Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline

Delayed sleep-wake phase disorder

ABSTRACT

One of seven circadian rhythm disorders, delayed sleep-wake phase disorder (DSWPD) commonly occurs in adolescents and young adults. The disorder is frequently confused with insomnia and can be a presenting complaint, as the individual is often stressed about being unable to fall asleep at the desired time. The underlying disruption occurs due to a shift between when the individual wants to sleep and when the individual can. Unlike patients with insomnia, patients with DSWPD can achieve sleep easily at later times, leading to later wake-up times. The inability to adapt to the societal norm in terms of the standard school, work, or social schedule leads to stressors, further complicating the disorder. Sleep questionnaires, sleep diaries, and actigraphy have improved identification of individuals with delayed sleep. Treatment of DSWPD involves the use of scheduled melatonin, scheduled sleep-wake times, and bright light therapy. If identified early, the disorder can be successfully managed.

Group bright light therapy compared to treatment as usual for delayed sleep-wake phase disorder among patients in psychiatric care (the SIP trials): a protocol for a pragmatic, randomised controlled trial

INTRODUCTION

Circadian rhythm sleep-wake disturbances appear to be prevalent in psychiatric populations and may maintain and exacerbate psychiatric symptoms. Bright light therapy (BLT) is, in addition to exogenous melatonin, the treatment of choice for circadian rhythm disorders like delayed sleep-wake phase disorder (DSWPD) and has yielded promising results in patients with comorbid psychiatric illness. However, such patients are rarely offered this treatment in outpatient clinics. The aim of this randomised controlled trial is to investigate whether group BLT for psychiatric outpatients is superior to treatment as usual (TAU).

METHODS AND ANALYSIS

60 patients with moderate-to-severe psychiatric illness who meet the criteria for DSWPD will be recruited from an outpatient psychiatric clinic in Norway. They will be randomised (1:1) to a group-based Sleep School Wake Up! For Circadian (SSWU-C) programme conjointly with TAU or to TAU while on a wait list for SSWU-C. The SSWU-C will be delivered over four biweekly sessions, each lasting 120 min; hence treatment will last 6 weeks. Assessments will be collected at baseline (T1) and after the intervention (T2). The primary outcome will be changes in sleep timing using measures such as sleep diaries, actigraphy and dim light melatonin onset (DLMO) at 6 weeks postintervention. Secondary outcomes include changes in other sleep metrics, symptoms of depression, anxiety, fatigue, problems with work and social adjustment and well-being. Mixed models will be used for data analyses.

ETHICS AND DISSEMINATION

Ethical approval was granted in 2020 by the Regional Ethics Committee in Western Norway (REK 2020/66304). Findings will be published in peer-reviewed journals and be presented at research conferences and in relevant media. The results may document the need for more specific sleep-directed treatments in psychiatric clinics as a way of treating not only circadian rhythm sleep-wake disorders but also as a treatment to alleviate psychiatric symptoms.

TRIAL REGISTRATION NUMBER

NCT05177055.

Efficacy of digital brief behavioural treatment for insomnia using a smartphone application in conjunction with light therapy in university students with insomnia symptoms with late chronotypes: A pilot randomized-controlled trial

The efficacy of digital brief behavioural treatment for insomnia using a smartphone application in conjunction with light therapy was investigated in university students who had insomnia symptoms with late chronotypes. In this two-arm parallel randomized-controlled trial, participants with insomnia symptoms and late chronotypes were recruited between October and November 2023. The duration of the intervention program was 4 weeks. The smartphone application provides digital brief behavioural treatment for insomnia, including programs for advanced phases. The intervention group used blue-light-emitting diode glasses in the morning after waking up for 2-4 weeks. The primary outcome was a change in the Insomnia Severity Index during the study period. The Insomnia Severity Index was obtained weekly using a web questionnaire. Of the 28 students, 14 each were assigned to the intervention and control groups. The mean Insomnia Severity Index scores at baseline were 12.2 and 12.5; after 4 weeks, they declined to 7.2 and 10.6 in the intervention and control groups, respectively. Primary analysis using a linear mixed model showed a significant improvement in the temporal trends of the Insomnia Severity Index in the intervention group (p < 0.001). The scores on the Morningness-Eveningness Questionnaire (p = 0.008) and RU-SATED (p = 0.005) significantly improved in the intervention group relative to the control group following the intervention. This study demonstrated the effectiveness of the digital brief behavioural treatment for insomnia with light therapy in participants with both insomnia symptoms and late chronotypes.

