The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Effect of daridorexant on nighttime wakefulness and next-morning sleepiness: assessing the transition from night to day in insomnia disorder

OBJECTIVE/BACKGROUND

Reducing wakefulness throughout the night without next-day residual effects are essential characteristics for drugs for chronic insomnia disorder. In Phase 3 trials, daridorexant significantly reduced polysomnography-determined wake after sleep onset (WASO) versus placebo, and rates of daytime somnolence were similar to placebo. This analysis examines the effect of daridorexant on WASO in each 2-h quarter (Q) of the night (8-h recording), and on next-morning sleepiness, daytime alertness and ability to function (assessed daily using visual analog scales [VAS]), and the correlation between these night and day assessments.

PATIENTS/METHODS

Data from 930 patients with insomnia disorder randomized to daridorexant 50 mg (n = 310), 25 mg (n = 310) or placebo (n = 310) for 3 months were analyzed.

RESULTS

At Month 1, daridorexant 25 mg and 50 mg significantly decreased WASO versus placebo in Q2 (least-square mean difference [LSMD] 25 mg: -4.7 min p < 0.0001; 50 mg: -7.1 min p < 0.0001), Q3 (LSMD 25 mg: -3.3 min p = 0.0086; 50 mg: -7.2 min p < 0.0001) and Q4 (LSMD 25 mg: -4.3 min p = 0.0055; 50 mg -8.5 min p < 0.0001). Results were similar at Month 3. VAS scores for next-morning sleepiness, daytime alertness and ability to function improved from Day 1 in all groups and continued to improve over time, with treatment numerically ranked as daridorexant 50 mg > 25 mg > placebo. No significant correlations were found between WASO (overall and at any quarter) and the three VAS scores.

CONCLUSION

Daridorexant reduces wakefulness throughout the entire night while independently decreasing morning sleepiness and improving daytime functioning and alertness.

Effectiveness of group-delivered cognitive behavioural therapy for insomnia in primary care: a pragmatic, multicentre randomised controlled trial

Insomnia is a prevalent disorder in the general population. Group delivery increases access to the treatment of choice for insomnia, cognitive-behavioural therapy for insomnia (CBT-I). The aim of this pragmatic randomized controlled trial was to investigate the effectiveness of low-threshold group-delivered CBT-I implemented in Norwegian primary care. The trial was registered in the ISRCTN registry (ISRCTN16185698), and conducted across 26 Healthy Life Centres. Inclusion criteria were age ≥ 18 years and insomnia symptoms with a significant impact (Insomnia Severity Index (ISI) ≥ 12). Eligible participants were randomized to group-delivered CBT-I or to a waiting list according to a 2:1 ratio. The intervention consisted of four 2-h sessions over 4 weeks, with 5-15 participants per group. Primary outcome was self-reported insomnia severity at 3-months follow-up, measured by the ISI. Participants were not blinded to group assignment, but those responsible for analyses and interpretation of the results were. In total, 308 participants were randomly allocated to group-delivered CBT-I (n = 181) or waiting list (n = 127). The mean difference in ISI score between groups at 3-months follow-up was -3.4 (95 % CI: 4.3 to -2.5), favoring the group-delivered CBT-I. Of those receiving group-delivered CBT-I, 51 (33.6 %) reported a clinically relevant improvement in insomnia severity (i.e., ≥ 8 points on ISI), compared to 15 (13.2 %) on the waiting list (OR 3.4, 95 % CI: 1.7 to 6.8). Thus, group-delivered CBT-I reduced insomnia severity at 3-months follow-up for adults with insomnia. Group-delivered CBT-I offered at Healthy Life Centres is a suitable low-threshold treatment for insomnia in primary care.

World Sleep Society recommendations for the use of wearable consumer health trackers that monitor sleep

Wearable consumer health trackers (CHTs) are increasingly used for sleep monitoring, yet their utility remains debated within the sleep community. To navigate these perspectives, we propose pragmatic, actionable recommendations for users, clinicians, researchers, and manufacturers to support CHT usage and development. We provide an overview of the evolution of multi-sensor CHTs, detailing common sensors and sleep-relevant metrics. We advocate for standardized 'fundamental sleep measures' across manufacturers, distinguishing these from proprietary exploratory metrics with future potential. We outline best practices for using CHT-derived sleep data in healthy individuals while addressing current device limitations. Additionally, we explore their role in evaluating and managing individuals at risk for or diagnosed with insomnia, sleep apnea, or circadian rhythm sleep-wake disorders. Guidance is provided on device selection to align with their intended use and on conducting and interpreting performance evaluation studies. Collaboration with manufacturers is needed to balance feature comprehensiveness with clinical utility and usability. Finally, we examine challenges in integrating heterogeneous sleep data into clinical health records and discuss medical device certification for specific wearable CHT features. By addressing these issues, our recommendations aim to inform the usage of CHTs in the global community and to begin bridging the gap between consumer technology and clinical application, maximizing the potential of CHTs to enhance both personal and community sleep health.

Obesity and sleep disorders: A bidirectional relationship

AIMS

Obesity and sleep disorders are highly prevalent conditions with profound implications for public health. Emerging evidence highlights a bidirectional relationship between these two conditions, with each exacerbating the other in a complex interplay of behavioral, physiological, and hormonal mechanisms. Sleep deprivation and poor sleep quality contribute to energy imbalance through dysregulation of appetite hormones (e.g., leptin and ghrelin), increased caloric intake, and reduced physical activity. Conversely, sleep disorders such as obstructive sleep apnea syndrome (OSAS), insomnia, and restless leg syndrome (RLS) are significantly more common in individuals with obesity.

DATA SYNTHESIS

This review explores the pathophysiological mechanisms underlying this relationship, including the roles of inflammation, autonomic dysregulation, and neuroendocrine pathways. Sleep loss exacerbates metabolic syndrome components, including insulin resistance and dyslipidemia, further perpetuating weight gain. Similarly, obesity-induced sleep disorders lead to pro-inflammatory states, vascular dysfunction, and sympathetic overactivation, compounding cardiometabolic risks. Specific conditions like OSA and RLS are examined as models of this interdependence, emphasizing their shared pathways and clinical implications.

CONCLUSIONS

The bidirectional link between obesity and sleep disorders underscores the importance of integrating sleep assessment and management into obesity treatment strategies. Addressing this relationship could mitigate the progression of cardiometabolic comorbidities and improve overall health outcomes. Moreover, the intertwined dynamics between obesity, sleep disorders, and mental health-mediated by inflammatory pathways, hormonal dysregulation, and neurobehavioral factors-highlight the critical need for integrated treatment approaches targeting physical, psychological, and sleep-related dimensions to enhance health and quality of life.

Integrating digital behavioural therapy for insomnia into primary care: A feasibility mixed-methods study

Digital cognitive behavioural therapy for insomnia has been developed to increase capacity and scalability for patients with insomnia, but implementation in primary care remains limited. The aim of the trial was to evaluate the implementation of digital insomnia therapy into primary care practice for patients with insomnia. We conducted a single-arm feasibility trial of digital behavioural therapy for insomnia (SleepFix) providing sleep restriction therapy with insomnia patients in primary care. Healthcare professionals (comprising General Practitioners, community pharmacists and nurses) were enrolled into the trial and, when deemed clinically appropriate, prescribed SleepFix to patients with insomnia. The primary outcome was uptake assessed by the number of downloads of SleepFix. Interviews with primary care healthcare professionals explored their attitudes towards implementing/using insomnia digital therapeutics in clinical practice, and patients about their experiences with SleepFix. Insomnia symptoms, mood and sleep quality were measured before and after the trial. This trial was prospectively registered (ACTRN12620000055909). Thirty healthcare professionals and 105 patients were enrolled into the trial. Fourteen healthcare professionals administered at least one insomnia digital therapeutic prescription between November 2021 and March 2022. Fifty patients downloaded and used SleepFix (47.6% uptake). In post-trial interviews, healthcare professionals felt they could incorporate digital sleep health into clinical practice and patients found SleepFix acceptable. There were significant improvements in insomnia symptoms, mood and sleep quality at week 6 (all p < 0.05). This trial shows a real-world implementation of a digital insomnia therapy into primary care that could provide a framework for prescribing digital sleep interventions.

Smartphone application-delivered cognitive behavioural therapy for insomnia with telephone support for insomnia disorder compared to a waitlist control: a randomised clinical trial

Although there have been promising findings for smartphone application (app)-delivered cognitive behavioural therapy for insomnia (CBT-I), previous trials have not screened participants rigorously for insomnia disorder and used therapist support. Based on the above, we aimed to examine the effects of smartphone app-delivered CBT-I with telephone support against a waitlist (WL) in a sample with insomnia disorder. A total of 64 participants with insomnia disorder were randomised to smartphone app-delivered CBT-I (n = 32) or a WL (n = 32). Smartphone app-delivered CBT-I consisted of six weekly smartphone app modules with 15 min of telephone support per week. At pre- and post-treatment, and the 3-month follow-up, we assessed insomnia symptoms and associated correlates and consequences. At post-treatment, we also assessed measures related to adherence (therapist support, exercise/module completion), self-rated perception of treatment content, activity, and adverse events. CBT-I significantly outperformed the WL with large effects on the primary outcome (d = 2.26) and was significantly different on most of the secondary outcomes with medium to large effects. CBT-I also resulted in a significantly larger proportion of treatment remitters (CBT-I: 64.5-77.4%, WL: 6.5-6.9%) and responders (CBT-I: 77.4-90.3%, WL: 19.4-24.1%) at post-treatment and follow-up, compared to the WL. Treatment was associated with high satisfaction, high adherence, low attrition, and few treatment-impeding adverse events. Based on the medium to large effects of smartphone app-delivered CBT-I with telephone support, this trial highlights the potential of delivering CBT-I exclusively through an app with therapist telephone support for high efficacy, satisfaction, and adherence.

