Insomnia disorder: clinical and research challenges for the 21st century

A cross-sectional study on the use of complementary and alternative medicine in insomnia patients referred to psychiatric clinics in Iran

OBJECTIVE

This study aimed to investigate the prevalence and types of Complementary and Alternative Medicine (CAM) utilization among Iranian patients referred to psychiatric clinics with self-reported insomnia. It also sought to explore demographic characteristics, attitude of the patients to CAM, the factors influencing patients' decision to use CAM, and factors thought to be linked to the adoption of CAM in this patient population.

METHODS

A cross-sectional study was conducted between July 2023 and October 2023 on 217 patients at outpatient academic psychiatric clinics affiliated with Shiraz University of Medical Sciences. Data was collected using the Persian version of the international questionnaire to measure use of complementary and alternative medicine (I-CAM-IR), assessing CAM usage, motives, specific modalities, and sources of exposure. Descriptive statistics were employed to analyze demographic characteristics, while Chi-square tests and logistic regression analyses were used to assess associations between demographic factors and CAM usage.

RESULTS

A total of 217 patients were initially recruited for the study; however, 12 participants were excluded due to incomplete or invalid data, resulting in a final sample of 205 participants included in the analysis. Of 205 participants, 68.3% reported CAM use, with herbal medicines (73.6%), Persian medicine (45.7%), vitamins and minerals (43.6%), and cupping (10.7%) being prominent modalities. Significant associations were observed between CAM use and demographic factors such as age (P = 0.006), gender (P < 0.001), education (P = 0.006), occupation (P = 0.002), father and mother education levels (P < 0.001, P = 0.015), and family income (P = 0.019). Most CAM users (78.1%) did not inform healthcare providers about their CAM use, with perceived effectiveness mainly focused on health promotion (80.6%).

CONCLUSION

This study reveals a substantial prevalence of CAM utilization among insomnia patients in psychiatric clinics of Iran, with demographic factors influencing CAM use. Healthcare providers should consider incorporating discussions about CAM into insomnia management strategies and be prepared to address patient preferences for complementary treatments. Future research should further explore the impact and outcomes of CAM utilization in managing insomnia to optimize patient care in psychiatric settings.

Integration of sleep and emotion treatment: a randomized trial of transdiagnostic CBT for comorbid insomnia

BACKGROUND

Insomnia frequently co-occurs with emotional disorders, yet integrated treatment approaches remain understudied. This study examined the efficacy of Transdiagnostic Cognitive Behavior Therapy (TCBT) for treating comorbid insomnia in patients with emotional disorders.

METHODS

In this double-blind randomized controlled trial, 32 university students with comorbid insomnia and emotional disorders were randomly assigned to either TCBT (n = 16) or waitlist control (n = 16). The TCBT group received 20 one-hour sessions of treatment. Insomnia severity was assessed using the Insomnia Severity Index (ISI) at baseline, post-treatment, and three-month follow-up.

RESULTS

Mixed-model ANOVA revealed significant main effects for time (F = 52.18, p < .001, Eta-Squared = 0.635) and group (F = 45.55, p < .001, Eta-Squared = 0.603), and a significant time × group interaction (F = 61.66, p < .001, Eta-Squared = 0.673). The TCBT group showed large effect sizes for insomnia reduction from pre- to post-treatment (Hedges' g = 3.75) and pre-treatment to follow-up (g = 3.07), with benefits maintained at three months. The waitlist group showed no significant changes.

CONCLUSIONS

TCBT demonstrated robust efficacy in treating comorbid insomnia among university students with emotional disorders, with effects maintained at follow-up. These findings suggest TCBT as a promising integrated treatment approach for this population.

TRIAL REGISTRATION

This randomized clinical trial comprised an intervention and a waitlist that was registered in the Iranian Registry of Clinical Trials (IRCT Id: IRCT20200112046097N1). (Registration Date: 26/07/2020).

Digital and AI-Enhanced Cognitive Behavioral Therapy for Insomnia: Neurocognitive Mechanisms and Clinical Outcomes

Background/Objectives: This systematic review explores the integration of digital and AI-enhanced cognitive behavioral therapy (CBT) for insomnia, focusing on underlying neurocognitive mechanisms and associated clinical outcomes. Insomnia significantly impairs cognitive functioning, overall health, and quality of life. Although traditional CBT has demonstrated efficacy, its scalability and ability to deliver individualized care remain limited. Emerging AI-driven interventions-including chatbots, mobile applications, and web-based platforms-present innovative avenues for delivering more accessible and personalized insomnia treatments. Methods: Following PRISMA guidelines, this review synthesized findings from 78 studies published between 2004 and 2024. A systematic search was conducted across PubMed, Scopus, Web of Science, and PsycINFO. Studies were included based on predefined criteria prioritizing randomized controlled trials (RCTs) and high-quality empirical research that evaluated AI-augmented CBT interventions targeting sleep disorders, particularly insomnia. Results: The findings suggest that digital and AI-enhanced CBT significantly improves sleep parameters, patient adherence, satisfaction, and the personalization of therapy in alignment with individual neurocognitive profiles. Moreover, these technologies address critical limitations of conventional CBT, notably those related to access and scalability. AI-based tools appear especially promising in optimizing treatment delivery and adapting interventions to cognitive-behavioral patterns. Conclusions: While AI-enhanced CBT demonstrates strong potential for advancing insomnia treatment through neurocognitive personalization and broader clinical accessibility, several challenges persist. These include uncertainties surrounding long-term efficacy, practical implementation barriers, and ethical considerations. Future large-scale longitudinal research is necessary to confirm the sustained neurocognitive and behavioral benefits of digital and AI-powered CBT for insomnia.

The dose-effect relationship between acupuncture and its effect on primary insomnia: a systematic review and meta-analysis

Background

The benefits of acupuncture on primary insomnia (PI) have been well established in previous studies. However, different acupuncture dosages may lead to controversy over its efficacy. Therefore, this systematic review and meta-analysis was conducted to assess the relationship between the dose and efficacy of acupuncture for the treatment of PI.