The Association Between Delayed Sleep-Wake Phase Disorder and Depression Among Young Individuals: A Systematic Review and Meta-Analysis: Association entre le syndrome de retard de phase et la dépression parmi les jeunes : revue systématique et méta-analyse

ObjectivesDelayed sleep-wake phase disorder (DSWPD) most commonly affects young individuals (adolescents and young adults), but it is often undetected in clinical practice. Despite several reports suggesting a link between DSWPD and depression, no systematic review has investigated this association. The aim of this systematic review was to determine whether DSWPD is associated with depression among young individuals.MethodsMEDLINE, EMBASE, PsycINFO, and CINAHL Plus were searched up to 29 July 2024. Primary studies investigating DSWPD and depression among young individuals were eligible. Methodological quality and risk of bias was assessed with the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Common-effect models were conducted to examine the relationship between DSWPD status (categorical variable: yes or no) and depression severity (continuous variable). PROSPERO ID: CRD42023458889.ResultsSixteen studies were included with 766 participants being evaluated against the diagnostic criteria for DSWPD from the International Classification of Sleep Disorders. Thirteen out of 15 studies demonstrated that young individuals with DSWPD had a significantly greater severity of depressive symptoms than young individuals without DSWPD. NIH quality assessment scores ranged between 5 and 9 (out of a total of 11). DSWPD status had a significantly large effect on depression severity in the common-effect model (N: 16 estimates, 693 participants, Cohen's d = 0.92, 95% confidence interval (95% CI) [0.76-1.08]). The subgroup analysis also demonstrated significant findings with the common-effect model that only utilized data from studies that controlled for psychiatric disorders (N: 12 estimates, 535 participants, Cohen's d = 0.88, 95% CI [0.70-1.06]).ConclusionsDSWPD is associated with a greater severity of depressive symptoms among young individuals. Although more research is required to understand this association, it may be useful to consider the presence of DSWPD when managing young individuals who present with persistent sleep disturbances (e.g., sleep-onset insomnia) and depressive symptoms.

Clinical Chronobiology: Circadian Rhythms in Health and Disease

Circadian rhythms (CRs) are entrainable endogenous rhythms that respond to external stimuli and regulate physiological functions. The suprachiasmatic nucleus (SCN) in the hypothalamus is the mammalian master clock that synchronizes all other tissue-specific peripheral clocks, primarily through gamma-aminobutyric acid (GABA) and vasoactive intestinal polypeptide (VIP). The SCN follows Earth's 24-hour cycle by light entrainment through the retinohypothalamic tract. At the cellular level, the core clock genes CLOCK, BMAL1, PER1-PER3, CRY1, and CRY2 regulate CRs in a negative feedback loop. The circadian disruption of the sleep-wake cycle manifests in at least six distinct clinical conditions. These are the circadian rhythm sleep-wake disorders (CRSWDs). Their diagnosis is made by history, sleep diaries, and actigraphy. Treatment involves a combination of timed light exposure, melatonin/melatonin agonists, and behavioral interventions. In addition, CR disturbances and subsequent misalignment can increase the risk of a variety of illnesses. These include infertility and menstrual irregularities as well as diabetes, obesity, fatty liver disease, and other metabolic syndromes. In addition, a disruption in the gut microbiome creates a proinflammatory environment. CR disturbances increase the risk for mood disorders, hence the utility of light-based therapies in depression. People with neurodegenerative disorders demonstrate significant disturbances in their CRs, and in their sleep-wake cycles. Circadian realignment therapies can also help decrease the symptomatic burden of these disorders. Certain epilepsy syndromes, such as juvenile myoclonic epilepsy (JME), have a circadian pattern of seizures. Circadian disturbances in epilepsy can be both the consequence and cause for breakthrough seizures. The immune system has its own CR. Disturbances in these due to shift work, for instance, can increase the risk of infections. CR disturbances can also increase the risk of cancer by impacting DNA repair, apoptosis, immune surveillance, and cell cycle regulation. Moreover, the timing of chemotherapeutic agents has been shown to increase their therapeutic impact in certain cancers.