Sleep Disorders in CKD: A Review

Sleep disorders are highly prevalent in patients with chronic kidney disease (CKD) but are often underrecognized. The most common sleep disturbances in people with CKD include insomnia, sleep apnea syndrome, restless legs syndrome, and periodic limb movement disorder. The presence of sleep disorders in CKD can further worsen the burden of high morbidity and mortality in a patient population with already high mortality rates. The detection and management of sleep disorders in patients with CKD are often challenging because the classic symptoms of sleep disorders (poor concentration, daytime sleepiness, and insomnia) overlap with CKD symptomatology. The treatment of one symptom may have a negative impact on others; hence treatment of these disorders is challenging and may need to be individualized and modified based on the response to treatment and the development of adverse effects. However, treatment of sleep disorders may have significant clinical benefits, leading to improved health-related quality of life. This Review presents an overview of sleep disorders in patients with CKD, with emphasis on relevant pathophysiology, diagnosis and treatment strategies.

Insomnia symptoms predict systemic inflammation in women, but not in men with inflammatory bowel disease

Insomnia has been suggested as a potential modulator of systemic inflammation. However, few studies have examined the longitudinal association between insomnia and inflammation as well as the role of sex differences, despite accumulating evidence of the vulnerability of women to immune consequences of disturbed sleep. In this study, we tested the association between self-reported insomnia symptoms and serum C-reactive protein, a marker of systemic inflammation, at 1-year follow-up, in 54 outpatients with inflammatory bowel disease (52.81 ± 16.09, 40.7% women). Insomnia symptoms were measured using the Insomnia Severity Index. After controlling for baseline inflammation and health variables, longitudinal moderated regression analysis showed that baseline insomnia symptoms predicted C-reactive protein levels at follow-up in women (β = 0.416, p = 0.014), but not in men (β = -0.179, p = 0.212). Results were not influenced by sex differences in insomnia severity or C-reactive protein levels. This study suggests insomnia symptoms may partially influence systemic inflammation in women with inflammatory bowel disease. Sex-specific psychological, immune and neuroendocrine pathways linking sleep to inflammation should be further elucidated.

Senegenin regulates the mechanism of insomnia through the Keap1/Nrf2/PINK1/Parkin pathway mediated by GAD67

GAD67 impacts insomnia as a key enzyme catalysing the conversion of glutamate (Glu) to gamma-aminobutyric acid (GABA). Senegenin enhances neuroprotection and is used widely to treat insomnia and other neurological diseases. This study aimed to investigate how senegenin regulates insomnia through a GAD67-mediated signalling pathway. We measured GAD67 expression levels in insomnia patients and evaluated the expression levels of GAD67 and Keap1/Nrf2/Parkin/PINK1-related cytokines following GAD67 lentiviral transfection in PC12 cells and in rat models. We also assessed cellular reactive oxygen species (ROS) and mitochondrial membrane potential levels. Additionally, EEG/EMG was used to analyse the sleep phases of rats and to assess memory and exploration functions. Pathological changes and the expression of GAD67 and sleep-related proteins in the hippocampus were examined. The results showed that GAD67 expression was increased in insomnia patients, ROS levels were elevated, and the mitochondrial membrane potential was decreased in the GAD67-KD group. Insomnia rats exhibited changes in sleep rhythm, learning, and exploration dysfunction, pathological changes in the CA1 region of the hippocampus, and differential expression of GAD67 and sleep-related factors. Inhibitory neurofactor expression levels were decreased in insomnia rats, showing a positive correlation in the GAD67-KD group and a negative correlation in the GAD67-OE group. Conversely, excitatory factor expression levels were increased in insomnia rats, showing a positive correlation in the GAD67-KD group and a negative correlation in the GAD67-OE group. Senegenin intervention modulated cytokine expression levels. In conclusion, GAD67 negatively regulates insomnia, and senegenin can regulate insomnia by mediating the expression of cytokines in the GAD67-regulated Keap1/Nrf2/Parkin/PINK1 pathway.

Predictability of sleep in insomnia: sleep patterns of patients from a sleep psychology clinic

The present study aims at identifying sleep patterns in insomnia in a clinical sample using three strategies to define poor nights. Sleep diaries and self-reported questionnaires were collected from 77 clinical patients with insomnia. The conditional probabilities of observing a poor night after 1, 2, or 3 consecutive poor nights were computed according to three strategies with same criteria for sleep onset latency, wake after sleep onset, and sleep efficiency, but varying criterion for total sleep time. Latent profile analyses were conducted to derive sleep patterns. Uni- and multivariate analyses were conducted to characterise the sleep patterns identified. A total of 1586 nights were analysed. The strategy used significantly influenced the average percentage of reported poor nights. Two to three sleep patterns were derived per strategy. Within each strategy, sleep patterns differed from each other on sleep variables and night-to-night variability. Results suggest the existence of sleep patterns in insomnia among individuals consulting in psychological clinics. Adding a total sleep time of 6-h cut-off as a criterion to define poor nights increases the accuracy of the strategy to define poor night and allows to identify sleep patterns of poor nights in insomnia.

Association between dual orexin receptor antagonists (DORAs) and suicidality: reports to the United States Food and Drug Administration Adverse Event Reporting System (FAERS)

BACKGROUND

Package inserts for the FDA-approved dual orexin receptor antagonists (DORAs) suvorexant, lemborexant and daridorexant state that suicide risk should be monitored. It remains unknown whether suicidality is attributed to DORAs. We aim to evaluate suicidality associated with DORAs reported to the FDA Adverse Event Reporting System (FAERS).

METHODS

The reporting odds ratio (ROR) was determined with trazodone as the control. Significant disproportionate reporting was determined when 95% confidence intervals (CIs) did not encompass 1.0. We used information components (ICs) to calculate the lower limit of the 95% CI (IC025). IC was significantly increased when the IC025 ≥0.

RESULTS

Suvorexant (0.025 ROR), lemborexant (0.019 ROR) and daridorexant (0.002 ROR) were significantly associated with lower odds of reported completed suicides compared to trazodone (p < 0.05). There was no significantly increased RORs for the DORAs regarding suicidal ideation, depression suicidal, suicidal behavior and suicide attempts. Nonsignificant associations between all parameters of suicidality were observed for each DORA using IC025.

CONCLUSION

We did not find a significant association between any parameter of suicidality captured in the FAERS for each DORA. All persons treated for insomnia pharmacologically/non-pharmacologically should be evaluated for emergence/worsening of any suicidality aspect.

Sleep-related safety behaviours predict insomnia symptoms 1 year later in a sample of university students

Several studies have demonstrated the relevance of cognitive factors in the development of insomnia complaints, but very few have investigated how these factors influence the development of insomnia complaints over time. In this study we set out to investigate key factors associated with present insomnia severity and the development of insomnia complaints over time. We employed a two-wave longitudinal design where we measured insomnia severity, pre-sleep arousal, dysfunctional beliefs about sleep, sleep-related worry and safety-behaviours in a sample of students at baseline and 1 year later. At baseline, 353 respondents filled in the questionnaires and 79 completed these a year later. In the cross-sectional analyses, pre-sleep arousal and sleep-related worry were unique contributors to insomnia severity. Using baseline data to predict insomnia severity 1 year later, only sleep-related safety emerged as a predictor. These findings suggest that sleep-related worry and pre-sleep arousal are the primary factors influencing current severity. In terms of development and/or persistence, sleep safety may constitute a potentially underestimated factor.

Chain-mediation effect of cognitive flexibility and depression on the relationship between physical activity and insomnia in adolescents

BACKGROUND

Physical activity has positive benefits in promoting the physical and mental health of adolescents. This study focuses on the importance of adolescent mental health issues, exploring the relationship between physical activity and insomnia in adolescents, as well as the mediating roles and pathways of cognitive flexibility and depression.

METHODS

A cross-sectional study was conducted using self-reports to collect data on physical activity, insomnia, cognitive flexibility, and depression. A total of 501 valid questionnaires were collected from two middle schools in the western region of Hunan Province.

RESULTS

Physical activity directly and significantly predicted insomnia negatively (β =-0.153, SE = 0.047, p < 0.01). However, the predictive effect of physical activity on insomnia was no longer significant in the indirect effect analysis (β =-0.053, SE = 0.041, p > 0.05). Serial mediation analyses identified significant indirect effects through cognitive flexibility and depression in sequence (β =-0.029, 95% CI [-0.053,-0.011]), accounting for 18.95% of the total effect.

CONCLUSIONS

The study strengthens evidence for the associations between adolescent physical activity, insomnia, cognitive flexibility and depression, demonstrating that the beneficial effects of physical activity on insomnia are sequentially mediated through cognitive flexibility and depression. Given the dual benefits of physical activity for both sleep quality and mental health, we recommend implementing targeted physical activity interventions for adolescents, with particular emphasis on activities designed to enhance cognitive flexibility.

Exploring Pregnant Women's Perspectives in Developing a WeChat-Delivered Cognitive Behavioral Therapy for Insomnia: A Qualitative Study

STUDY OBJECTIVES

This study aims to explore the perception of a WeChat-delivered cognitive behavioral therapy for insomnia (CBT-I) to manage insomnia in pregnant women in mainland, China.

METHODS

A descriptive qualitative research design was used. Focus groups and individual interviews with semi-structured questions were conducted via a video conferencing platform with 29 Chinese pregnant women with insomnia symptoms during December 2023 to March 2024. Data were analyzed using content analysis.

