low-low]) and a discordant dimension (quadrants 1 & 3 [high-low and low-high]). The question for the present analysis was, what percentage of subjects populate each quadrant and is it the case that the discordant dimension contains only a small percentage of subjects?

Methods

Illness severity and daytime dysfunction data was collected from individuals with sleep continuity complaints in archival/community-based sample (N = 4680; 60% female; Ages 18–89) (www.sleeplessinphilly.com). Illness severity was operationalized as Total Wake Time (TWT; [SL+WASO+EMA=TWT]) and daytime dysfunction was operationalized as the composite score of six daytime symptoms items. Median splits were calculated for each variable and subjects were typed accordingly (HH, LL, HL, & LH).

Results

Surprisingly, the sample was relatively equally distributed into the two dimensions; 38% and 23% for the concordant dimension and 13% and 26% for discordant dimension.

Conclusion

The 39% of subjects in the discordant groups might be thought of as complaining good sleepers (LH) and noncomplaining poor sleepers (HL). Other investigators have identified the LH subjects as individuals with “insomnia identity”. Alternatively, it is possible to characterize the whole dimension as being related to a mismatch between the individual’s sleep need and sleep ability. Those who need a lot, may suffer a lot, in the face of only a little (LH) whereas those who need a little, may suffer only a little, in the face of a lot (HL).

Support

 

1108 Associations Between Insomnia And Anxiety Symptoms: Which Elements Of Insomnia Are Associated With Which Elements Of Anxiety?

Introduction

It is still not clear which aspects of insomnia are associated with various aspects of anxiety problems. Knowing this could better guide treatment of insomnia comorbid with anxiety.

Methods

Data from the Sleep and Healthy Activity, Diet, Environment, and Socialization (SHADES) study were used, including N=1003 adults age 22-60. All participants completed the Insomnia Severity Index (ISI) and the GAD7 anxiety questionnaire. The ISI was divided into 3 sections, based on prior work: SLEEP symptoms (difficulty sleeping), DAYTIME symptoms (difficulty functioning), and PERCEPTION symptoms (dissatisfaction). GAD7 items included anxiety level, loss of control, worry about many things, difficulty relaxing, restlessness, irritability, and fear. Logistic regression analyses examined each symptom, with each component of the ISI as predictor, as well as age, sex, race/ethnicity and education as covariates.

Results

SLEEP symptoms were independently associated with control (OR=1.09, p=0.03), many worries (OR=1.1, p=0.017), restlessness (OR=1.1, p=0.009), and irritability (OR=1.1, p=0.04). DAYTIME symptoms were independently associated with anxiety level (OR=1.3, p&lt;0.0005), control (OR=1.2, p&lt;0.0005), many worries (OR=1.3, p&lt;0.0005), difficulty relaxing (OR=1.2, p=0.004), restlessness (OR=1.3, p=0.001), and irritability (OR=1.2, p&lt;0.0005). PERCEPTION symptoms were uniquely, independently associated with anxiety level (OR=1.1, p=0.03), control (OR=1.2, p=0.001), many worries (OR=1.2, p=0.001), difficulty relaxing (OR=1.4, p&lt;0.0005), irritability (OR=1.2, p=0.018), and feelings of fear (OR=1.2, p=0.002).

Conclusion

The DAYTIME and PERCEPTION symptoms of insomnia were strongly related to anxiety symptoms. Current treatments for insomnia focus mainly on improving sleep. Future research should test the hypothesis that treating daytime symptoms of insomnia may aid patients with comorbid anxiety.

Support

The SHADES study was funded by R21ES022931. Dr. Grandner is supported by R01MD011600.

0404 Jewish-Arab Disparities in Sleep Behaviors and Differential Ethnic Impact on Daytime Functioning, Driving Safety, and Health in Israel

Introduction

In Israel, those with Arabic as compared to Jewish ethnicity, exhibit poorer health and motor vehicle safety behaviors. Their ethnic differences in sleep duration and quality may modulate their vulnerabilities to these behaviors.