Methods

Seven databases were searched from inception until May 30, 2024. The included randomized controlled trials (RCTs) with acupuncture for PI on the Pittsburgh Sleep Quality Index (PSQI) scores were divided into three categories according to the therapeutic dose of acupuncture (frequency, session, and course): low dosage, medium dosage, and high dosage. The correlation between the dose and the effect of treatment was analyzed. Risk of bias was assessed using Cochrane Collaboration's risk of bias tool. Meta-analyses were performed using RevMan v.5.4 and Stata 16.0 software.

Results

A total of 56 studies were included. There were 17 sham acupuncture-controlled RCTs that are notable because of their high quality. Overall, the effect on the reduction of the PSQI scores varied across the different acupuncture dosages. For the frequency of acupuncture, the results showed a significant improvement in the moderate frequency (three sessions per week) and high frequency (five to seven sessions per week) categories. With regard to the acupuncture session, it was shown that moderate session (12-20 sessions) and high session (24-30 sessions) had better effects on the reduction of the PSQI scores, with low session (≤10 sessions) being not significant. For the acupuncture course, there were no differences in the short course (≤2 weeks) and the long course (>4 weeks) between the acupuncture group and the control group. Medium course (3-4 weeks) was considered as the optimal course. In addition, there were no differences between acupuncture and SATV (sham acupuncture therapy at verum points) on the same acupuncture points in the PSQI scores. The results of GRADE assessment demonstrated that the level of evidence was very low to moderate, probably due to the poor methodological quality and the substantial heterogeneity among studies.

Conclusions

A dose-effect relationship was found between the acupuncture dose and the PSQI scores. Although sham acupuncture needling at the same points as those in acupuncture may not be a true placebo control, this was utilized in a minority of studies. Collectively, the data suggest that at least three sessions per week for 3-4 weeks and a total of at least 12 acupuncture sessions would be the optimal clinical response.

Systematic review registration

https://www.crd.york.ac.uk/, identifier CRD42024560078.

Identification and validation of diagnostic genes IFI44 and IRF9 in insomnia-associated autoimmune uveitis

Objective

Insomnia is increasingly recognized as a significant factor in the development of various autoimmune diseases, including autoimmune uveitis (AU). We investigated insomnia-associated genes that may contribute to AU pathogenesis and sought to identify potential biomarkers for insomnia-associated AU.

Methods

Microarray data related to insomnia and AU were downloaded from the Gene Expression Omnibus (GEO) database and analyzed. The GEO2R tool was used to identify differentially expressed genes (DEGs) that were common between insomnia and AU. Weighted gene co-expression network analysis (WGCNA), protein-protein interaction (PPI), functional enrichment, and CMap analyses were then performed to identify pathogenic genes, underlying mechanisms, and potential therapeutic drugs for insomnia-associated AU. Least absolute shrinkage and selection operator regression was employed to screen for candidate biomarkers, and their diagnostic performance was evaluated using receiver operating characteristic (ROC) curves and quantitative polymerase chain reaction (qPCR). Finally, molecular docking was applied to verify binding activities.

Results

We identified 138 up-regulated and 85 down-regulated DEGs that were common to insomnia and AU. PPI network analysis highlighted 10 key genes, CMap analysis identified 30 compounds, and WGCNA revealed 54 key genes and 30 compounds. Intersection of the above-mentioned key genes and compounds identified six genes and five compounds. After verification by qPCR and ROC curve analysis, IFI44 and IRF9 were confirmed as hub genes. Finally, two compounds were selected based on docking scores of less than -7 kcal/mol.

Conclusion

Our study demonstrated involvement of the viral response in both insomnia and AU and identified the diagnostic significance of IFI44 and IRF9 in these conditions. These findings provide novel insights for future diagnostic and therapeutic strategies to treat insomnia-associated AU.

Predictors of Poor Sleep Quality in Elderly Individuals in Western Iran: A Population-Based Cross-Sectional Study

BACKGROUND

Poor sleep quality in the elderly is a prevalent issue that can significantly impact overall health and quality of life. This study aimed to assess the prevalence of sleep disorders and the factors contributing to poor sleep quality among older adults in Western Iran. Study Design: This is a cross-sectional study.

METHODS

This study involved 403 elderly people. The following tools were employed to collect data: the Pittsburgh Sleep Quality Index (PSQI), the Leisure and Pleasure Activities Database (a quality-of-life tool), the standardized Depression, Anxiety and Stress Scale (DASS-21), and the Abbreviated Mental Test (AMT)for cognitive assessment. A backward stepwise selection method was employed to finalize the variables for multiple logistic regression analysis.

RESULTS

The overall prevalence of poor sleep quality was 44.7%. With each one-point increase in stress, the likelihood of experiencing poor sleep quality increases significantly (adjusted OR: 1.09, P<0.001). The number of children in the household was found to have a protective effect against poor sleep quality (adjusted OR=0.63, P=0.008). Furthermore, elderly individuals working as housekeepers had higher odds of poor sleep quality than those employed elsewhere (adjusted OR=7.45, P=0.005).

CONCLUSION

A significant association was observed between elevated stress levels and poor sleep quality. Interestingly, the presence of children in the household appeared to offer a protective effect. Conversely, individuals in household management roles faced a dramatically increased risk of poor sleep quality. These findings offer preliminary evidence for the potential effectiveness of early interventions and prevention strategies designed to improve sleep quality and reduce social frailty in the elderly.

Effect of Herbal Medicine (Hwanglyeonhaedok-tang) on Insomnia Patients with Bedtime Procrastination: study protocol for a randomized controlled trial

Objectives

Insomnia, characterized by difficulty initiating or maintaining sleep, affects a significant portion of the global population. Bedtime procrastination, which is a voluntary delay in going to bed, is a major contributing factor to the prevalence of sleep deprivation in modern societies. Hwanglyeonhaedok-tang (HJD decoction) has shown promise in improving the symptoms of insomnia. This study aimed to evaluate the efficacy of HJD decoction in patients with insomnia and bedtime procrastination.