RESULTS

Three themes and 10 subthemes were identified: (1) Appreciating sleep intervention for pregnancy insomnia; (2) Suggestions for intervention contents; (3) Recommendations on the format of WeChat articles. Participants appreciated the intervention's focus on pregnancy insomnia, recognizing its potential to address previously overlooked challenges. Participants indicated a willingness to engage with the program, although they raised concerns about an excessive focus on sleep-related issues. Suggestions for content improvement included using clear and plain language, incorporating scientific explanations to reinforce credibility, combining generalized content with personalized insomnia solutions, and including information relevant to the perinatal period. Participants also emphasized the need for family involvement to support them in managing insomnia. Regarding the format of WeChat articles, participants highlighted form is secondary to content helpfulness, while many suggested using engaging titles and visuals. Additionally, some prefer the short-form videos delivered via short video platforms over WeChat-delivered methods.

CONCLUSIONS

WeChat for delivering CBT-I for reducing insomnia symptoms was well received by the Chinese pregnant women and the identified main features may facilitate the design for future intervention studies.

The predictive value of insomnia for the treatment outcome of pharmacotherapy, psychotherapy, and combined therapy in major depressive disorder: A mega-analysis of five randomised clinical trials

BACKGROUND

Insomnia represents a common sleep disorder in major depressive disorder (MDD) that is associated with unfavourable treatment outcomes. Yet, it is unknown whether this relationship varies between treatment modalities. The present study aimed to evaluate the predictive value of insomnia for remission status following pharmacotherapy, psychotherapy, and combined therapy.

METHODS

Data were obtained from five randomised clinical trials investigating the efficacy of MDD treatment in a homogeneous study population. Patients with MDD (N = 898) aged between 18 and 65 years were assessed for insomnia (item score ≥ 2) and remission (total score ≤ 7) using the Hamilton depression rating scale (HDRS-17). Logistic regression analyses were performed to evaluate and compare the predictive value of pre-treatment insomnia for remission status following 24 weeks of treatment while controlling for sex, age, and baseline depression severity.

RESULTS

Insomnia was associated with significantly lower odds of remission overall (OR = 0.618, 95%CI [0.450-0.849]) as well as for pharmacotherapy (OR = 0.219, 95%CI [0.069-0.692]) and combined therapy (OR = 0.583, 95%CI [0.348-0.976]) but not for psychotherapy. The predictive value was, however, not significantly different between the treatment modalities even though direct comparisons revealed significantly higher odds of remission following psychotherapy compared to pharmacotherapy in the insomnia relative to the control group (OR = 3.414, 95%CI [1.013-11.505]).

CONCLUSION

Insomnia is associated with a decreased likelihood of remission in MDD. The most profound impact is observed for pharmacotherapy and combined therapy whereas the clinical relevance for psychotherapy appears modest.

Non-guided, mobile, CBT-I-based sleep intervention in War-torn Ukraine: A feasibility study

BACKGROUND

War conditions can severely impact sleep and mental health at the population level, especially in the conflicts of such tremendous scale as in Ukraine. The aim of this research was to study whether a mobile, unguided Cognitive Behavioral Therapy-based Intervention for sleep problems, Sleep2, is feasible, acceptable, and potentially able to reduce mental health/sleep problems symptoms.

METHODS

A single-arm, open-label, uncontrolled pre-post evaluation study was conducted with 487 registered participants: 283 started, 160 (56.55%) finished, out of which 95 completed without an ambulatory heart rate (HR) sensor and 65 with. Assessments were conducted through online questionnaires and objective measurements via HR sensors. Besides feasibility and acceptability, outcome measures included symptoms in several mental health domains alongside self-reported and objectively reported sleep parameter.

RESULTS

Engagement with the Sleep2 app was high, achieving an 80.72% compliance rate, alongside high levels of feasibility and acceptance. Participants reported significant pre-post reductions in the severity of symptoms, with sleep problems decreasing by 22.60% (Cohen's d = 0.53), insomnia by 35.08% (d = 0.69), fear of sleep by 32.43% (d = 0.25), anxiety by 27.72% (d = 0.48), depression by 28.67% (d = 0.52), PTSD by 32.41% (d = 0.51), somatic symptoms by 24.52% (d = 0.51), and perceived stress by 17.90% (d = 0.39). Objective sleep measurements showed a significant reduction in sleep onset latency only.

CONCLUSION

The 'Sleep2Ukraine' program demonstrated high feasibility and acceptance, with significant improvements in subjective sleep and mental health measures among participants. However, given the study's uncontrolled design and reliance on self-selected participants, these findings should be considered preliminary. Randomized controlled trials are needed to establish efficacy. Nonetheless, the results highlight the potential of culturally adapted, scalable, mobile-based CBT-I interventions to address sleep and mental health needs in war-affected populations.

Innovative Digital Cognitive Behavioral Treatment for Insomnia Disorder in Adults (dCBT-i): Framework Development

BACKGROUND

Chronic insomnia, or insomnia disorder, is a major health issue with a prevalence of up to 15%. The recommended first-line treatment is cognitive behavioral therapy for insomnia (CBT-i), which, unfortunately, remains insufficiently accessible. Digitalization has the potential to reduce health care access inequalities by offering more flexible and accessible care options. Digital CBT-i (dCBT-i) has been shown to be as effective as in-person CBT-i, highlighting its potential for broader implementation.

OBJECTIVE

This study aimed to develop an evidence-based dCBT-i program grounded in theoretical and clinical knowledge, designed for efficient integration into health care systems, and to establish it as the first prescribed digital treatment in France.

METHODS

The program was constructed based on validated CBT-i theory and practice, incorporating the latest scientific data on CBT for insomnia. It was designed as a robust multicomponent therapy, integrating an initial standardized assessment and daily intelligent adaptation to enable digital phenotyping and provide personalized treatment.

RESULTS

We developed an innovative digital solution that combines scientific rigor with practical application. The program includes a standardized initial evaluation and dynamic personalization through intelligent algorithms. These features allow for the adaptation of therapy based on patient progress and needs, ensuring individualized care.

CONCLUSIONS

The development of this dCBT-i program represents a significant milestone in digital health care, offering a scalable solution to the accessibility challenges of traditional CBT-i. Future steps involve conducting clinical studies to further evaluate its effectiveness and optimize its implementation within health care systems.

Reasonable access to brief behavioural insomnia treatment among medical and psychiatric outpatients (RABBIT): a multicentre randomised controlled trial protocol

INTRODUCTION

Insomnia is a significant global health issue associated with substantial economic costs. International guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as the first-line treatment for chronic insomnia; however, pharmacotherapy remains more common in clinical practice. Maintaining the effectiveness while reducing the time and frequency of CBT-I is essential for its implementation. We conducted a randomised controlled trial (RCT) to evaluate the effectiveness of a brief behavioural treatment for insomnia (BBTI) that focuses on sleep restriction and stimulus control (SC)-both established as effective standalone interventions. This article presents the study protocol to examine whether adding BBTI to treatment as usual improves outcomes in patients with chronic insomnia.

METHODS AND ANALYSIS

We will conduct a multicentre RCT. We will randomly assign patients with chronic insomnia to two groups (BBTI vs sleep hygiene) in a 1:1 ratio. The BBTI consists of three 15 min sessions over 4 weeks delivered by healthcare professionals following a detailed manual. The primary outcome is the Insomnia Severity Index at 8 weeks. Secondary outcomes include sleep latency, wake after sleep onset, total sleep time, sleep efficiency, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9 and EuroQol-5D-5L. We will conduct the assessment at weeks 0 (baseline), 4 (end of intervention), 8 (post-intervention, primary endpoint) and 12 (follow-up). We will assess each sleep variable from the sleep diary at weeks 0 and 8. The analysis will be performed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee for Clinical and Epidemiological Research of Toyama University (approval no. R2023152).

TRIAL REGISTRATION NUMBER

UMIN000052911; pre-results.

Heart rate variability analysis in comorbid insomnia and sleep apnea (COMISA)

Obstructive sleep apnea (OSA) and insomnia are the two most prevalent sleep disorders, often co-occurring in a condition termed comorbid insomnia and sleep apnea (COMISA). While autonomic nervous system (ANS) dysfunction resulting from each of these disorders has been separately established through heart rate variability (HRV) analysis, the specific overnight ANS alterations due to COMISA have not been explored. This study aims to characterize nocturnal ANS alterations attributable to COMISA through time and frequency HRV analysis, distinguishing them from those of isolated insomnia or OSA. A total of 5,335 electrocardiograms from the Sleep Heart Health Study (SHHS) dataset were included in this research. Based on overnight polysomnography and sleep questionnaires, participants were categorized into No-OSA (2,738 subjects), Insomnia (190 subjects), OSA (2,260 subjects), or COMISA (147 subjects) groups. Classic time and frequency HRV features, along with specific frequency measures, were computed to characterize HRV behavior throughout the whole night, in both wakefulness and sleep periods. The analysis revealed that COMISA-specific ANS dysfunction manifests as reduced parasympathetic activity during wakefulness and heightened sympathetic activation during sleep. While primary ANS dysfunctions seem to result from recurrent apneic events affecting frequency features present in both OSA and COMISA, insomnia significantly alters mean heart rate during sleep, thus being the only feature distinguishing these two conditions. In conclusion, the combined effects of OSA and insomnia induce specific ANS dysfunction at night, highlighting the need for further HRV studies to better understand the impact of COMISA on ANS and its cardiovascular implications.Clinical trial registration: The clinical trial identifier of the original SHHS database is NCT00005275, https://sleepdata.org/datasets/shhs .