Novel assessment of CPAP adherence data reveals distinct diurnal patterns

STUDY OBJECTIVES

Obstructive sleep apnea is a prevalent condition effectively treated by continuous positive airway pressure (CPAP) therapy. CPAP adherence data, routinely gathered in clinical practice, include detailed information regarding both duration and timing of use. The purpose of the present study was to develop a systematic way to measure the diurnal pattern of CPAP adherence data and to see if distinct patterns exist in a clinical cohort.

METHODS

Machine learning techniques were employed to analyze CPAP adherence data. A cohort of 200 unselected patients was assessed and a cluster analysis was subsequently performed. Application of this methodology to 17 patients with different visually noted patterns was carried out to further assess performance.

RESULTS

Each 30-day period of CPAP use for each patient was characterized by 4 variables describing the time of day of initiation and discontinuation of CPAP use, as well as the consistency of use during those times. Further analysis identified 6 distinct clusters, reflecting different timing and adherence patterns. Specifically, clusters with relatively normal timing vs delayed timing were identified. Finally, application of this methodology showed generally good performance with limitations in the ability to characterize shift worker and non-24 rhythms.

CONCLUSIONS

This study demonstrates a methodology for analysis of diurnal patterns from CPAP adherence data. Furthermore, distinct timing and adherence patterns are demonstrated. The potential impact of these patterns on the beneficial effects of CPAP requires elucidation.

CITATION

Scharf MT, Androulakis IP. Novel assessment of CPAP adherence data reveals distinct diurnal patterns. J Clin Sleep Med. 2025;21(3):493-502.

Stuck in time: The slow march of circadian medicine and how to speed it up

While there is considerable enthusiasm for the translational and clinical applications of chronobiology, their actual implementation is not progressing as rapidly as might be expected. Here we discuss the possibility that this may relate to a combination of conceptual, methodological, evidentiary and training challenges. These are compounded by the remaining, profound cultural differences between basic and applied chronobiologists. We argue that all these issues can be overcome by cross-faculty teaching, time, patience and goodwill, together with a set of more formal actions, such as the establishment of a collaborative framework for evidence generation, the engagement of relevant stakeholders and public health campaigns based on already available evidence. We hope that chronobiology, and in particular the transformative power of circadian medicine, will change health outcomes, increase safety and improve quality of life for patients worldwide. Now is the time to bring "internal time" into medicine.

Integrating Assessment of Circadian Rhythmicity to Improve Treatment Outcomes for Circadian Rhythm Sleep-Wake Disorders: Updates on New Treatments

Purpose of Review

Despite advancements in basic circadian research, development of new diagnostic and treatment strategies for circadian rhythm sleep-wake disorders (CRSWDs) has been slow. Here, we review the most recent innovations in human circadian assessment and emerging new therapies for CRSWDs.

Recent Findings

Researchers have improved existing circadian assessment methods to overcome logistical barriers and developed novel circadian assessment methods. New treatments for CRSWDs involve pharmacological and behavioral treatments that modulate circadian phase, amplitude, and/or robustness of the central circadian clock.

Summary

Commercialization of these emerging tools will require overcoming barriers, such as additional testing to confirm the underlying pathology and mechanism of action of potential treatments. Clinicians and scientists are also called to survey adjacent fields and adopt existing diagnostic tools that may offer diagnostic clarity in CRSWDs. Lastly, we must continue to advocate for medical insurance coverage of current and future tools and technologies to improve patient care.

Assessment of adverse events of tasimelteon: a real-world pharmacovigilance study based on FAERS

BACKGROUND

Tasimelteon is a novel dual melatonin receptor agonist approved for the treatment of non-24-hour sleep-wake disorder (N24HSWD). The purpose of this study was to provide a comprehensive analysis of post-marketing adverse events (AEs) for tasimelteon by analyzing the U.S. FDA Adverse Event Reporting System (FAERS) database.