Methods

7,230 Israeli individuals (N=5,880 Jewish and N=1350 Arabic) responded to the 2017 Israeli Bureau of Statistics population-based survey of households. Variables were self-reported. Outcomes included sleepiness, sleep medications, functional impairment, drowsy driving, overall health, 1-year health change, and obesity. Predictors included categorical sleep duration (&lt;=5, 6, 7, 8 [reference], or &gt;=9 hours) and sleep disturbance in the past month (none [reference], mild [1/week], moderate [2-3/week], or severe [&gt;3/week]). Covariates included age, sex, and financial status. Ethnicity (Jewish/Arabic) was treated as a predictor of sleep and behavioral outcomes.

Results

When compared to normal (8-hour) sleepers, Jewish as compared to Arabic individuals were more likely to to sleep &lt;=5h (RRR=3.99, p&lt;0.0005), 6h (RRR=4.65, p&lt;0.0005), and 7h (RRR=3.34, p&lt;0.0005), and were more likely to report severe sleep difficulties (RRR=1.49, p&lt;0.0005) and sleepiness (oOR=1.52, p&lt; 0.0005). Yet, they were less likely to report functional impairment (oOR=0.65, p&lt;0.0005), drowsy driving (OR=0.58, p&lt;0.0005), worse health (oOR=0.51, p&lt;0005), worsening health (oOR=0.70, p&lt;0.0005), or obesity (OR=0.64, p&lt;0.0005). Significant ethnicity by sleep duration interactions (p&lt;0.05) characterized sleepiness, sleep medications, functional impairment, health, and health change. Moreover, significant ethnicity by sleep disturbance interactions (p&lt;0.05) characterized the same outcomes, in addition to drowsy driving. Overall, the impact of sleep duration and sleep difficulties was generally greater among Arabs for all variables.

Conclusion

Despite Jewish individuals endorsing relatively shorter sleep and more severe sleep difficulties, Arabs seem to be more vulnerable to the health and functional outcomes. This finding may explain some of the discrepancies in the health and safety outcomes between these ethnic groups.

Support

Dr. Grandner is supported by R01MD011600

1175 Sleep Disorders Screening in Primary Care: Prevalence of Diagnosis and Treatment in the EMR

Introduction

Undetected and untreated sleep disorders likely precipitate or exacerbate medical and/or psychiatric illnesses. Given this, primary care is an ideal point for managing sleep disorders, yet prior research shows that PCPs diagnose and/or treat sleep disorders at rates far below population prevalences. The purpose of this study was to determine the current rate of detection and treatment of sleep disorders within primary care settings.

Methods

EMR data from two health care systems was analyzed. The proportion of PCPs diagnosing and treating one or more sleep disorders was calculated (per year) for 5 years (2014-2018). Also calculated was the percent of PCP caseload diagnosed and/or treated for sleep disorders.

Results

The two systems comprised n=1021 PCPs. From 2014-2018, the proportion of PCPs diagnosing patients with sleep disorders fluctuated between 58-89%. The proportion treating sleep disorders fluctuated between 50-91%. Non-parametric one-sample run tests (SPSS) indicate these are random distributions (p&gt;0.05). PCPs’ use of medications to treat sleep disorders is trending downward over time within one system (per linear regression, p=0.03, R-squared=0.8). Other temporal trends were not evidenced. The average percentage of diagnosed and treated patients per PCP was around 2.5% of their caseloads. Between-system differences were observed.

Conclusion

There is a profound mismatch between percentage of PCPs identifying patients with sleep disorders (60-90%) and the percentage of patient caseload diagnosed and/or treated for sleep disorders (2.5%). This suggests that the majority of PCPs are willing to assess for sleep health but do so in only a small minority of patients. These data, along with our survey data (elsewhere in this volume) suggest that the intention-action gap could be closed if PCPs were appropriately resourced.

Support

There was no funding for this study.

0464 Sleep Continuity by Neighborhood: Are There Differences?

Introduction

To our knowledge, no prior work has been conducted on whether sleep continuity disturbance (e.g., SL; WASO; EMA, etc.) varies by neighborhood. While differences on these metrics have been found by, e.g., race and socioeconomic status, it may also be that sleep continuity disturbance varies relative to where one lives and works. Accordingly, an analysis was undertaken to assess whether regional differences exist with respect to sleep continuity disturbance (SCD).