Terminology and definitions of sleep problems and disorders used in chronic musculoskeletal pain research-a scoping review with recommendations for future research

ABSTRACT

Sleep problems and disorders are prevalent in individuals with chronic musculoskeletal pain (CMP). Yet, previous reviews have struggled to draw precise conclusions due to inconsistent terminology and definitions of sleep problems and disorders. This review analyzed 225 studies to map terminology and definitions for sleep problems and disorders in CMP research. The included studies provided 326 definitions for 39 terminologies. The terminologies "insomnia," "poor sleep quality," and "sleep disturbance" were the most commonly used, though definitions varied significantly. Definitions of, for example, insomnia included different questionnaires, diagnostic criteria, and symptom-based assessments. This pattern was seen across most terminologies. This review also found overlapping definitions, such as the Pittsburgh Sleep Quality Index being used for 7 different terminologies. Inconsistent and overlapping use of terminologies and definitions creates confusion and potentially obscures sleep-pain links and the effectiveness of sleep interventions for CMP. This review makes recommendations for CMP researchers to choose the most appropriate terminology and definition for their research aim but also underlines the need for a consensus on terminology and measurement approaches. Standardizing terminology and definitions will enhance research accuracy, improve comparability, and strengthen the evidence base in the sleep-CMP field.

Why some embrace and others hesitate? A behavioral analysis of insomnia sufferers’ engagement with acupuncture treatment

BACKGROUND

Acupuncture is emerging as a promising treatment for insomnia. However, the determinants driving patients’ decisions to pursue or adopt this treatment modality remain underexplored.

AIM

To identify the key factors shaping the willingness of patients with insomnia to seek and engage in acupuncture from a patient-centered perspective.

METHODS

A semi-structured focus group design was used, with a research framework integrating the capability, opportunity, motivation-behavior model, and theoretical domains framework. The results were mapped onto constructs of a behavioral wheel derived from the capability, opportunity, motivation-behavior/theoretical domains framework matrix. Data analyses employed abductive thematic analysis.

RESULTS

Data saturation was achieved after ten focus group sessions, involving a total of 45 participants. Key facilitators for patients with insomnia seeking acupuncture included: (1) Cultural beliefs in ethnic medicine; (2) Concerns about the adverse effects of, and dependence on, hypnotics; (3) Expectations of improvement in comorbid symptoms; (4) Desire for more communication with the clinician; and (5) Incentives from peers and online key opinion leaders. Barriers were: (1) Limited knowledge of acupuncture indications; (2) Accessibility burden; (3) Needle-phobia; and (4) Safety concerns. Additionally, prior acupuncture experiences, family/friend attitudes, and treatment costs (reimbursement rate in health insurance) served as both facilitators and barriers.

CONCLUSION

The interrelated facilitators and barriers underscore that the decision to use acupuncture for insomnia is a complex issue involving efficacy/safety, culture, economics, information dissemination, and communication factors. Expanding patient education on acupuncture, increasing media exposure, and improving governmental oversight of this process are essential. Investing in high-quality acupuncture services in public hospital nighttime clinics and community health centers is expected to address accessibility challenges. Acupuncturists need to improve doctor-patient communication, including guiding patients to set treatment expectations that are grounded in reality to enhance service quality. For patients with significant needle-phobia, cognitive manipulation or hypnosis techniques may be employed to improve treatment compliance.

Dual trajectory of insomnia and depressive symptoms in women from early pregnancy to 6 months postpartum: a prospective cohort study

BACKGROUND

Perinatal insomnia and depression significantly impact maternal-infant health, but their co-developing trajectories are poorly understood. This study examines their heterogeneous progression, interrelationships, and predictive factors across the perinatal period.

METHODS

This was part of a mother-infant cohort study conducted in the obstetrics outpatient clinic of a tertiary hospital in Wuhan, Hubei Province. Pregnant women were enrolled (N = 1034) at early pregnancy (< 14 weeks) from July 2022 to September 2023. The perinatal depressive symptoms, insomnia severity, anxiety symptoms, and social capital were reassessed at 5-time points from enrollment (T0) to 6 months postpartum using the Edinburgh postnatal depression scale, the Insomnia Severity Index, the Pregnancy-related Anxiety Questionnaire, and the Personal Social Capital Scale 16, respectively. The follow-up time points were 16-20 weeks of gestation (T1), 28-36 weeks of gestation (T2), six weeks postpartum (T3) and six months postpartum (T4), respectively. Group-based trajectory modelling and binary logistic regression modelling were used to analyze the data (n = 436).

RESULTS

We identified three trajectories for perinatal insomnia and depression symptoms. Insomnia: no insomnia (27.7%), subclinical (54.5%), clinical (17.8%). Depression: low-stable (38.7%), moderate-stable (43.9%), high-improving (17.4%). The dual trajectory analysis revealed significant co-occurrence patterns between insomnia and depression trajectories (p < 0.001). Members of the high-improving depression group were more likely to have clinical insomnia trajectories. Baseline ISI ≥ 8, EPDS ≥ 10, and PRAQ ≥ 24 predicted the higher trajectories of perinatal insomnia and depressive symptoms (all p < 0.05).

CONCLUSIONS

Perinatal insomnia and depression follow three distinct but interrelated trajectories, identifiable through early screening. Risk-stratified interventions should consider their co-occurrence patterns to optimize outcomes.

Electro-Acupuncture Therapy Alleviates Post-Stroke Insomnia by Regulating Sirt1 and the Nrf2-ARE Pathway

Post-stroke insomnia (PSI) is a common complication following stroke, which seriously affects patients' life quality. Electro-acupuncture (EA) is an innovative form of traditional Chinese acupuncture that combines electricity with needles to achieve the prevention and treatment of diseases. However, there is limited understanding regarding the treatment mechanism of EA in PSI. In our study, we aimed to investigate the role of EA on PSI development. Our study findings indicated that the quality of sleep, levels of neurotransmitters 5-hydroxytryptamine (5-HT) and gamma-aminobutyric acid (γ-GABA), and antioxidant levels showed significant improvement following EA treatment in PSI clinical samples and rat models, while the levels of pro-inflammatory factor interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and astrocyte damage were notably reduced. Furthermore, it was discovered that the levels of sirtuin 1 (Sirt1) were reduced in PSI, a condition that was significantly ameliorated by EA treatment. Additionally, the inhibition of Sirt1 caused a marked elevation in astrocyte apoptosis, inflammatory response, and oxidative stress. Besides, the nuclear factor E2-related factor 2 (Nrf2)-antioxidant response element (ARE) pathway was deactivated in the PSI rat model and Sirt1-silenced cells. However, the suppressive impact was successfully counteracted by EA or estazolam (ES), and the overexpression of Nrf2 partially alleviated the increase in apoptosis, inflammation, and oxidative stress caused by Sirt1 knockdown. Taken together, these findings indicated that EA improved sleep quality and silenced Sirt1-induced apoptosis, inflammation, and oxidative stress in PSI by activating the Nrf2-ARE pathway.

The Latest Advances in Non-Invasive Neurostimulation for Insomnia: A Review

Insomnia has become a serious public health problem. Because sedative-hypnotics may cause cognitive and psychomotor impairment, serious adverse events, and long-term dependence, it is still controversial whether sleep medications are the first choice for patients with insomnia. Cognitive-behavioral therapy for sleep is limited by poor access, high cost, and poor response in some patients. With the development of sleep neuroscience, physical therapy has shown its advantages in treating insomnia. It can not only avoid the adverse reactions of drugs, but also make up for the lack of standardization of sleep cognitive behavioral therapy. In particular, non-invasive nerve stimulation technology has been increasingly used in the clinical treatment of insomnia in recent years. However, the public lacks understanding of the technology type, principle and efficacy of this treatment strategy, and the research reviews are insufficient, which may limit the choice of insomnia treatment for sleep workers. Therefore, we reviewed the latest research on non-invasive neurostimulation techniques for insomnia in recent years, mainly focusing on virtual reality, biofeedback, transcranial magnetic stimulation, transcranial electrical stimulation, transcutaneous auricular vagus nerve stimulation and other novel neuromodulation techniques, with the aim of providing more options for insomnia treatment and looking forward to the future development of sleep science.

The Future of Non-Invasive Brain Stimulation in Sleep Medicine

Non-invasive brain stimulation (NIBS) methods carry particular appeal as non-pharmacological approaches to inducing or improving sleep. However, intense research efforts to use transcranial magnetic stimulation (TMS) and electrical stimulation (tES) for sleep modulation have not yet delivered evidence-based NIBS treatments in sleep medicine. The main obstacles lie in insufficiently robust stimulation protocols that affect neurophysiological and self-reported sleep parameters, inadequately controlled-and explained-placebo effects, and heterogeneity in patient populations and outcome parameters. Recent technological advances, e.g., transcranial ultrasound stimulation (TUS) and temporal interference stimulation (TIS), make deep brain structures feasible targets. Real-time approaches, e.g., closed-loop auditory stimulation (CLAS), demonstrate efficacious modulation of different sleep oscillations by tuning stimulation to ongoing brain activity. The identification of sleep-regulatory regions and cell types in the cerebral cortex and thalamus provides new specific targets. To turn this neuroscientific progress into therapeutic advancement, conceptual reframing is warranted. Chronic insomnia may not be optimally suited to demonstrate NIBS efficacy due to the mismatch between self-reported symptoms and polysomnographic sleep parameters. More feasible initial approaches could be to (1) modulate specific sleep oscillations to promote specific sleep functions, (2) modify nightmares and traumatic memories with targeted memory reactivation, (3) increase 'wake intensity' in patients with depression to improve daytime fatigue and elevate sleep pressure and (4) disrupt pathological activity in sleep-dependent epilepsies. Effective treatments in these areas of sleep medicine seem in reach but require rigorously designed clinical trials to identify which NIBS strategies bring real benefit in sleep medicine.