METHODS

Four algorithms are employed in this study to mine the significant signals: multi-item gamma poisson shrinker (MGPS), Bayesian confidence propagation neural network (BCPNN), reporting odds ratio (ROR), and proportional reporting ratio (PRR).

RESULTS

Tasimelteon was the primary suspected drug in 5,125 adverse event reports that were identified between the first quarter of 2014 and the first quarter of 2024. Significant system organ categories (SOC) included psychiatric disorders, general disorders and administration site conditions, and nervous system disorders. We not only confirmed the adverse reactions outlined in the prescribing information such as somnolence, nightmare or abnormal dreams, and inhibitory drug interaction, but also revealed new potential risks that were not documented, such as insomnia and sleep disorder.

CONCLUSIONS

This study revealed the characteristics of tasimelteon-associated adverse drug reactions, improved understanding of drug safety, and provided valuable signals for optimizing drug use regimens. Additional large-scale prospective studies remain necessary in the future.

Managing sleep issues in Parkinson's disease: an up-to-date review

INTRODUCTION

In Parkinson's disease (PD), sleep-wake problems are disease-related symptoms that occur throughout the day and have a negative impact on patients' quality of life to an extent that is equal to or greater than that of typical motor symptoms.

AREAS COVERED

Insomnia due to fragmented sleep and excessive daytime sleepiness (EDS) worsen as PD progresses. Nighttime wearing-off and early morning-off should be considered first when fragmented sleep is reported in PD patients. If the main complaint of patients with insomnia is difficulty falling asleep, restless legs syndrome should be differentiated first. Obstructive sleep apnea causes sleep quality deterioration and fragmented sleep. For rapid eye movement sleep behavior disorder (RBD), preventative measures against sleep-related trauma are necessary. RBD has also attracted attention as a PD precursor state and as a disease progression marker that is associated with specific PD clinical subtypes. In PD patients, the sleep-wake phase may advance/delay or become irregular due to circadian dysfunction.

EXPERT OPINION

Importantly, sleep-wake problems are core symptoms related to the pathogenesis and progression of PD, and addressing a wide range of these symptoms will improve patients' quality of life.

Rhythms of light: Understanding the role of circadian timing in alertness and cognitive performance

The nonimage-forming effects of light are pivotal in regulating cognitive functions, including alertness, sustained attention, and higher-order cognitive processes. These cognitive domains are deeply influenced by the sleep-wake cycle, which are governed by two key processes: the homeostatic process, which builds sleep pressure during wakefulness, and the circadian process, which aligns with environmental light cues to regulate wakefulness and sleep. When these processes fall out of sync-a condition known as circadian misalignment-alertness, sustained attention, and cognitive performance can suffer significantly. This misalignment is often observed in shift workers, individuals experiencing jet lag, and those with circadian rhythm sleep disorders. However, strategic light exposure can help mitigate these cognitive impairments by realigning circadian rhythms, enhancing wakefulness during desired periods, and facilitating sleep when needed. This chapter examines the complex interplay between light, circadian rhythms, the sleep-wake cycle, and cognitive functioning, offering a comprehensive exploration of how these factors shape cognitive performance throughout the day and under conditions of circadian misalignment. It also discusses the broader implications of these interactions for cognitive health and performance.

Circadian rhythm disorders in the blind

Non-24-h sleep-wake disorder in blind patients without light perception is an orphan circadian rhythm sleep-wake disorder and is extremely rare in sighted people. Non-24-h sleep-wake disorder is characterized by insomnia and daytime sleepiness alternating with asymptomatic episodes. The frequency of symptomatic periods depends on the daily desynchronization of endogenous circadian pattern of each patient. Diagnosis requires anamnesis, a sleep diary, and actigraphy, if possible; in addition, repeated 24-h measures of circadian markers such as melatonin secretion are also required. Treatment consists of sleep hygiene, behavioral therapy, and melatonin/melatonin agonist administration. Melatonin treatment should start when the circadian rhythm of the patient is in phase with the solar cycle. Efficacy of treatment may be evident after weeks even months from the beginning. There is often a relapse when the medication is stopped.