Methods

The study utilized a cross-sectional group design in an archival/community dataset that was collected in the Philadelphia area (www.sleeplessinphilly.com). This dataset (n = 2840) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints (63.4% female; 36.6% male; average age 38). Study subjects who endorsed &gt;30 minutes on &gt;3 days/week on SL, WASO & EMA were categorized by zip code and into four regional groups: Center City (n=258); South Philadelphia (n=103); North & Northeast Philadelphia (n=400) and West Philadelphia (n=345). Contingency analyses and ANOVAS were used to assess for regional group differences.

Results

It was found that SCD rates significantly differed by region. Differences in percent endorsement by region were as follows, SL:, 64.1% (Northeast/North), 63.5 (South), 56.3% (West Philadelphia), & 48.7% (Center City); WASO: 45% (Northeast/North), 40% (South), 36.5% (West Philly), & 32.4% (Center City); EMA: 46.4% (South); 43.7 (Northeast/North); 43.7 (West Philly); 43.1 (Center City).

Conclusion

The Northeast/North region of Philadelphia had the highest rates, and center city had the lowest rates of SCD for the early part of the night (SL & WASO). Early morning SCD was most common for “South Philly and least common for Center City. Analyses are on-going in relation to other regional differences (demographic, income, crime stats, etc.) and those found to vary by region will be assessed for their predictive value.

Support

No support was provided for this abstract

0351 Sleep Continuity, Sleep-Related Daytime Dysfunction, and Problem Endorsement: Do These Vary Concordantly by Age?

Introduction

It is well documented that sleep continuity (i.e., SC [ability to initiate and/or maintain sleep]) worsens with age. It is unclear whether problem endorsement and/or daytime dysfunction show similar age-related trends. Accordingly, an analysis was undertaken to assess whether initial, middle, and/or late insomnia all exhibit age related change and whether problem endorsement and/or daytime dysfunction show comparable age-related changes.

Methods

The study utilized a cross-sectional group design in an archival/community dataset (www.sleeplessinphilly.com). This dataset (N=932) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints. Participants were categorized as: Young Adults (18-29 years); Adults (30-44 years); Middle Age Adults (45-64 years); and Older Adults (65-89 years). Age groups were matched to the Older Adults group (n=233) by sex, race, and BMI. ANOVAs with Bonferroni corrections (alpha = .001), and contingency analyses were performed to assess for age group differences.

Results

It was found that, as expected, SC worsens with age but that this was limited to middle and late insomnia. Further, problem endorsement increased with age (except for SL) but sleep-related daytime dysfunction did not (except for concentration issues).

Conclusion

These results have several implications. Methodologically speaking, when evaluating the effects and/or correlates of SC, it may be wise to concomitantly assay “is this a problem for you” and “does this affect your daytime function”, as SC can occur without perceived daytime consequences, especially in older adults. Conceptually speaking, the observed discordance requires further exploration. In the past, it has been argued that sleep need is reduced in older adults. While this is a reasonable hypothesis (no need, no functional consequence), it remains to be demonstrated that older adults require less sleep.

Support

 

0868 How Do Sleep Morbidities Differ Amongst Pregnant Women, Women Who Are Intending To Conceive, And Women Who Are Not Intending To Conceive?

Introduction

Maternal sleep disturbance is common during pregnancy and is associated with adverse maternal and child outcomes, such as postpartum depression and preterm birth. The extent to which sleep disorder symptoms are normative among women of reproductive age, however, is largely unknown. The present study’s primary aim was to explore cumulative sleep morbidity and the incidence of disorder-specific symptoms among reproductive-aged women of different childbearing statuses.

Methods

Sleep morbidity variables were examined cross-sectionally among three groups of reproductive-aged nulliparous women: those 1) currently pregnant (n=148), 2) currently intending to conceive (n=233), and 3) not currently intending to conceive (n=379). All subjects self-reported sleep disorder symptoms at baseline using the Sleep Disorders Symptom Checklist-25 (SDS-CL-25). This instrument measures symptoms related to 13 sleep disorders scaled 0 (never) to 4 (&gt; 5 days per week). Average scores were calculated for each item, each of 13 sleep disorders, and for the whole instrument (0-100).