Examining the burden of major depressive disorder with moderate-to-severe insomnia symptoms in five European countries

BACKGROUND

Insomnia is a core and prevalent symptom of major depressive disorder (MDD). However, the impact of insomnia on health-related outcomes among patients with MDD remains inadequately understood. This study evaluated the clinical, humanistic, and economic burden of adults with MDD with moderate-to-severe insomnia symptoms (MDDIS) compared to adults with MDD and no-or-mild insomnia symptoms (other-MDD) and adults in the general population without MDD (non-MDD).

METHODS

Data from the European (France, Germany, UK, Italy, Spain) 2020 National Health and Wellness Survey were utilized to identify participants who self-reported a diagnosis of depression, stratified by insomnia status (MDDIS: Insomnia Severity Index [ISI] score ≥ 15; other-MDD: insomnia not experienced in past 12 months or ISI score < 15), and those who did not (i.e. non-MDD). Matched bivariate analyses compared MDDIS with other-MDD and non-MDD.

RESULTS

The study included 1888 MDDIS, 3905 other-MDD, and 52,074 non-MDD participants. In adjusted analyses, MDDIS participants reported greater severity of depressive and anxiety symptoms, daytime sleepiness, more healthcare provider, psychiatrist and emergency room visits, hospitalizations, and 6-month per-person direct medical costs compared to other-MDD and non-MDD (all P < 0.01) and greater medication non-adherence compared to other-MDD (P < 0.001). MDDIS participants reported poorer mental and physical functioning, poorer health-related quality of life, higher work and activity impairment, and higher annualized per-person indirect costs compared to other-MDD and non-MDD (all P < 0.001).

LIMITATIONS

The cross-sectional nature of the study limits causal inferences.

CONCLUSIONS

This study highlights the severe global burden of MDDIS and the importance of addressing insomnia symptoms with targeted interventions in the treatment of MDD.

Dreaming of Better Treatments: Advances in Drug Development for Sleep Medicine and Chronotherapy

Throughout history, the development of new sleep medicines has been driven by progress in our understanding of the mechanisms underlying sleep. Ancient civilisations used their understanding of the sedative nature of natural herbs and compounds to induce sleep. The discovery of barbiturates and bromides heralded a new era of synthetic sleep medicine in the 19th century. This was followed by the development of benzodiazepines that were used to inhibit signalling throughout the brain by promoting gamma-amino butyric acid release and thereby produce loss of consciousness. As our understanding of sleep has deepened, newer therapies have more specifically targeted the wake-inducing neurotransmitter orexin with fewer side effects. Given the newly highlighted role of kinases in sleep/wake regulation, we predict that the next breakthroughs in sleep medicine will likely target these kinases. Given the fundamental role that sleep plays in maintaining brain health through processes such as glymphatic clearance, sleep medicine has therapeutic potential beyond just sleep. Recent evidence suggests that sleep disruptions directly contribute to the build-up of pathological neuronal proteins in neurodegenerative disorders. Therefore, sleep medicine could improve prognosis in disorders such as these. Great attention must be paid to the mechanism of action of each sleep medicine, however, as sleep medicines which do not fully mimic sleep could actually worsen disease progression.

Expert Consensus on the Use of Diphenhydramine for Short-Term Insomnia: Efficacy, Safety, and Clinical Applications

Insomnia is the most prevalent sleep disorder, estimated to affect at least one-third of the global population. There are a variety of treatment options available for both acute and chronic insomnia. Currently, the pharmacological arsenal for treating insomnia includes short- or intermediate-acting benzodiazepine hypnotics, non-benzodiazepine hypnotic sedatives, melatonin receptor agonists, orexin receptor antagonist, and sedating antidepressants. Diphenhydramine, a first-generation antihistamine, is commonly used in the treatment of allergies and dermatitis. This review examines the preclinical and clinical efficacy and safety evidence of diphenhydramine in treating short-term insomnia. Additionally, it provides expert consensus on its implementation as an over-the-counter medication for this condition. The available evidence indicates that diphenhydramine is an effective treatment for acute insomnia in adults, offering a safe and affordable option for most patients suffering from this condition. Experts concur that there is strong evidence supporting the recommendation of diphenhydramine for the treatment of acute insomnia in adults.

Efficacy of cognitive behavioral therapy for insomnia and lemborexant medication for different subtypes of chronic insomnia: study protocol for a randomized controlled trial

INTRODUCTION

Insomnia is a prevalent yet under-characterized disorder, particularly regarding the heterogeneity of patients and their associated responses to different treatment modalities. This often leads to suboptimal management. There is a need to consider personalized approaches tailored to the characteristics of insomnia phenotypes with regard to objective evidence of shortened sleep duration (< 6 h). This study will examine whether there is a differential treatment response to cognitive behavioral therapy for insomnia (CBT-I) versus pharmacotherapy (lemborexant) as a function of insomnia phenotypes (i.e., ± 6 h of sleep).

METHODS

This study is a three-arm pragmatic randomized clinical trial, which will enroll 90 adults with chronic insomnia disorder and anxiety/depressive symptoms. Eligible participants will be randomized to one of three conditions (1:1:1) involving CBT-I, lemborexant (Dual Orexin Receptor Antagonist) or placebo medication. Treatment outcomes will be assessed at post-treatment and 6-month follow-up. Insomnia symptom severity as measured by the Insomnia Severity Index will serve as the primary outcome for treatment comparisons. Secondary outcomes will include daily sleep/wake variables derived from the Consensus Sleep Diary, subjective measures of fatigue, mood, mental well-being, functional impairments, and sleep-related beliefs and attitudes. In addition, changes in cognitive performance will be examined as an exploratory outcome. Sleep reactivity and arousal level will be evaluated as potential mediators of treatment-related changes in CBT-I and pharmacotherapy.

DISCUSSION

This study will contribute to the development of personalized medicine for managing different insomnia phenotypes and will have implication for knowledge mobilization of sleep research.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT06779149. Registered on 12 January 2025.

The Future of Insomnia Research-There's Still Work to Be Done

Insomnia Disorder (ID) is a highly debilitating disorder affecting up to 10% of the general population. In recent years, the number of studies in this area has increased rapidly, resulting in a wealth of accumulated knowledge. ID is generally regarded as a hyperarousal disorder affecting cognitive, emotional, cortical and physiological domains. Nevertheless, there is still a significant lack of knowledge about the pathophysiology of ID. For example, the existence of insomnia subtypes is discussed, albeit no uniform definition has yet been found. Significant progress has been made in understanding the neurobiology of insomnia, which points to a dysfunction in emotion regulation. However, neuroimaging studies frequently have small sample sizes and allow only for limited causal conclusions. The assessment of sleep has been significantly influenced by the increasing availability of methods for ambulatory sleep measurement. While these methods enable sleep to be measured more cost-effectively than polysomnography, many devices lack sufficient empirical evidence of validity. In terms of insomnia treatment, cognitive behavioural therapy for insomnia (CBT-I) has been shown to be highly effective. However, the underlying mechanisms of CBT-I remain partially unclear, and the optimal sequence for applying the individual components, as well as the effectiveness of CBT-I in cases of comorbidity, remain open questions. Furthermore, many widely applied pharmacological treatment approaches are used off-label with only a limited empirical evidence base. This narrative review aims to summarise the current state of research on ID and attempts to outline a selection of the important future challenges in insomnia research.

Integrative sleep management: from molecular pathways to conventional and herbal treatments

Sleep is regarded as one of the most crucial factors in keeping a healthy lifestyle. To function normally, a person needs at least 6-8 h of sleep per day. Sleep influences not only our mood but also the efficiency with which we complete tasks. Sleep disorders exhibit diverse etiologies across different conditions and populations, with genetic and environmental factors playing a significant role in their development. Many issues emerge as a result of inadequate sleep. Unhealthy food and lifestyle choices have increased our susceptibility to sleep disorders. A well-balanced diet rich in essential vitamins and minerals can have a profound impact on sleep patterns, enhancing both the duration and quality of rest. The primary categories of sleep disorders include insomnia, sleep apnea (SA), narcolepsy, parasomnias, circadian rhythm disorders, and restless legs syndrome (RLS). The drugs used to treat sleep disorders are primarily habit-forming and have a history of withdrawal effects. This insufficiency in medication has prompted the hunt for newer, better options. Nutraceuticals are well-suited to the treatment of such illnesses. Its non-toxic, non-habit-forming properties, and practical efficiency have made it an outstanding choice. This review provides nutraceuticals used in sleep disorders. A comprehensive literature search was conducted utilizing several databases, including Google Scholar, Elsevier, Springer Nature, Wiley, PubMed, and EKB. Nutraceuticals are products that employ food or dietary components to treat or prevent disease. In the therapy of sleep disorders, nutraceuticals such as Artemisia annua, valerian, rosemary, jujube, Passionflower, lemon balm, ashwagandha, kava-kava, lavender, and chamomile have been shown to have remarkable benefits. These remedies exert their effects through multiple mechanisms, both directly by modulating neurotransmitter and hormonal pathways within sleep circuits, and indirectly by enhancing sleep quality through the alleviation of stress, inflammation, and oxidative stress. Clinical studies were piloted to validate the efficacy of natural sleep aids. Future research should focus on elucidating the precise mechanisms through which natural products influence sleep.

Efficacy of a Self-Guided Internet Intervention With Optional On-Demand Feedback Versus Digital Psychoeducation on Sleep Hygiene for University Students With Insomnia: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy for insomnia (iCBT-I) provides flexibility but requires significant time and includes potentially challenging components such as sleep restriction therapy. This raises questions about its incremental effectiveness compared to less demanding minimal interventions such as sleep hygiene psychoeducation.