Methods

This study employs a parallel-group design, comparing HJD decoction to usual care in a 11 ratio. Sixty participants with insomnia and bedtime procrastination will be enrolled. The experimental group will receive HJD decoction for 4 weeks, while both groups will undergo a brief behavioral treatment for insomnia. The primary outcome will be the change in the Insomnia Severity Index score (ISI) from baseline to 4 weeks. Secondary outcomes include sleep diary metrics, the Pittsburgh Sleep Quality Index (PSQI), and Bedtime Procrastination Scale (BPS). The exploratory outcomes include perceived stress, anxiety, smartphone use, and heart rate variability.

Conclusion

This trial examines the role of herbal medicine in treating a specific type of insomnia that is increasingly common in modern society. The combination of HJD decoction with behavioral intervention offers a comprehensive approach to treating insomnia complicated by bedtime procrastination. The results will provide valuable insights into integrative treatment strategies for sleep disorders in the digital age.

A comparative study of depressive and anxiety symptoms, insomnia, and sleepiness in patients with obstructive sleep apnea, restless legs syndrome, or both (CO-ROSA): preliminary findings from a retrospective study

Patients with obstructive sleep apnea (OSA), restless legs syndrome (RLS), or both may exhibit varied manifestations of depressive and anxiety symptomatology, reflecting the complex interplay between sleep disturbances, neurotransmitter imbalances, and psychosocial stressors in these often overlapping conditions. The aim of this study was to compare depressive and anxiety symptomatology, insomnia severity, and sleepiness in these conditions. Patients were enrolled and subdivided into those with OSA, RLS, and OSA + RLS. All were evaluated using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Insomnia Severity Index, and Epworth Sleepiness Scale. A total of 159 patients were enrolled, with OSA (n = 85), RLS (n = 11), and OSA + RLS (n = 63). A significant difference was observed for PHQ-9 (higher in patients with RLS, associated or not with OSA); however, the groups also differed for age (older in RLS) and apnea-hypopnea index (AHI) (higher in OSA). The group difference in PHQ-9 persisted also after ruling out the confounding effects of age and AHI. Our study highlights the significant burden of depressive symptomatology in patients with OSA, RLS, or both. RLS patients consistently exhibited higher levels of depressive symptomatology compared with OSA patients, emphasizing the need for comprehensive assessment and tailored management strategies targeting both sleep-related and psychiatric symptoms in this population.

Effects of insomnia treatments on cognitive function: A meta-analysis of randomized controlled trials

BACKGROUND

Globally, insomnia has been shown to impact cognitive function, which has prompted the exploration of effective treatments to enhance cognitive outcomes. Both pharmacological and non-pharmacological interventions vary in their effects, indicating that further research for optimized therapeutic strategies is needed.

METHODS

Searches of PubMed, EMBASE, Web of Science, the Cochrane Library, and PsychInfo from database inception until August 2024 were conducted to identify relevant randomized controlled studies investigating the impacts of insomnia treatments on cognitive function. The standardized mean difference (SMD) and 95% confidence interval (CI) were calculated for all studies. Sensitivity analysis, publication bias, and meta-regression were performed.

RESULTS

A total of 14,829 records were retrieved, with 24 randomized controlled studies assessing the impact of insomnia treatment on cognition. Pooled analysis indicated that non-pharmacological interventions significantly enhanced cognitive function (SMD: 0.27, 95% CI: 0.04-0.49, p = 0.019), with notable improvements observed in memory (SMD: 1.18, 95% CI: 0.25-2.12, p = 0.013), attention (SMD: 0.32, 95% CI: 0.15-0.50, p < 0.001), and daily living activities (SMD: 0.29, 95% CI: 0.20-0.39, p < 0.001) based on self-reported measures. Longer follow-up periods were associated with more pronounced cognitive benefits (SMD: 0.34, 95% CI: 0.14-0.54, p = 0.001).

CONCLUSIONS

The critical role of insomnia treatments, particularly non-pharmacological interventions, in improving cognitive function is highlighted, emphasizing the importance of tailored therapeutic approaches to optimize cognitive outcomes and overall well-being.

Effect of daridorexant on sleep architecture in patients with chronic insomnia disorder: a pooled post hoc analysis of two randomized phase 3 clinical studies

STUDY OBJECTIVES

Post hoc analysis to evaluate the effect of daridorexant on sleep architecture in people with insomnia, focusing on features associated with hyperarousal.

METHODS

We studied sleep architecture in adults with chronic insomnia disorder from two randomized phase 3 clinical studies (Clinicaltrials.gov: NCT03545191 and NCT03575104) investigating 3 months of daridorexant treatment (placebo, daridorexant 25 mg, daridorexant 50 mg). We analyzed sleep-wake transition probabilities, EEG spectra, and sleep spindle properties including density, dispersion, and slow oscillation phase coupling. The wake EEG similarity index (WESI) was determined using a machine learning algorithm analyzing the spectral profile of the EEG.

RESULTS

At month 3, daridorexant 50 mg decreased wake-to-wake transition probabilities (p < .05) and increased the probability of transitions from wake-to-N1 (p < .05), N2 (p < .05), and REM sleep (p < .05), as well as from N1-to-N2 (p < .05) compared to baseline and placebo. Daridorexant 50 mg decreased relative beta power during wake (p = .011) and N1 (p < .001) compared to baseline and placebo. During the wake, relative alpha power decreased (p < .001) and relative delta power increased (p < .001) compared to placebo. Daridorexant did not alter EEG spectra bands in N2, N3, and REM stages or in sleep spindle activity. Daridorexant decreased the WESI score during wake compared to baseline (p = .004). Effects with 50 mg were consistent between months 1 and 3 and less pronounced with 25 mg.

CONCLUSIONS

Daridorexant reduced EEG features associated with hyperarousal as indicated by reduced wake-to-wake transition probabilities and enhanced spectral features associated with drowsiness and sleep during wake and N1.