Irregular sleep-wake rhythm disorder: From the pathophysiologic perspective to the treatment

Irregular sleep-wake rhythm disorder (ISWRD) is an intrinsic circadian rhythm disorder caused by loss of the brain's circadian regulation, through changes of the input and/or output to the suprachiasmatic nucleus (SCN), or of the SCN itself. Although there are limited prevalence data for this rare disease, ISWRD is associated with neurodegenerative disorders, including the Alzheimer disease (AD) and the Parkinson disease (PD), which will become increasingly prevalent in an aging population. It additionally presents in childhood developmental disorders, psychiatric disorders, and traumatic brain injury (TBI). Patients present with unpredictable, short sleep periods over a 24-h period, with significant day-to-day and weekly variability. Symptoms manifest as insomnia and excessive daytime sleepiness. Sleep logs and actigraphy monitoring capture rest-activity patterns required for diagnosis. Treatment aims to enhance external circadian cues through timed light therapy, behavioral activity regimens, and melatonin, but efficacy remains quite limited. Pathophysiology of ISWRD in association with various diseases and their specific management are discussed. There is a need for further investigation of disease pathophysiology, development of widely applicable tools for diagnosis, and development of treatments.

Assessing Sleep Disorders in an Inpatient Child and Adolescent Psychiatric Unit

Sleep and mental health have a strong relationship. There is a lack of training in Sleep Medicine for Psychiatrists. Sleep problems often accompany mental health issues, especially in children and adolescents on inpatient psychiatry units. Recognizing common sleep disorders is important in these settings. It is also important to involve pediatric sleep specialists when needed. This article addresses common sleep disorders observed in inpatient child and adolescent psychiatry units and outlines optimal management strategies.

Advanced sleep phase syndrome: Role of genetics and aging

Advanced sleep phase (ASP) is seldom brought to medical attention because many individuals easily adapt to their early chronotype, especially if it emerges before the age of 30 and is present in a first-degree relative. In this case, the disorder is considered familial (FASP) and is mostly discovered coincidentally in the presence of other sleep disorders, mainly obstructive sleep apnea syndrome (OSAS). The prevalence of FASP is currently estimated to be between 0.21% and 0.5%. Autosomal dominant mutations in circadian clock genes like PER2, CK1, PER3, CRY2, TIMELESS, and DEC2 have been linked to FASP, some with pleiotropic effects influencing other health aspects like migraine and depression. Early morning awakening is, instead, more common among older individuals, occurring in almost 4% of cases, without considering associated comorbidities. Advanced sleep-wake phase disorder (ASWPD) is characterized by a consistent and distressing anticipation of sleep-wake timing, affecting almost 1% of middle-aged individuals. On average, women have a shorter circadian period than men, making them more susceptible to ASWPD, albeit no significant gender discrepancies have been observed. Age-related alterations in circadian rhythms are exacerbated and compounded by neurodegenerative disorders, impacting the suprachiasmatic nucleus (SCN), sensitivity to light, and light responsiveness in those affected. Conflicting data has surfaced regarding the protective or detrimental effects of ASWPD in studies on aging, mild cognitive impairment (MCI), and diverse dementia conditions.

Association between polypharmacy and the long-term prescription of hypnotics in Japan: a retrospective cross-sectional study

Introduction

Hypnotic polypharmacy and its long-term prescriptions constitute the inappropriate use of hypnotics. However, the relationship between hypnotic polypharmacy and prolonged prescriptions remains unclear. This study aimed to elucidate the association between hypnotic polypharmacy and the duration of hypnotic prescriptions.

Methods

This retrospective, cross-sectional study utilized a large dataset from the Japan Medical Data Center. The study population included adults who had been prescribed hypnotics between April 2020 and March 2021, with a focus on those receiving hypnotics in March 2021. Hypnotic polypharmacy was defined as the concurrent prescription of two or more hypnotics in March 2021. The duration of hypnotic prescriptions was measured by calculating the number of months between April 2019 and March 2021 during which hypnotics were prescribed. A binary logistic regression analysis was conducted to assess the relationship between hypnotic polypharmacy and long-term hypnotic prescriptions, adjusting for relevant covariates.