OBJECTIVE

This study aimed to assess the incremental efficacy of self-guided iCBT-I with optional on-demand feedback for university students with insomnia compared to a single session of digital psychoeducation on sleep hygiene.

METHODS

In a randomized controlled trial, 90 students with insomnia (Insomnia Severity Index ≥10) were randomly allocated to self-help-based iCBT-I (45/90, 50%) or one session of digital sleep hygiene psychoeducation with stimulus control instructions (active control group [aCG]: 45/90, 50%). The self-help-based iCBT-I consisted of 6 sessions on psychoeducation, sleep restriction, and stimulus control, including written feedback on demand from an eCoach. Assessments occurred at baseline (T1), 8 weeks after treatment (T2), and at a 6-month follow-up (T3) via web-based self-assessment and diagnostic telephone interviews. The primary outcome was insomnia severity at T2. Analyses of covariance were conducted in an intention-to-treat sample. Secondary outcomes included diagnoses of insomnia and major depression, sleep quality, sleep efficiency, worrying, recovery experiences, recovery activities, presenteeism, procrastination, cognitive irritation, and recuperation in sleep.

RESULTS

There was no difference in insomnia severity at T2 between the iCBT-I group (mean 11.27, SD 5.21) and aCG group (mean 12.36, SD 4.16; F1,989.03=1.12; P=.29; d=-0.26; 95% CI 0.68 to 0.17). A significant difference emerged at T3 (iCBT-I: mean 9.43, SD 5.36; aCG: mean 12.44, SD 5.39; F1,426.15=4.72; P=.03), favoring iCBT-I with a medium effect (d=-0.57; 95% CI 1.07 to -0.06). Most secondary outcomes revealed no significant differences between the groups. In total, 51% (23/45) of participants in the iCBT-I group completed all 6 sessions, and 69% (31/45) completed the 4 core sessions.

CONCLUSIONS

In the short term, students might benefit from low-intensity, easily accessible digital sleep hygiene psychoeducation or iCBT-I. However, it appears that iCBT-I offers superiority over sleep hygiene psychoeducation in the long term.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017737; https://drks.de/search/de/trial/DRKS00017737.

Effectiveness of digital cognitive behavioral therapy for insomnia in nurses with shift work sleep disorder: Results of a randomized controlled trial

BACKGROUND

Shift work is associated with many adverse effects on health and, in particular, affects sleep. In nurses, one of the most common forms of insomnia is shift work sleep disorder. Traditional face-to-face cognitive behavioral therapy for insomnia is often impractical for shift-working nurses due to irregular work schedules. Digital therapy presents a promising alternative to provide nurses with access to cognitive behavioral therapy for insomnia.

OBJECTIVE

To investigate the effectiveness of the digital SleepCare intervention for reducing insomnia in nurses being affected by shift work sleep disorder.

DESIGN

Randomized controlled trial.

PARTICIPANTS

74 nurses affected by shift work sleep disorder.

METHODS

In a two-armed randomized controlled trial, SleepCare was compared to shift work-specific psychoeducation published digitally by the German Sleep Society. The diagnosis of shift work sleep disorder was established through a clinical interview. The primary outcome was insomnia severity as measured by the Insomnia Severity Index at baseline before randomization, at 8 weeks, and 3 months after randomization. Further indicators of mental health and long-term hair cortisol concentration were evaluated as secondary endpoints.

RESULTS

Intention-to-treat analysis of covariance showed a greater reduction in insomnia severity in the intervention group versus psychoeducation, at both post-intervention (d = 1.11[0.7-1.6]) and follow-up (d = 0.97 [0.5-1.4]), corresponding to between-group differences of 5.0 and 5.3 points on the Insomnia Severity Index, respectively. 56 % completed at least five of the six sessions and results indicated larger effects for these intervention completers with d = 1.49 and d = 1.28, respectively. Statistically significant effects were observed for sleep-related, but not other mental health indicators, for example, stress and depression. Reduced hair cortisol levels were observed post-intervention in the SleepCare group (V = 82, p = .008; Δ = -1.8 pg/mg, 44 % reduction from baseline).

CONCLUSIONS

SleepCare was effective in reducing insomnia symptoms to a clinically meaningful extent and is one of the first digitally delivered programs to adapt cognitive behavioral therapy for insomnia with specific exercises to address nurses' needs for shift work. The development of effective strategies to promote treatment adherence seems necessary, as substantially larger effects were observed for intervention completers.

REGISTRATION

German Clinical Trials Register - DRKS; DRKS00027411 (https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00027411). Registration date: March 9, 2022. Start of recruitment: May 13, 2022.

Six-year trajectories of core depressive symptoms and insomnia symptoms in depressed older adults: a NESDO study

OBJECTIVES

This study aimed to identify trajectories of core depressive symptoms and insomnia symptoms in depressed older adults, their prevalence and association, and predictors of unfavorable trajectories.

METHOD

We examined 6-year follow-up data of 329 depressed older adults from the Netherlands Study of Depression in Older persons. Core depressive symptoms and insomnia symptoms were assessed with the Inventory of Depressive Symptomatology. We applied growth mixture modeling to identify classes of participants with similar trajectories of core depressive symptoms and insomnia symptoms. The association between core depressive and insomnia symptom trajectories and predictors of these trajectories were examined.

RESULTS

We identified three core depressive symptom trajectories: low and declining (40.4%), moderate and declining (37.4%), and high and stable (22.2%); and four insomnia symptom trajectories: moderate and declining (13.7%), low and increasing (7.6%), moderate and stable (55.6%), and high and stable (23.1%). Participants with favorable core depressive symptom trajectories often had unfavorable insomnia symptom trajectories. Older age, chronic diseases, and functional limitations predicted unfavorable core depressive symptom trajectories. Functional limitations predicted unfavorable insomnia symptom trajectories.

CONCLUSION

Trajectories of core depressive and insomnia symptoms in depressed older adults were partly associated, but insomnia symptoms often persisted despite improving core depressive symptoms, highlighting the importance of different targeted interventions.

Stepped care for insomnia in primary care using digital and face-to-face cognitive behavioral therapies: A pragmatic nonrandomized clinical trial

OBJECTIVE

To evaluate the effectiveness of a stepped-care intervention for insomnia in primary care.

METHODS

In this non-randomized pragmatic clinical trial, patients from primary care clinics and with chronic insomnia disorder were allowed to choose between continuing their usual treatment (prescribed sleep medication) or receiving digital CBT-I (dCBT-I), either alone or in combination with medication. After the first treatment step, non-remitters were provided with the choice of receiving face-to-face CBT-I (FtFCBT-I), medication, or no additional treatment. The primary outcome was insomnia symptoms as measured by the Insomnia Severity Index.

RESULTS

Among 154 adults with insomnia, 73 were allocated to dCBT-I, 66 to combined treatment and 15 to medication alone based on their preference. When compared to medication alone, first-step treatment with dCBT-I or combined treatment both produced significantly larger effects on reducing insomnia severity (dCBT-I vs Med, difference in the mean changes = -3.3; Comb vs Med, -3.7), and led to higher percentages of responders (dCBT-I vs Med, 54.8 % vs 16.0 %, OR = 6.38; Comb vs Med, 53.6 % vs 16.0 %, OR = 6.07) and remitters (dCBT-I vs Med, 65.8 % vs 9.4 %, OR = 18.61; Comb vs Med, 67.5 % vs 9.4 %, OR = 20.13). Adding FtFCBT-I as second-step treatment offered an added value for non-remitters after the first-step treatment. Improvements achieved at post-treatment were sustained through the 6-month follow-up for most of the treatment sequences.

CONCLUSIONS

These findings demonstrated the feasibility and efficiency of implementing digital and in-person CBT-I within a stepped-care model in primary care practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03633305.

A narrative review of sleep and breast cancer: from epidemiology to mechanisms

Breast cancer is the leading cause of cancer-related death and the most common cancer among women worldwide. It is crucial to identify potentially modifiable risk factors to intervene and prevent breast cancer effectively. Sleep factors have emerged as a potentially novel risk factor for female breast cancer. Current epidemiologic studies suggest a significant impact of sleep factors on breast cancer. Exposure to abnormal sleep duration, poor sleep quality, sleep disorders, sleep medication use, or night shift work can increase the risk of breast cancer by decreasing melatonin secretion, disrupting circadian rhythm, compromising immune function, or altering hormone levels. However, there are still controversies regarding the epidemiologic association, and the underlying mechanisms have yet to be fully elucidated. This paper summarizes the epidemiologic evidence on the associations between sleep factors, including sleep duration, sleep quality, sleep disorders, sleep medication use, sleep habits, and night shift work, and the development of breast cancer. The potential mechanisms underlying these associations were also reviewed.

Nonpharmacological interventions to promote sleep in the adult critical patients unit: A scoping review

BACKGROUND

Sleep and circadian rhythms are markedly altered in intensive care unit (ICU) patients. Numerous factors related to the patient and the ICU environment affect the ability to initiate and maintain sleep. Therefore, nonpharmacological interventions could play an essential role in improving sleep and circadian rhythm.

OBJECTIVE

The aim of this study was to examine nonpharmacological interventions evaluated for promoting sleep in adult ICUs.

METHODS

A scoping review was conducted, including randomised controlled trials, nonrandomised controlled trials, quasi-experimental trials, and other controlled studies investigating the effects of nonpharmacological interventions promoting sleep in adult ICU patients.