CLINICAL TRIALS

ClinicalTrials.gov NCT03545191: study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants with insomnia disorder. URL: Study Details | study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants with insomnia disorder | ClinicalTrials.gov ClinicalTrials.gov NCT03575104:study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants who experience difficulties sleeping. URL: study details | study to assess the efficacy and safety of ACT-541468 (daridorexant) in adult and elderly participants who experience difficulties sleeping | ClinicalTrials.gov.

Elevated peripheral glutamate and upregulated expression of NMDA receptor NR1 subunit in insomnia disorder

Background

The present study explored the serum glutamate (Glu), glutamine (Gln), glutamic acid dehydrogenase (GAD) concentrations and the mRNA expression levels of the N-methyl-D-aspartate receptor (NMDAR) NR1 subunit in the peripheral blood of patients with insomnia disorder (ID). To our knowledge, this is the first study showing an increase in the mRNA expression levels of the NMDAR NR1 subunit in patients with ID.

Methods

This study included 30 ID patients and 30 matched healthy controls. We investigated the demographic and illness information and assessed subjective sleep quality using the Pittsburgh Sleep Quality Index. The Hamilton Depression Scale-17 and Hamilton Anxiety Scale were used to evaluate the patients' symptoms of depression and anxiety, respectively. The quantifications of Glu, Gln and GAD concentrations were performed by Enzyme-linked immunosorbent assay (ELISA). Real-time PCR was used to detect the mRNA expression levels of the NMDAR NR1 subunit in peripheral blood.

Results

Compared with the healthy control group, the serum Glu concentrations and the mRNA expression levels of the NMDAR NR1 subunit in the ID group were significantly higher. However, there was no significant difference in Gln and GAD between the two groups. The receiver operating characteristic (ROC) analysis showed that the mRNA expression levels of the NMDAR NR1 subunit could distinguish ID patients from healthy individuals (area under the curve: 0.758; sensitivity: 73.3%; specificity: 76.7%). A negative correlation was found between the mRNA expression levels of the NMDAR NR1 subunit for age, total duration of illness, and age of first onset in the ID group, whereas a positive correlation was detected for daytime dysfunction.

Conclusion

Glutamatergic neurotransmission was abnormal in ID patients. Additionally, the mRNA expression levels of the NMDAR NR1 subunit appeared to have potential as a clinical biomarker for ID. However, the sample size of our study was limited, and future studies with larger sample sizes are needed to further validate and explore the mechanisms involved and to assess the reliability of the biomarker.

Sex Differences in the Associations Between Chronic Diseases and Insomnia Symptoms Among Older Adults in India

Background

Sleep problems are a critical issue in the aging population, affecting quality of life, cognitive efficiency, and contributing to adverse health outcomes. The coexistence of multiple diseases is common among older adults, particularly women. This study examines the associations between specific chronic diseases, multimorbidity, and insomnia symptoms among older Indian men and women, with a focus on the interaction of sex in these associations.

Methods

Data were drawn from 31,464 individuals aged 60 and older in the Longitudinal Ageing Study in India, Wave-1 (2017-18). Insomnia symptoms were assessed using four questions adapted from the Jenkins Sleep Scale (JSS-4), covering difficulty falling asleep, waking up, waking too early, and feeling unrested during the day. Multivariable logistic regression models, stratified by sex, were used to analyze the associations between chronic diseases and insomnia symptoms.

Results

Older women had a higher prevalence of insomnia symptoms than men (44.73% vs 37.15%). Hypertension was associated with higher odds of insomnia in both men (AOR: 1.20) and women (AOR: 1.36). Women with diabetes had lower odds of insomnia (AOR: 0.80), while this association was not significant in men. Neurological or psychiatric disorders, stroke, and bone and joint diseases were linked to higher odds of insomnia in both sexes. Chronic lung disease was associated with insomnia in men (AOR: 1.65), but not in women. Additionally, having three or more chronic diseases significantly increased the odds of insomnia in both men (AOR: 2.43) and women (AOR: 2.01).

Conclusion

Hypertension, bone and joint diseases, lung diseases, stroke, neurological or psychiatric disorders, and multimorbidity are linked to insomnia symptoms in older Indian adults. Disease-specific management and routine insomnia screening are crucial for promoting healthy aging in this vulnerable population.

Educating Nurses in Sleep Screening, Brief Intervention, and Referral for Treatment

BACKGROUND

Poor sleep is an unrecognized problem among cancer survivors that affects quality of life. However, screening for sleep disorders is not routine in cancer care. To fill this gap, a self-paced online training program was designed for RNs to screen patients for sleep disturbance and provide brief intervention or referral for treatment (Sleep-SBIRT).

METHOD

A three-phase evaluation pilot study included the following steps: (a) develop an online training program with in situ simulation; (b) implement the program with RNs at a comprehensive cancer center; and (c) evaluate module and quiz completion rates and focus group thematic analysis.

RESULTS

Of the 22 RNs participating, 17 completed online modules and in situ simulation. The RNs were satisfied (M = 4.74/5, SD = 0.42) and self-confident (M = 4.45/5, SD = 0.45) with the learning. Focus group themes were learning new knowledge, learning online effectively, applying learning to in situ simulation, and intending to implement.

CONCLUSION

The RNs gained knowledge applying Sleep-SBIRT, but future larger studies are warranted. [J Contin Educ Nurs. 2024;55(8):387-392.].

Sleep disturbance associated with the menopause

IMPORTANCE AND OBJECTIVES

Sleep disturbance is one of the most common and debilitating symptoms experienced by women during the menopause transition. However, there are currently no therapies specifically approved for sleep disturbance associated with the menopause. Here, we consider how to characterize sleep disturbance associated with the menopause and discuss its etiology, including the latest advances in our understanding of the neuronal circuits that regulate reproduction, body temperature, sleep, and mood; and reflect on its impact on women's health and well-being. We also examine the current treatment landscape and look to the future of treatment for this condition.

METHODS

We conducted a review of the literature and combined this with discussion with experts in the fields of sleep and menopause as well as experiences from our own clinical practices.