Results

Initial results indicated that pregnant women (M=22.80, SD=11.49) had a higher rate of cumulative sleep morbidity than women who were intending to conceive (M=20.33, SD=11.14) and women who were not intending to conceive (M=20.15, SD=12.03) (p=.05). Pregnant women also had increased rates of insomnia (M pregnant=8.38, SD=3.77; M intending=6.86, SD=3.60; M not intending=6.53, SD=3.47; p&lt;.001) and restless legs syndrome/periodic limb movement disorder (M pregnant=2.77, SD=3.05; M intending=2.02, SD=2.28; M not intending=1.99, SD=2.43; p= .004) as compared to non-pregnant women.

Conclusion

These data suggest, as is widely held, that pregnant women have greater levels of sleep disturbance than women of a common reproductive age who are currently intending to conceive or who are not currently intending to conceive. The observed sleep disturbance appears to be limited to sleep initiation and maintenance and RLS/PLMs symptomatology. Additional analyses are ongoing.

Support

Perlis & Kloss: R21HD083628; Perlis K24AG055602

0544 Reconsidering Stimulus Control: Activities in Bed Associated with Sleep-Related Outcomes

Introduction

The typical advice is that in order to avoid insomnia, people should avoid activities in bed other than sleep. Yet, activities such as reading and watching TV in bed are common.

Methods

Data were obtained from the Sleep and Health Activity, Diet, Environment, and Socialization (SHADES) Study, N=1,007 adults age 22-60. Sleep hygiene was assessed using items from the Sleep Practices and Attitudes Questionnaire (SPAQ), which asked whether respondents agree/disagree that they do the following in bed: Read, Watch TV, Eat, Work, Worry, and/or Argue. These were analyzed in relation to Insomnia Severity Index (ISI) score, Pittsburgh Sleep Quality Index (PSQI) score, Epworth Sleepiness Scale (ESS) score, Fatigue Severity Scale (FSS) score, and self-reported sleep duration (TST), sleep latency (SL), and wake after sleep onset (WASO). Covariates included age, sex, education, and income.

Results

Those that frequently engaged in activities were: reading (75%), watching TV (63%), eating (42%), working (32%), worrying (82%), and arguing (23%). Reading was associated with less WASO (B=-14min, p=0.02). Watching TV was associated with higher ISI (B=1.22, p=0.04), PSQI (B=1.04, p=0.007), and ESS (B=0.87, p=0.049), and less TST (B=-0.29, p=0.04). Eating was associated with higher ISI (B=1.75, p=0.01), PSQI (B=1.23, p=0.008), and FSS (B=4.36, p=0.002). Working was associated with higher ISI (B=1.82, p=0.019), PSQI (B=1.65, p=0.001), and ESS (B=1.78, p=0.002). Worrying was associated with higher ISI (B=7.34, p&lt;0.0005), PSQI (B=4.40, p&lt;0.0005), ESS (B=2.53, p=0.001), FSS (B=9.51, p&lt;0.0005), and SL (B=19.39, p&lt;0.0005), and less TST (B=-0.55, p=0.023). Arguing was associated with higher ISI (B=3.78, p&lt;0.0005), PSQI (B=3.15, p&lt;0.0005), ESS (1.47, p=0.023), and SL (B=10.97, p=0.013), and lower TST (B=-0.71, p=0.001).

Conclusion

Individuals who perform mentally distressing activities such as worrying and arguing experience especially worse sleep, and those who read in bed have fewer awakenings.

Support

The SHADES study was funded by R21ES022931. Dr. Grandner is supported by R01MD011600.

0405 Sleep Duration and Sleep Disturbance Related to Obesity, Health, Motor Vehicle Safety, and Daytime Functioning in Israel: Data From the 2017 Israel Social Survey

Introduction

Previous studies suggest the Israeli population exhibits relatively short sleep duration and experiences sleep difficulties. This analysis evaluates the relationships between habitual sleep and outcomes of interest in this population.

Methods

Data were obtained from 7,230 Israeli individuals. The sample consisted a 2017 population-based survey of households, conducted by the Israeli Bureau of Statistics. All variables were self-reported. Outcomes of interest included drowsy driving, sleep medication use, functional impairment, sleepiness, overall health, 1-year health change, and obesity. Predictors included categories of sleep duration (&lt;=5, 6, 7, 8 [reference], or &gt;=9 hours) and sleep disturbance in the past month (none [reference], mild [1/week], moderate [2-3/week], or severe [&gt;3/week]). Covariates included age, sex, ethnic group, and financial status. Binary and ordinal logistic regressions were employed to evaluate the relationship between them and post-hoc analyses evaluated the relationships between subgroups.