RESULTS

A total of 57 articles and 14 ongoing trials were included in the review, of which 38 were randomised clinical trials. Nine nonpharmacological interventions to improve sleep in critically ill patients were evaluated: earplugs and/or eye masks, aromatherapy, bundles, music intervention, massage or acupressure, noise masking, bright light, and dynamic light. Most included trials simultaneously assessed the effect of more than one intervention on perceived sleep quality using questionnaires. The association between the interventions and improved sleep varied. In the case of multicomponent interventions, it is difficult to identify which components might have influenced sleep improvement.

CONCLUSIONS

Numerous studies have evaluated various nonpharmacological interventions to promote sleep in critically ill patients, several of which improved perceived sleep quality. However, the substantial variability of the assessed interventions and their implementation complicates drawing reliable conclusions.

REGISTRATION

The protocol for this scoping review was registered with the Open Science Framework under the identifier https://doi.org/10.17605/OSF.IO/MPEQ5.

Does Keeping a Sleep Diary Alter the Perception of Sleep Quality? Testing Measurement Reactivity in Healthy Adults

Measurement reactivity, where the act of measuring a behavior changes that behavior, has been documented across various health outcomes. However, its effects on sleep remain understudied, despite the widespread use of sleep diaries in clinical and research settings. In this randomized experiment, 190 healthy young adults (aged 18-40 years; 63% female) were assigned to complete either a sleep diary (Consensus Sleep Diary) or a physical activity diary (Physical Activity Scale) for seven days. All participants completed the Pittsburgh Sleep Quality Index (PSQI) and the International Physical Activity Questionnaire (IPAQ) before and after the diary period. Daily diary completion rates were high (97.3%). Linear mixed-effects models revealed no significant main effects of time (pre vs. post) or condition (sleep vs. physical activity diary), and no significant interaction between time and condition for either PSQI or IPAQ scores. These results suggest stability in sleep quality and physical activity measures, with no evidence of measurement reactivity. An exploratory analysis comparing "good" and "poor" sleepers (based on baseline PSQI scores) found a significant effect of sleep quality group and a time × group interaction on PSQI scores. In this adequately powered short-term study of young adults, we found no evidence of measurement reactivity to daily sleep diaries. These findings suggest that in healthy individuals, completing a week of sleep diaries is unlikely to impact PSQI scores substantially. We discuss our results in terms of the direct controllability of sleep quality, which might make it less susceptible to measurement reactivity relative to other health outcomes.

Impact of consultation liaison services on postoperative psychotropic drug use

OBJECTIVE

In clinical practice, most cases of postoperative delirium are treated by an attending surgeon who is not a specialist in delirium treatment. We investigated the postoperative use of psychotropic drugs with and without psychiatric consultation liaison service (CLS).

METHOD

Patients who received specific psychotropic drugs postoperatively under general anesthesia were included. The participants were divided into two groups, with and without CLS intervention. The type and dosage of psychotropic drugs used, presence of delirium, and adverse drug events (ADEs) caused by psychotropic drugs administered postoperatively were investigated.

RESULTS

Of the 509 patients who were newly prescribed the psychotropic drugs postoperatively, 67 patients (13 %) received CLS intervention. In the non-CLS group, 65 % (43/66) of patients who received antipsychotics after surgery did not have delirium, which was significantly higher than in the CLS group (65 % vs 22 %, p < 0.01). Haloperidol was the most commonly used antipsychotic postoperatively, and the median daily dose was significantly higher in the non-CLS group (0.22 mg/day vs 0.38 mg/day, p = 0.04).

CONCLUSION

CLS interventions may contribute to a reduction in unnecessary administration of antipsychotic drugs and dosages.

Negative effects of cognitive behavioral therapy for insomnia: Psychometric evaluation of an insomnia-specific extension for the Negative Effect Questionnaire

INTRODUCTION

Negative effects of psychotherapy encompass unwanted events caused by the treatment. Evidence exists that cognitive behavioral therapy for insomnia (CBT-I) can lead to negative effects (e.g., exhaustion, reduced motivation). Psychometrically validated instruments are needed to enable systematic investigation of negative effects and their consequences. This study aimed to develop an insomnia-specific extension for the Negative Effect Questionnaire (NEQ) and to evaluate its psychometric properties.

METHOD

Based on a literature review, an item pool was developed as an extension to the NEQ. This item pool was iteratively refined. Both the NEQ and the developed item pool were administered to participants enrolled in a stepped-care model for insomnia that includes an internet-delivered CBT-I. The psychometric properties of the item pool were evaluated using confirmatory factor analyses (CFAs). Additionally, responses to open-ended questions were categorized and analyzed.

RESULTS

Data from 210 participants were available. In the newly developed item pool, participants reported a mean of 4.7 negative effects (range: 0 to 22). CFA indicated a good fit (RSMEA = 0.05; SRMR = 0.07) of a model with five latent factors (somatic symptoms, cognitive symptoms, safety, emotional symptoms, daytime functioning). The correlation analyses between the model's latent factors and the NEQ subscales indicated adequate discriminant validity.

DISCUSSION

The observed prevalence rates of insomnia-specific negative effects highlight the need to assess the negative effects of CBT-I with an insomnia-specific instrument. The CFA suggests that the 24-item NEQ-Insomnia is a valid instrument, suitable for standalone use or as an extension to the NEQ for assessing the negative effects of CBT-I.

Cost-Effectiveness Analysis of Daridorexant for the Pharmacological Treatment of Chronic Insomnia Disorder in Adults

OBJECTIVE

Daridorexant 50 mg is recommended for treating chronic insomnia in England, Wales (NICE, 2023) and Scotland (Scottish Medicines Consortium, 2024). This study examines the model and cost-effectiveness profile that led to these positive reimbursements.

METHODS

The cost-effectiveness model integrated data from daridorexant 50 mg phase III trials (studies 301 and 303) and the National Health and Wellness Survey (NHWS). Clinical parameters were the Insomnia Severity Index (ISI) score and adverse events. Using the NHWS, ISI data were mapped to utility, healthcare resource use, and work productivity. Daridorexant 50 mg was priced at £1.40/day. The base-case time horizon was 1 year. A lifetime model explored long-term effects. Parameters, data inputs, structural uncertainty, and alternative scenarios are all presented.

RESULTS

In the 12-months model compared with placebo, daridorexant was estimated to have an incremental cost of £389 and generate an additional 0.024 quality-adjusted life-years (QALYs), resulting in an incremental cost-effectiveness ratio (ICER) of £16,300 per additional QALY from a health service perspective. Due to selective attrition, the ICER improved to £9580 per QALY for those continuing treatment for >12 months. Adopting a societal productivity perspective, daridorexant was estimated to offer £596 (£330-£896) total productivity savings versus £411/year in treatment costs, leading to a situation of dominance. Lifetime modeling improved the long-term cost effectiveness of daridorexant under the assumption that any waning of treatment effect led to further dropout.

CONCLUSION

Daridorexant 50 mg is estimated to be a cost-effective pharmacological treatment for chronic insomnia disorder in adult patients.

Web-based cognitive-behavioral therapy for insomnia in cancer survivors: The OncoSleep randomized trial

PURPOSE

Insomnia is highly prevalent among cancer survivors and can have serious implications if inadequately treated. Cognitive-behavioral therapy for Insomnia (CBT-I) is recommended as the first-line treatment for insomnia but is rarely available to cancer survivors. We tested the effectiveness of a web-based CBT-I program, OncoSleep, in cancer survivors.

METHODS

Cancer survivors with insomnia (n = 154) were randomly assigned (1:1) to digital CBT-I (6 weekly self-guided modules plus online clinician support) or a waitlist control group. Patient-reported outcome measures of insomnia severity (primary outcome), daytime functioning, and sleep diaries were administered online at baseline and post-treatment (8 weeks). Intention-to-treat analyses were performed using mixed-effects models. Statistical tests were two-sided.

RESULTS

The treatment group reported an average 11.0-point reduction in the Insomnia Severity index (ISI), compared to a 1.4-point reduction in the control group (p<.001). Statistically significant group-by-time interactions were observed: web-based CBT-I produced significant, large effects for improvements in insomnia severity (d = -2.56), cognitive functioning (d = 0.95), physical (d = 1.24) and psychological quality of life (d = 0.80), and fatigue (d = -1.35). Small-to-large effect sizes were found for reductions in anxiety (d = -0.77), depression (d = -0.71), and pain (d = -0.40). Change in insomnia severity mediated the effect of digital CBT-I on daytime outcomes.

CONCLUSIONS

Web-based CBT-I with clinician support appears to be an effective treatment for insomnia in cancer survivors, offering meaningful benefits for comorbid symptoms and quality of life. Further studies with active comparisons and longer follow-up periods are needed to confirm these findings. Digital CBT-I could be integrated into cancer rehabilitation programs to reduce the burden of insomnia. [ClinicalTrials.gov: NCT04898855].

Applying therapist-guided digital cognitive behavioral therapy for insomnia in psychiatry: a mixed-methods process evaluation

INTRODUCTION

Insomnia is prevalent, particularly among individuals with mental health complaints. However, Cognitive Behavioral Therapy for Insomnia (CBT-I), the first-line treatment, is underutilized in care settings. This study evaluated a therapist-guided digital CBT-I (i-Sleep), gathering insights from participants and therapists to optimize the intervention and inform implementation strategies.

METHODS

A mixed-methods process evaluation, guided by the RE-AIM framework, was conducted alongside an effectiveness trial. Data were collected from i-Sleep participants with clinically relevant insomnia and various mental health complaints across all care levels, ranging from pre-clinical (unattended), to those referred to general or specialized care. Additionally, data were collected from i-Sleep therapists.