DISCUSSION AND CONCLUSIONS

Sleep disturbance associated with the menopause is characterized by frequent night-time awakenings and increased awake time after sleep onset. Its impacts are wide-ranging, negatively affecting health as well as personal and social relationships, productivity, and work performance. There is currently an unmet need for effective, safe, and well-tolerated treatments to address this important symptom, and wider recognition of the association between sleep disturbances and the menopause is needed. Sleep disturbances associated with the menopause can result from hormone changes as well as vasomotor and mood symptoms. Growing research has contributed to our knowledge of the role of hypothalamic estrogen-sensitive kisspeptin/neurokinin B/dynorphin neurons. These neurons are thought to integrate the gonadotropin-releasing hormone pathway and the pathways responsible for the homeostatic control of body temperature and the circadian regulation of sleep-wake cycles. Understanding these neurons offers the potential to create treatments that target a key cause of sleep disturbance associated with the menopause. Further research to understand their etiology and characterize the neuronal circuits responsible could benefit the development of these targeted treatment approaches.

The Prevalence and Correlates of Depression, Anxiety, and Insomnia among Camp Residing Palestinian Women Migrants during the Outbreak of the War on Gaza: A Cross-Sectional Study from Jordan

Background and Objectives: The current war on the Gaza strip and the circulating violent content is believed to negatively impact the mental health of the Palestinians living in refugee camps outside their homeland. This study explores the prevalence and correlates of depression, anxiety, and insomnia in a cohort of female Palestinian refugees in Jordan who have family members entangled in the persistent conflict in the Gaza strip. Materials and Methods: This cross-sectional study employed validated tools to assess depression, anxiety, and insomnia in women residing in a Gaza camp located in Jerash, Jordan. The correlates were determined by regression analysis. Results: The study unearths disconcerting statistics from 177 recruited women, revealing alarmingly high rates of severe depression (73%), anxiety (60%), and insomnia (65%). Multivariable analysis revealed that severe depression was significantly associated with prior diagnosis with chronic diseases (OR = 3.0, CI = 1.36-6.58), and having a first-degree relative in Gaza (OR = 0.42, CI = 0.20-0.85). Additionally, severe insomnia was associated with "losing relatives or friends in the war" (OR = 3.01, CI = 1.41-6.44), and "losing connection with families and friends" (OR = 3.89, CI = 1.58-9.53). Conclusions: The implications of these results are profound, underscoring the immediate and imperative need for both medical and psychiatric interventions aimed at addressing the substantial psychological burden borne by this population because of the ongoing conflict.

Neurexan Prescription Is Associated with Lower Risk of Sleep Disorder Recurrence and Depression Prevalence as Compared to Z-Drugs and Benzodiazepines: A Retrospective Database Analysis in Germany

Real-world evidence on the association between natural medicinal products and the recurrence of sleep disorders is currently limited, particularly when compared to the evidence reported for prescription hypnotics. In a retrospective cohort analysis, we investigated patients with sleep disorders prescribed either the natural medicinal product Neurexan (Nx4), benzodiazepines, or nonbenzodiazepines (Z-drugs) using the IQVIA Disease Analyzer database, which encompasses electronic medical records nationwide in Germany. A 1:1 matching procedure based on age, sex, prevalent depression, anxiety or adjustment disorder, and the number of medical consultations in the past 12 months resulted in four cohorts: patients prescribed Nx4 were matched with those prescribed Z-drugs (two cohorts with 8594 matched patients each), and another cohort of patients prescribed Nx4 were matched with those prescribed benzodiazepines (7779 matched pairs). Results from multivariable-adjusted Cox regression models demonstrated that Nx4 was associated with a significantly lower risk of recurrent sleep disorder diagnosis within 30-365 days after prescription compared to both Z-drugs (HR = 0.65, 95%CI = 0.60-0.70, p < 0.001) and benzodiazepines (HR = 0.85, 95%CI = 0.79-0.93, p < 0.001). Additionally, Nx4 was associated with a lower prevalence of depression compared to Z-drugs (HR = 0.90, 95%CI = 0.83-0.98, p = 0.020) and benzodiazepines (HR = 0.89, 95%CI = 0.82-0.97, p = 0.009). These findings suggest an association between Nx4 and improved sleep and mental health outcomes. However, due to inherent limitations in the study design, the causality of this relationship cannot be stated.

Daridorexant treatment for chronic insomnia: a real-world retrospective single-center study

INTRODUCTION

Chronic insomnia disorder (CID) significantly impacts well-being and daily functioning. Daridorexant, a double orexin receptor blocker, has shown efficacy in randomized clinical trials and has been recently approved for the treatment of CID in adult patients. This retrospective observational study aimed to describe real-world data on daridorexant effectiveness and safety in adult patients with CID.

METHODS

Consecutive patients initiating on-label daridorexant at the Sleep Medicine Centre, University Hospital of Rome Tor Vergata were enrolled. Baseline and 30-day follow-up (FU) evaluations included patients' and CID characteristics, comorbidities, and clinicians' and patients' subjective ratings of changes with the Clinical and Patient Global Impression-Improvement scores (CGI-Is and PGI-Is), as well as Insomnia Severity Index (ISI) scores in a subgroup of patients.

RESULTS

Sixty-nine patients initiated 50-mg daily dosage. At FU, 58% of both patients and clinicians rated CID as improved on CGI-Is and PGI-Is, with no differences based on comorbidities, sex, or number of previous medications. No significant predictors of CGI-Is and PGI-Is improvement were identified. At FU, ISI scores (n = 24) significantly decreased from 18.25 ± 3.21 to 12.08 ± 6.12 (Z = 8.000; p < 0.001). Of these, eight patients (33.3%) had absence of insomnia symptoms, and no patients reported a worsening in ISI score categories.

CONCLUSIONS

This study suggests daridorexant to be effective and safe in real-world CID treatment whether used as a first-ever treatment, switch, or add-on, as reflected by subjective and objective measures and the absence of serious treatment-related adverse events. Future research on larger cohorts should explore daridorexant potential across diverse patient characteristics.

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.