Results

We included 112,256 patients (mean age: 49.5 years, females: 47.1%). Among them, 67.9% received hypnotic monotherapy, and 32.1% received hypnotic polypharmacy. Compared with adults who were prescribed hypnotics for 1 month, the association with polypharmacy was stronger in those who were prescribed hypnotics for ≥4 months as the duration of the prescription increased (adjusted odds ratio [aOR]: 1.15, 95% confidence interval [CI]: 1.04-1.27, p=0.006 for 4-6 months; aOR 1.35, 95% CI 1.23-1.49, p<0.001 for 7-9 months; aOR 1.58, 95% CI 1.43-1.73, p<0.001 for 10-12 months; and aOR 3.24, 95% CI 2.99-3.52 for 13-24 months).

Conclusions

This study demonstrated a significant association between hypnotic polypharmacy and long-term prescriptions of hypnotics. Initiating insomnia treatment with hypnotic monotherapy may reduce the likelihood of long-term prescriptions, and limiting the duration of hypnotic prescriptions could potentially prevent polypharmacy.

Registry and survey of circadian rhythm sleep-wake disorder patients

Objective

Circadian Sleep Disorders Network has created a registry of circadian rhythm sleep-wake disorder (CRSWD) patients, and a survey of their experiences. The purpose of the registry is to provide volunteers willing to participate in research; the purpose of the survey is to fill some of the knowledge gaps on these disorders, including information on subjective patient experience and the efficacy and durability of treatments.Researchers are invited to contact Circadian Sleep Disorders Network for permission to use the registry to find potential research participants, and to further analyze the survey data.

Patients

Over 1627 patients have participated; 1298 have completed the entire survey. Here we present results based on the 479 clinically diagnosed CRSWD patients.

Methods

The survey covers a variety of topics relating to CRSWDs, including diagnosis, comorbidities, treatments, and work/educational accommodations.

Conclusions

Results of this survey diverged from much of the literature. More than half the participants reported tiredness even when sleeping on their preferred schedule. While depression may cause sleep problems, our data suggests that sleep/circadian problems often precede depression.There were more people suffering from sighted non-24-hour sleep-wake rhythm disorder than some of the literature would lead us to expect.Current treatments did not appear to be helpful to a large percentage of our participants. Most of them did not find light therapy helpful and nearly all participants who tried phase-delay chronotherapy reported at best only short-term improvement. A sizable proportion of people who tried phase-delay chronotherapy subsequently developed non-24-hour sleep-wake rhythm disorder.

Sleep interventions in pediatric oncology: A systematic review of the evidence

Sleep concerns are common during pediatric cancer treatment and can last into survivorship. The current systematic review sought to identify intervention studies that addressed sleep as a primary or secondary outcome during pediatric cancer treatment up to 5 years after completing treatment. Quality assessment was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The review identified 16 studies with a total of 943 participants that tested a wide range of interventions including psycho-educational, stress management techniques, medications, and physical activity. Most studies included tested interventions in small samples. None of the included studies had a high risk of bias for all domains, but all included studies had a high risk of bias for at least two risk domains. Several feasible pilot studies were identified that warrant further research to test efficacy. Implications for future research and clinical practice to manage sleep concerns are discussed.

Sleep and sleep disorders in people with Parkinson's disease

Sleep disorders are common in people with Parkinson's disease. These disorders, which increase in frequency throughout the course of the neurodegenerative disease and impair quality of life, include insomnia, excessive daytime sleepiness, circadian disorders, obstructive sleep apnoea, restless legs syndrome, and rapid eye movement (REM) sleep behaviour disorder. The causes of these sleep disorders are complex and multifactorial, including the degeneration of the neural structures that modulate sleep, the detrimental effect of some medications on sleep, the parkinsonian symptoms that interfere with mobility and comfort in bed, and comorbidities that disrupt sleep quality and quantity. The clinical evaluation of sleep disorders include both subjective (eg, questionnaires or diaries) and objective (eg, actigraphy or video polysomnography) assessments. The management of patients with Parkinson's disease and a sleep disorder is challenging and should be individualised. Treatment can include education aiming at changes in behaviour (ie, sleep hygiene), cognitive behavioural therapy, continuous dopaminergic stimulation at night, and specific medications. REM sleep behaviour disorder can occur several years before the onset of parkinsonism, suggesting that the implementation of trials of neuroprotective therapies should focus on people with this sleep disorder.