Results

Drowsy driving was associated with &lt;=5h, 6h, and 7h sleep duration categories, and severe sleep disturbance. The use of sleep medication use was associated with &lt;=5h and &gt;=9h, and all levels of sleep disturbance. Functional impairment and sleepiness were both associated with &lt;=5h, 6h, 7h, and &gt;=9h, and all levels of sleep disturbance. Their reported overall health was linked to sleep duration of &lt;=5h and &gt;=9h, and all levels of sleep disturbance. Worsening health was associated with &lt;=5h and all levels of sleep disturbance. Obesity was associated with &lt;=5h and severe sleep disturbance. In post-hoc analyses restricted to individuals with no sleep disturbance, habitual sleep duration was still statistically significantly related to drowsy driving, sleep medications, sleepiness, and health change.

Conclusion

Short sleep duration and sleep disturbance are associated with worse motor vehicle safety, health, and functioning in the Israeli population. Effects of sleep duration were generally maintained even for those without sleep disturbance. These results may help focus public health efforts on improving sleep health.

Support

Dr. Grandner is supported by R01MD011600

1109 Broadly Assessing Sleep Complaints In A Sample Of Patients With ADHD

Introduction

It is commonly observed in clinical settings that patients with ADHD regularly present with comorbid “sleep disturbances”. In the absence of broad based sleep disorders assessments, it is thought that this represents Delayed Sleep Phase Disorder (DSPD). Recently, a surveillance study was undertaken in a university-based, outpatient specialty clinic for adults with ADHD, by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain which sleep disorders symptoms are common in this clinical cohort.

Methods

SDS-CL-25 data were collected in 150 subjects (93/57 male/female, mean age 32.8, age range 18-79). The SDS-CL-25 is a 25 item instrument developed to screen for 13 sleep disorders at one time (Sleep Dx symptoms are endorsed on Likert-scales; 0 [never] 4 [&gt;5x/week]). For the purposes of this study, the percentage of subjects endorsing frequent symptomatology (sum of the percent of endorsements for columns 3 & 4)was calculated per symptom. Sums of &gt;20% were considered, a priori, to be of clinical significance.

Results

Patients endorsed: increased fatigue (59%); SL or WASO or EMA’s &gt;30 minutes (40%; 26%; 21%, respectively); late preferred time to bed (31%); work & school limits sleep opportunity (30%); variable time to and out of bed (27%); and snoring (21%). The average percent endorsement was 15% (range 0-59%).

Conclusion

These results suggest that, consistent with clinical observations, adult patients diagnosed with ADHD frequently endorse late preferred time to bed, variable sleep wake schedules, work/school limitations on sleep opportunity, and sleep onset problems that are accompanied by daytime fatigue. This constellation of symptoms is consistent with the notion that patients with ADHD tend to have comorbid DSPD. The high prevalence of middle and late insomnia was unexpected and suggests that Insomnia Disorder (proper) may also be a feature of ADHD.

Support

No support was provided for this abstract.

0153 Patient-Defined Insomnia Severity: How Much Wakefulness is Problematic?

Introduction

While Insomnia Disorder is formally defined in the ICSD-3 and DSM-5, neither diagnostic system adopts quantitative criteria for illness severity. Interestingly, quantitative criteria are provided for frequency and chronicity (i.e., ≥ 3 days / week for ≥ 3 months). For research purposes, illness severity has long been defined using the “30 minute rule” (SL and/or WASO and/or EMA of ≥ 30 minutes is the threshold for clinical relevance). In the present analysis, this threshold was assessed for its significance to patients.

Methods

Sleep continuity disturbance (SCD; SL, WASO, and EMA) and problem endorsement data were collected from an archival/community-based sample (N = 4680; 60% female; Ages 18–89 years; www.sleeplessinphilly.com). Problem endorsement was evaluated through questions that included, “Do you consider this a problem?” after participants reported length of SL, WASO, and EMA. Problem endorsement percentages were calculated for 5 minute bins for between 0 and 65 minutes, with one additional bin for &gt; 65 minutes. The temporal bins were compared for significant deviations using absolute (percent of subjects at 0–5 and 5–10 minutes) and moving references (last significant percent).