Bioactive compounds from Ocimum tenuiflorum and Poria cocos: A novel natural Compound for insomnia treatment based on A computational approach

Insomnia, a widespread public health issue, is associated with substantial distress and daytime functionality impairments and can predispose to depression and cardiovascular disease. Cognitive Behavioral Anti-insomnia therapies including benzodiazepines often face limitations due to patient adherence or potential adverse effects. This study focused on identifying novel bioactive compounds from medicinal plants, aiming to discover and develop new therapeutic agents with low risk-to-benefit ratios using computational drug discovery methods. Through a systematic framework involving compound library preparation, evaluation of drug-likeness and pharmacokinetics, toxicity prediction, molecular docking, and molecular dynamic simulations, two natural compounds such as 2-(4-hydroxy-3-methoxyphenyl)-8-methoxy-6-prop-2-enyl-3,4-dihydro-2H-chromen-3-ol from Ocimum tenuiflorum and 7-(2-hydroxypropan-2-yl)-1,4a-dimethyl-9-oxo-3,4,10,10a-tetrahydro-2H-phenanthrene-1-carboxylic acid from Poria cocos exhibited high binding affinity with orexin receptor type 1 (OX1R) and type 2 (OX2R), surpassing commercial drugs used in insomnia treatment. Additionally, they showed interactions with critical amino acid residues within the receptors that play crucial roles in competitive inhibitor activity, like commercial drugs such as Suvorexant, Lemborexant, and Daridorexant. Further, molecular dynamics simulations of the protein-ligand complexes under conditions that mimic the in vivo environment revealed both compounds' sustained and robust interactions with the OX1R and OX2R, reinforcing their potential as effective therapeutic candidates. Furthermore, upon evaluating both compounds' drug-likeness, pharmacokinetics, and toxicity profiles, it was discerned that they displayed considerable drug-like properties and favorable pharmacokinetics, along with diminished toxicity. The research provides a solid foundation for further exploring and validating these compounds as potential anti-insomnia therapeutics.

The RU_SATED as a measure of sleep health: cross-cultural adaptation and validation in Chinese healthcare students

BACKGROUND

The RU_SATED scale is a multidimensional instrument measuring sleep health, consisting of Regularity, Satisfaction, Alertness, Timing, Efficiency, Duration dimensions. We adapted and validated the Chinese RU_SATED (RU_SATED-C) scale.

METHODS

The RU_SATED-C scale was developed through a formal linguistic validation process and was validated in an observational longitudinal survey design. Healthcare students completed the RU_SATED scale, Sleep Quality Questionnaire, and Patient Health Questionnaire-4 among two sites of Hangzhou and Ningbo, China. Psychometric assessments included structural validity, longitudinal measurement invariance, convergent and divergent validity, internal consistency, and test-retest reliability.

RESULTS

A total of 911 healthcare students completed the RU_SATED-C scale at baseline (Time 1, T1) and follow-up (Time 2, T2) with an average time interval of 7 days + 5.37 h. Confirmatory factor analysis (CFA) confirmed a single-factor model and resulted in an acceptable model fit. The two-factor model previously found in the Japanese version fit better than the one-factor model, whereas the one-factor model fit had a better fit than the two-factor model found in the English version. Longitudinal CFA resulted in negligible changes in fit indices for four forms of increasingly restrictive models and supported that a single-factor model was equivalent over time. The data also endorsed longitudinal measurement invariance among the two-factor models found in the English and Japanese samples. The RU_SATED-C scale total score displayed a moderately strong negative correlation with sleep quality; however, negligible associations were observed with anxiety and depression. Ordinal Cronbach's alpha and Ordinal McDonald's omega at T1 and T2 ranged from suboptimal to acceptable. The RU_SATED-C scale and all items were significantly correlated across time intervals.

CONCLUSION

The RU_SATED-C scale is an easy-to-use instrument with potentially valid data for the measurement of multidimensional sleep health. Use of the RU_SATED-C scale can help raise awareness of sleep health and could pave the way for important efforts to promote healthy sleep.

Treatment of insomnia based on the mechanism of pathophysiology by acupuncture combined with herbal medicine: A review

Insomnia is a sleep disorder which severely affects patients mood, quality of life and social functioning, serves as a trigger or risk factor to a variety of diseases such as depression, cardiovascular and cerebrovascular diseases, obesity and diabetes, and even increases the risk of suicide, and has become an increasingly widespread concern worldwide. Considerable research on insomnia has been conducted in modern medicine in recent years and encouraging results have been achieved in the fields of genetics and neurobiology. Unfortunately, however, the pathogenesis of insomnia remains elusive to modern medicine, and pharmacological treatment of insomnia has been regarded as conventional. However, in the course of treatment, pharmacological treatment itself is increasingly being questioned due to potential dependence and drug resistance and is now being replaced by cognitive behavior therapy as the first-line treatment. As an important component of complementary and alternative medicine, traditional Chinese medicine, especially non-pharmacological treatment methods such as acupuncture, is gaining increasing attention worldwide. In this article, we discuss the combination of traditional Chinese medicine, acupuncture, and medicine to treat insomnia based on neurobiology in the context of modern medicine.

A Systematic Review and Meta-Analysis Protocol to Establish How Common Clinical Acupoint Stimulation-Related Therapies Should Be Used for Managing Insomnia

Background

Many studies have now investigated the effects of common clinical acupoint stimulation-related therapies (ASRTs) following the meridian theory of traditional Chinese medicine for the management of insomnia. However, ASRT choice is currently based on personal clinical experience or patient preference. This study will review the common ASRTs reported in clinical trials and analyze their efficacy and safety for managing insomnia with or without co-morbidities.

Methods

English and Chinese databases will be thoroughly searched, and other potentially eligible trials will be obtained by reviewing reference lists of identified studies and previous reviews. Only randomized controlled trials (RCTs) of common clinical ASRTs to manage insomnia published in peer-reviewed journals will be considered. Sleep quality questionnaires or indices will be considered as the main outcome, while the secondary outcomes will include sleep parameters, daytime dysfunction, quality of life, and adverse effects. Two reviewers will independently investigate eligible RCTs, extract information, analyze their methodological quality, and employ Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria to evaluate the strength of the evidence. The treatment impact of various ASRTs will be calculated using meta-analysis techniques, and the degree of study heterogeneity will be assessed using Cochrane's Q and I-squared statistics. Subgroup and sensitivity analyses will be used to evaluate the reliability of the results.