RESULTS

A total of 181 i-Sleep participants (mean age = 46.7 years, SD = 13.2) enrolled, with an attrition rate of 21.6%. Participants reported benefits including faster sleep onset, fewer nighttime awakenings, increased daytime energy, and positive lifestyle changes, though some experienced minimal gains or adverse effects. Satisfaction with the intervention ranged from 7.1 to 7.3 across care levels. Post-intervention, 89.4% of all participants indicated they would recommend iCBT-I. Satisfaction with therapist guidance was high (M = 7.7-8.3), though preferences for format and frequency varied. Therapists (n = 15, mean experience = 0.8 years, SD = 1.1) suggested addressing practical constraints and enhancing training for better integration into routine care.

CONCLUSION

Our findings highlight the feasibility and potential of therapist-guided iCBT-I to improve sleep in individuals with mental health complaints across all care settings. Universal implementation could offer significant benefits, while adaptable content and flexible guidance may better meet individual needs.

TRIAL REGISTRATION

Netherlands Trial Register (NL9776) registered on 07/10/2021.

Echoes in the night: How sleep quality influences auditory health

The intricate relationship between sleep disorders and hearing loss emerges as a burgeoning field of scholarly inquiry. Numerous studies have illuminated a potential correlation between the two, affecting the quality of life and overall health of individuals. Hearing loss, or auditory impairment, serves as a critical indicator of physiological dysfunction, casting a pall over the daily existence and professional endeavors of those affected, potentially leading to irreversible deafness if left untreated. Sleep disorders may cause physical and psychological changes that further affect hearing, while auditory dysfunction may detrimentally impact sleep experienced by individuals. Although certain studies have failed to find a direct link between sleep duration and hearing loss, it is evident that sleep-related issues do increase the risk of hearing loss. Thus, understanding the relationship between sleep disorders and hearing loss, alongside the underlying mechanisms, will help establish interventions aimed at enhancing sleep quality and safeguarding auditory health. This systematic review endeavors to elucidate the correlation between sleep disorders and hearing loss, offering valuable insights and guidance for future basic research and clinical applications.

Assessment of an App-Based Sleep Program to Improve Sleep Outcomes in a Clinical Insomnia Population: Randomized Controlled Trial

BACKGROUND

Insomnia is the most commonly reported sleep disturbance and significantly impacts mental health and quality of life. Traditional treatments for insomnia include pharmacological interventions or cognitive behavioral therapy for insomnia (CBT-I), but these options may not be accessible to everyone who needs treatment.

OBJECTIVE

This study aims to assess the effectiveness of the app-based Headspace Sleep Program in adults with clinical insomnia on sleep disturbance and mental health outcomes, compared with a waitlist control group.

METHODS

This randomized controlled trial included 132 adults with clinical insomnia who were assigned to either the Headspace Sleep Program (an 18-session self-guided, in-app program utilizing CBT-I techniques augmented by mindfulness) or a waitlist control group. Sleep disturbance outcomes were assessed by changes in insomnia symptoms (measured using the Insomnia Severity Index) and sleep efficiency (measured via sleep diary and actigraphy). Mental health outcomes included perceived stress (measured by the 10-item Perceived Stress Scale), depressive symptoms (measured by the 8-item Patient Health Questionnaire), sleep quality (measured by the Pittsburgh Sleep Quality Index), anxiety symptoms (measured by the 7-item Generalized Anxiety Disorder Scale), and mindfulness (measured by the Mindful Attention Awareness Scale). Changes from baseline to postintervention and follow-up were assessed for each outcome.

RESULTS

Participants had a mean (SD) age of 37.2 (10.6) years, with 69 out of 132 (52.3%) identifying as female. Those randomized to the Headspace Sleep Program group experienced significantly greater improvements in insomnia symptoms from baseline to postintervention and follow-up compared with participants in the waitlist control group (P<.001, η²p=0.107). Improvements from baseline to postintervention and follow-up were also observed in the Headspace Sleep Program group for sleep efficiency, as measured by both sleep diary (P=.01, η²p=.03) and actigraphy outcomes (P=.01, η²p=.03). Participants in the Headspace Sleep Program group showed greater improvements in insomnia remission rates (8/66, 12%, at postintervention and 9/66, 14%, at follow-up) and treatment response (11/66, 17%, at postintervention and 15/66, 23%, at follow-up) compared with the control group (remission rate 2/66, 3%, at postintervention and 0/66, 0%, at follow-up; treatment response 3/66, 5%, at postintervention and 1/66, 2%, at follow-up). The results suggest significant improvements in depressive symptoms (P=.01, η²p=.04), anxiety symptoms (P=.02, η²p=.02), and mindfulness (P=.01, η²p=.03) in the Headspace Sleep Program group.

CONCLUSIONS

The Headspace Sleep Program is an effective intervention for improving sleep disturbances in adults with clinical insomnia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05872672; https://clinicaltrials.gov/ct2/show/NCT05872672.

Group cognitive behavioural therapy for insomnia compared with treatment as usual for sleep problems in psychiatric care (the SIP trials): a protocol for a pragmatic, randomised controlled trial

INTRODUCTION

Insomnia is prevalent in psychiatric populations and may contribute to maintain and exacerbate psychiatric symptoms. Cognitive behavioural therapy for insomnia (CBTi) is the treatment of choice also for insomnia comorbid to psychiatric illness. However, patients are rarely offered CBTi in psychiatric outpatient clinics. The aim of this randomised controlled trial is to investigate whether CBTi delivered in groups in a psychiatric outpatient clinic is superior to treatment as usual (TAU).

METHODS AND ANALYSIS

In the Sleep in Psychiatric Care trial, 60 patients with moderate to severe psychiatric illness who meet the criteria for insomnia disorder will be recruited from an outpatient psychiatric clinic in Norway. The patients will be randomised (1:1) either to group-based CBTi (Sleep School Wake Up for Insomnia; SSWU-I) or to a wait list (WL) while they are all receiving TAU for their psychiatric disorder. SSWU-I will comprise five bi-weekly sessions, each lasting 120 min, hence the treatment period is 8 weeks. Assessment will be conducted at baseline (T1) and after 8 weeks (T2). The primary outcome will be self-rated insomnia symptoms using the Insomnia Severity Index and the Bergen Insomnia Scale. Secondary outcomes include measures of symptoms of dysfunctional beliefs and attitudes about sleep, depression, anxiety, fatigue, problems with work and social adjustment and well-being. Mixed model analyses will be conducted to test the hypotheses.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Regional Committee for Medical and Health Research Ethics, in Western Norway (REK 2020/66304). Findings will be published in peer-reviewed journals and presented at research conferences and in relevant media. The results may document the need for specific sleep-directed treatments in psychiatric clinics as a way of treating insomnia disorder as well as to alleviate psychiatric symptoms.

TRIAL REGISTRATION NUMBER

NCT04463498.

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).

Analysis of sedative-hypnotic drug use trends in children and adolescents (2018-2023): a study based on outpatient prescription data from a general hospital

Objective

This study aims to analyze the use of sedative-hypnotic drugs among children and adolescents in a hospital setting, providing a reference for optimizing drug use.

Methods

A retrospective analysis was conducted on the prescription data of sedative-hypnotic drugs for children and adolescents aged 6-18 years from 2018 to 2023 at the outpatient department of the hospital. Data were organized using Excel and analyzed using statistical software such as SPSS, with descriptive statistics and independent samples t-tests used to analyze medication patterns across different age groups and genders.

Results

The majority of prescriptions originated from the psychiatry department. The most common diagnoses included depressive state, anxiety state, and sleep disorders. Combination therapy with benzodiazepines and antidepressants was the most common treatment regimen. The number of prescriptions showed a yearly increasing trend, rising from 160 in 2018 to 1,583 in 2023, and the total usage also increased annually, from 30.47 g in 2018 to 260.15 g in 2023. Despite the increase in total usage, the drug usage per prescription decreased year by year. Most patients had a medication duration of less than 30 days, and the per capita usage increased with longer medication durations. Lorazepam and zopiclone were the most frequently used drugs. The study also found that the duration of medication use was significantly longer in female patients than in males, and significantly longer in the 6-12 age group compared to the 13-18 age group.

Conclusion

The use of sedative-hypnotic drugs in children and adolescents has shown a yearly increasing trend, and the management of sedative-hypnotic drug use in children and adolescents should be strengthened.

A multi-institutional cohort study on risk of sleep disorders in dry eyes patients using TriNetX

To explore the relationship between DED and sleep disorders and examine the impact of DED's duration on sleep disorders. This multi-institutional, retrospective cohort study used the TriNetX database. We recruited participants with and without DED diagnosis from 2004 to 2023. Dry eye patients were propensity-matched to individuals from our non-DED cohort (1:1 ratio) based on variables such as age (every 5 year), sex, ethnicity, race, and relevant comorbidities. The Cox proportional hazards regression model was utilized to assess the impact of variables on sleep disorder risk, reporting hazard ratios (HRs) with 95% confidence intervals (CI). Kaplan-Meier survival analysis and log-rank tests were applied to estimate the cumulative incidence of sleep disorder. A total of 688,413 DED adult patients (64.91% female; mean age at index 56.96 ± 15.93) and 688,413 propensity-matched non-DED comparators (64.92% female; mean age at index 56.96 ± 15.93) were recruited. Our analysis showed an overall increased risk of uveitis among DED patients at 5-year time points (HR = 1.04) and all-year (19 years) follow-up durations (HR = 1.03). We observed a higher risk of sleep apnea in DED individuals irrespective of follow-up intervals. Further analyses revealed this increased risk specifically in those diagnosed with Sjögren syndrome (HR = 1.22). This study highlights the significant link between sleep disorders and DED, emphasizing the role of sleep apnea in DED patients. Aqueous-deficient DED has a more pronounced impact on sleep disturbances compared to evaporative DED, while the influence of DED on non-physiological insomnia may be overstated.