Results

The first temporal bin to differ from the absolute reference for SL, WASO, and EMA was the 26–30 minute bin. At this threshold, 87%, 70%, and 94% of the subjects’ identifying SL, WASO and EMA as being problematic (and was deemed statistically different from “normal” [0–10 minute values]).

Conclusion

These data suggest that the “30 minute rule” (which is of unknown provenance) roughly corresponds to the level of illness severity (lowest common threshold) identified by patients as problematic. While the threshold for SL and EMA show a clear majority, the lower percentage of subjects for WASO suggests that people are more tolerant of middle of the night wakefulness.

Support

 

1111 Do Sleep Disorder Symptom Endorsements Differ Between ADHD Subtypes?

Introduction

To date, research on differences in sleep complaints between patients with different subtypes of ADHD has been mixed. On balance, the evidence tends towards ADHD-Combined Presentation (ADHD-C) being associated with more severe sleep and sleep-related daytime complaints than ADHD-Primarily Inattentive (ADHD-I). In order to further assess this issue a surveillance study was undertaken in an active ADHD clinic by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain whether the two subtypes differ for any of 13 sleep disorders symptoms.

Methods

Subjects (n = 132; 83 male, 49 female, mean age 32.8, age range 18-79), presenting to the clinic for evaluation for ADHD were given the SDS-CL-25. The SDS-CL-25 is a 25-item instrument developed to screen for multiple sleep disorders at one time (problems are endorsed on a Likert-scale; 0 = never and 4 = more than 5x/week). Endorsements greater than 3x/week were counted as positive for the symptom and less than three days per week was considered negative.

Percent per group was compared using Chi Square Analyses. Cumulative morbidity means were also analyzed using t-tests. The subtype, ADHD-I (n=71) and ADHD-C (N=61), was established using EMR records.

Results

No significant differences between patients with ADHD-I and ADHD-C were detected.

Conclusion

The lack of finding in the present analysis may reflect a lack of difference or a failure to detect differences based on the small sample sizes or lack of statistical control for likely confounders (age, sex, illness severity or chronicity, SES status, etc.). Analyses are ongoing.

Support

No support was provided for this abstract.

1093 Population-level Suicide Ideation: Impact Of Combined Roles Of Sleep Duration, Sleep Disturbance, And Daytime Sleepiness

Introduction

Poor sleep has been shown to be related to suicide ideation and depressed mood, but population-level studies have not been done to explore the specific issues within sleep that effect mood, specifically leading to suicide ideation.

Methods

Data from adults 18 and older in the 2015-2016 National Health and Nutrition Examination Survey (NHANES) who provided complete data were used (N=5,123). Suicide ideation was recorded as the presence of thinking that “you would be better off dead” in the past 2 weeks. Sleep duration was recorded in half-hour increments and transformed to represent absolute distance from 7 hours (to model u-shaped association). Sleep disturbance was recorded as presence of “difficulty falling asleep, staying asleep, or sleeping too much” non, several days, or more than half the days of the past 2 weeks. Sleepiness was frequency feeling “overly sleepy during the day” in the past 12 months. Covariates included age, sex, race/ethnicity, and presence of depressed mood in the past 2 weeks. Additional impact of difficulty thinking/concentrating in the past 2 weeks was explored. NHANES sample weights were used in analyses.

Results

In adjusted analyses, increase likelihood of suicide ideation was associated with distance from 7hrs (OR=1.24/hr, p=0.008), sleep difficulties most of the time (OR=2.46, p=0.001), but not sleepiness. When both sleep variables were adjusted for each other, results remained significant for U-shaped sleep duration (OR=1.21/hr, p=0.02) and sleep disturbance (OR=2.31, p=0.003). These were attenuated but remained significant when difficulty thinking/concentrating was introduced; a significant sobel test (p&lt;0.0001) suggested partial mediation, with this variable accounting for approximately 13% of the variance of the relationship to sleep.

Conclusion

In the population, improper and poor sleep was associated with a greater risk of suicide ideation.

Support

Dr. Grandner is supported by R01MD011600