Results

Our systematic review and meta-analysis will present up-to-date evidence on: 1) which common clinical ASRTs are beneficial for the management of insomnia; and 2) whether the effects of common clinical ASRTs on insomnia vary depending on clinical, participant, and treatment characteristics.

Conclusion

The results of our review should help decision-makers make educated choices regarding evidence-based non-pharmacological management options for insomnia.

Study Registration

The International Platform of Registered Systematic Review and Meta-analysis (INPLASY), record INPLASY2021120137.

Chronic Insomnia Disorder across Europe: Expert Opinion on Challenges and Opportunities to Improve Care

One in ten adults in Europe have chronic insomnia, which is characterised by frequent and persistent difficulties initiating and/or maintaining sleep and daily functioning impairments. Regional differences in practices and access to healthcare services lead to variable clinical care across Europe. Typically, a patient with chronic insomnia (a) will usually present to a primary care physician; (b) will not be offered cognitive behavioural therapy for insomnia-the recommended first-line treatment; (c) will instead receive sleep hygiene recommendations and eventually pharmacotherapy to manage their long-term condition; and (d) will use medications such as GABA receptor agonists for longer than the approved duration. Available evidence suggests that patients in Europe have multiple unmet needs, and actions for clearer diagnosis of chronic insomnia and effective management of this condition are long overdue. In this article, we provide an update on the clinical management of chronic insomnia in Europe. Old and new treatments are summarised with information on indications, contraindications, precautions, warnings, and side effects. Challenges of treating chronic insomnia in European healthcare systems, considering patients' perspectives and preferences are presented and discussed. Finally, suggestions are provided-with healthcare providers and healthcare policy makers in mind-for strategies to achieve the optimal clinical management.

Targeting Orexin Receptors for the Treatment of Insomnia: From Physiological Mechanisms to Current Clinical Evidence and Recommendations

After a detailed description of orexins and their roles in sleep and other medical disorders, we discuss here the current clinical evidence on the effects of dual (DORAs) or selective (SORAs) orexin receptor antagonists on insomnia with the aim to provide recommendations for their further assessment in a context of personalized and precision medicine. In the last decade, many trials have been conducted with orexin receptor antagonists, which represent an innovative and valid therapeutic option based on the multiple mechanisms of action of orexins on different biological circuits, both centrally and peripherally, and their role in a wide range of medical conditions which are often associated with insomnia. A very interesting aspect of this new category of drugs is that they have limited abuse liability and their discontinuation does not seem associated with significant rebound effects. Further studies on the efficacy of DORAs are required, especially on children and adolescents and in particular conditions, such as menopause. Which DORA is most suitable for each patient, based on comorbidities and/or concomitant treatments, should be the focus of further careful research. On the contrary, studies on SORAs, some of which seem to be appropriate also in insomnia in patients with psychiatric diseases, are still at an early stage and, therefore, do not allow to draw definite conclusions.

Long-Term Safety and Tolerability of Daridorexant in Patients with Insomnia Disorder

BACKGROUND AND OBJECTIVE

Daridorexant is a dual orexin receptor antagonist for the treatment of insomnia. In two phase III, 12-week studies in patients with insomnia disorder, daridorexant improved sleep and daytime functioning while maintaining a favorable safety profile. The objective of this 40-week extension study was to assess the long-term safety and tolerability of daridorexant.

METHODS

Adults with insomnia disorder who completed the 12-week studies were invited to enroll in this double-blind extension study. Patients originally randomised to daridorexant (10 mg/25 mg/50 mg) remained on their respective treatments; patients randomised to placebo were re-randomised to daridorexant 25 mg or placebo. The 40-week treatment period was followed by a 7-day placebo run-out. The primary objective was to assess safety/tolerability. Exploratory objectives were to evaluate the efficacy of daridorexant on sleep (self-reported total sleep time) and daytime functioning (Insomnia Daytime Symptoms and Impacts Questionnaire).

RESULTS

In total, 804 patients were enrolled in the study, of whom 801 received at least one dose of the study treatment and 550 patients (68.4%) completed the study. Overall incidence of treatment-emergent adverse events was similar across groups (35-40%). Daridorexant did not induce next-morning sleepiness and no withdrawal-related symptoms or rebound were observed after treatment discontinuation. Improvements in sleep and daytime functioning were maintained through to the end of the study and were most pronounced with daridorexant 50 mg. Daridorexant 50 mg, compared with placebo, increased self-reported total sleep time by a least-squares mean of 20.4 (95% confidence interval [CI] 4.2, 36.5), 15.8 (95% CI - 0.8, 32.5) and 17.8 (95% CI - 0.4, 35.9) minutes and decreased (i.e., improved) Insomnia Daytime Symptoms and Impacts Questionnaire total scores by a least-squares mean of - 9.3 (95% CI - 15.1, - 3.6), - 9.5 (95% CI - 15.4, - 3.5) and - 9.1 (95% CI - 15.6, - 2.7), at weeks 12, 24 and 36 of the extension study, respectively.

CONCLUSIONS

Treatment with daridorexant, for up to 12 months, was generally safe and well tolerated. Exploratory efficacy analyses suggest that the sustained improvements in sleep and daytime functioning with daridorexant 50 mg support its use for long-term treatment of insomnia disorder, without concerns of new safety signals.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03679884) [first posted: 21 September, 2018], https://clinicaltrials.gov/ct2/show/NCT03679884 .

Insomnia among female flight attendants: Related factors and its association with mental health

BACKGROUND

Sleep and mental health are very important in the aviation industry. Reports show that gender is one of the risk factors of insomnia, and most Asian flight attendants are female. Therefore, it is necessary to understand insomnia, and the correction to mental health among female flight attendants.

OBJECTIVE

To investigate the prevalence of insomnia in female flight attendants and its association with mental health.

METHODS

We used a cross-sectional design. We recruited 412 female flight attendants with more than 3 months of working experience. We collected the socio-demographic and work-related data, measured insomnia and mental health by the Athens Insomnia and Brief Symptom Rating Scales. Descriptive statistics, single-factor analysis of variance, Pearson's correlation analysis, and structural equation modeling were performed to analyze the relationships.

RESULTS

There are 45.4% of female flight attendants having insomnia, and 24.8% had suspicious insomnia. The most considerable and serious insomnia problem was falling asleep (15.3%, 4.9%). Factors related to insomnia include smoking, drinking, family load (e.g., housekeeping and caring for family), economic stress and late-night/early morning workdays during last month. Also, insomnia had a direct association with mental health (T = 17.11, p < 0.001).

CONCLUSION

We found that insomnia is negatively correlated with the above factors and mental health. We recommend that airline industries can run their sleep-education programs and provide relevant mental-health-promotion programs for flight attendants.

Assessing cognitive behavioral therapy for insomnia in individuals with cannabis use disorder utilizing actigraphy and serum biomarkers: A pilot study

OBJECTIVE/BACKGROUND

This pilot study aims to assess the effect of Cognitive Behavioral Therapy for insomnia (CBTi) in individuals with cannabis use disorder and insomnia. It also aims to investigate the effect of CBTi on levels of serum inflammatory markers in relation to insomnia symptoms.

METHODS/PATIENTS

Individuals with cannabis use disorder and insomnia symptoms were recruited over 18 months. Data collected included demographics, self-reported sleep parameters, and cannabis use. Blood samples were drawn to measure IL-2, IL-6, CRP, and cortisol. Participants completed the Insomnia Severity Index questionnaire (ISI) and the Patient Health Questionnaire-4 (PHQ-4), and they were provided with an actigraphy (wrist) device for 1 week before CBTi and a subsequent week after completing the 4 CBTi sessions.

RESULTS

Nineteen participants were enrolled in the study. The mean ISI score decreased from moderately severe insomnia at baseline to no clinically significant insomnia after CBTi with a sustained decrease at 3- and 6-months follow-up. Actigraphy showed a significant decrease in sleep onset latency (SOL) after CBTi. Three months after CBTi, 80% of participants reported a decrease in their cannabis use. There was also a significant and sustained decrease in mean PHQ-4 scores after CBTi. Although only trending towards significance, the levels of three out of four biomarkers (IL-2, IL-6, CRP) were decreased 6 months after CBTi.

CONCLUSIONS

CBTi is effective as a short- and long-term treatment of insomnia and comorbid anxiety/depression in individuals who regularly use cannabis. A potential added benefit is a reduction in cannabis consumption and inflammatory serum biomarkers.

Transcranial magnetic stimulation combined with transcranial direct current stimulation in patients with chronic insomnia: a case report

Long-term insomnia affects the normal life and work of individuals and increases the risk of various health problems, including mental illness. Therefore, there is an urgent need for an efficient and safe treatment for improving sleep. In this study, we report the case a 52-year-old woman who received repetitive transcranial magnetic stimulation (rTMS) combined with transcranial direct current stimulation (tDCS) after agreeing to publish her case. In order to evaluate the quality of sleep and the stability of emotional symptoms, clinical evaluations were conducted at baseline, after 10 treatment sessions, after 20 treatment sessions, and 1 month after the end of treatment. After completing rTMS combined with tDCS, the patient showed an overall clinical improvement, with clinical changes mainly observed in the Pittsburgh Sleep Quality Index, Hamilton Depression Scale, Hamilton Anxiety Scale scores and polysomnography, and this improvement was maintained 1 month after the intervention. This case provides the first evidence for the feasibility, tolerability, and safety of combined rTMS and tDCS in a patient with chronic insomnia.

CLINICAL TRIAL REGISTRATION

Registry: Chinese Clinical Trial Registry; Name: Clinical study of repetitive transcranial magnetic stimulation combined with transcranial direct current stimulation in the treatment of chronic insomnia; URL: http://www.chictr.org.cn/edit.aspx?pid=57440&htm=4; Identifier: ChiCTR ChiCTR2100052681.

CITATION

Zhou Q, Liu Z, Zhao S, et al. Transcranial magnetic stimulation combined with transcranial direct current stimulation in patients with chronic insomnia: a case report. J Clin Sleep Med. 2022;18(12):2871-2873.

"Thinking About Thinking" in Insomnia Disorder: The Effect of Cognitive-Behavioral Therapy for Insomnia on Sleep-Related Metacognition

Metacognition is defined as the ability to reflect on one’s mental state and to govern thoughts and beliefs. Metacognitive dysfunctions are typical of several psychopathologic conditions, and also a feature of insomnia disorder, possibly playing a crucial role in its genesis and maintenance. In the context of insomnia, metacognition describes how individuals react to their own sleep-related thoughts and beliefs, boosting the hyperarousal state experienced by these patients. Up to now, no studies evaluated the effect of cognitive behavioral therapy for insomnia (CBT-I) on metacognitive functioning. Therefore, the aim of our study was to evaluate the effect of CBT-I administered in group format in patients with insomnia disorder. As expected, all patients showed significant improvements in both insomnia and sleep diary parameters after treatment. Furthermore, an improvement was observed also in dysfunctional metacognitive levels, assessed by means of the Metacognitions Questionnaire-Insomnia (MCQ-I). However, 63% of patients still showed a MCQ-I score above the clinical cutoff after treatment. Dividing the sample on the basis of MCQ-I questionnaire scores after CBT-I, we found that patients, who still presented metacognitive impairment, received significant beneficial effects from CBT-I both on insomnia symptoms and on dysfunctional beliefs, but not on dysfunctional metacognitive functioning. These findings suggest that metacognition should be carefully evaluated in insomnia patients and further studies are needed to evaluate long-term implications of this remaining dysfunction.