Insomnia in Adults in the Primary Care Clinic Setting

Insomnia is one of the most common sleep concerns raised by patients both to primary care as well as sleep specialists. Chronic insomnia has a lifetime prevalence of approximately 30% in the general population, resulting in roughly $100 billion dollars healthcare expenditures annually. Given the complexity of insomnia this can become burdensome for primary care providers. In this article we will highlight the main issues and how to manage these individuals in the primary care clinic.

Logistic regression analysis of risk factors influencing childhood enuresis: a comprehensive survey study

OBJECTIVE

To identify risk factors associated with childhood enuresis.

METHODS

We conducted a retrospective analysis of 146 children aged 6 to 13 years diagnosed with enuresis at Anhui Province Children's Hospital between June 2020 and June 2023. Children were categorized based on bedwetting frequency: those with less frequent episodes (once a week to twice a month) were placed in the mild group (60 cases), and those with frequent episodes (two or more times per week) were placed in the severe group (86 cases). We compared demographic data, family histories, and personal characteristics between the groups and performed logistic regression to determine significant risk factors.

RESULTS

The analysis revealed that a stubborn personality, nocturnal polyuria, sleep-wake disorders, and bladder dysfunction significantly increased the risk of enuresis (P < 0.05). These findings underscore the importance of a holistic approach in evaluating psychological aspects, nocturnal urination patterns, sleep quality, and bladder health in managing enuresis.

CONCLUSION

The study identifies stubborn personality, nocturnal polyuria, sleep-wake disorders, and bladder dysfunction as independent risk factors for childhood enuresis. Understanding these factors is crucial for developing targeted interventions that can enhance the management and outcomes of enuresis. Future research should explore the interrelationships among these factors to refine preventive and therapeutic strategies for early childhood enuresis.

Low-dose exogenous melatonin plus evening dim light and time in bed scheduling advances circadian phase irrespective of measured or estimated dim light melatonin onset time: preliminary findings

STUDY OBJECTIVES

The purpose of the present study was to preliminarily evaluate whether knowing the dim light melatonin onset (DLMO) time is advantageous when treating delayed sleep-wake phase disorder with low-dose melatonin treatment plus behavioral interventions (ie, evening dim light and time in bed scheduling).

METHODS

In this randomized, controlled, double-blind trial, 40 adults with delayed sleep-wake phase disorder were randomly assigned to 4 weeks of 0.5 mg timed to be administered either 3 hours before the DLMO (measured DLMO group, n = 20) or 5 hours before sleep-onset time per actigraphy (estimated DLMO group, n = 20), in conjunction with behavioral interventions. The primary outcome was change in the DLMO (measured in-home). Secondary outcomes included sleep parameters per diary and actigraphy (sleep-onset and -offset times and total sleep time), Morningness-Eveningness Questionnaire, Multidimensional Fatigue Inventory, PROMIS-Sleep Disturbance, PROMIS-Sleep Related Impairment, and Pittsburgh Sleep Quality Index. Mixed-effects models tested for group differences in these outcome.

RESULTS

After applying the Bonferroni correction for multiple comparisons (significant P value set at < .004), there were significant main effects for visit on all outcomes except for the Pittsburgh Sleep Quality Index and total sleep time per wrist actigraphy and diary. There were no group-by-visit interactions for any of the outcomes (P > .004).

CONCLUSIONS

Scheduled low-dose melatonin plus behavioral interventions may improve many circadian and sleep parameters regardless of whether melatonin administration is scheduled based on estimated or measured DLMO. A larger-scale trial is needed to confirm these preliminary findings.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: The Clinical Utility of Measuring the Circadian Clock in Treatment of Delayed Sleep-Wake Phase Disorder; URL: https://clinicaltrials.gov/study/NCT03715465; Identifier: NCT03715465.

CITATION

Swanson LM, de Sibour T, DuBuc K, et al. Low-dose exogenous melatonin plus evening dim light and time in bed scheduling advances circadian phase irrespective of measured or estimated dim light melatonin onset time: preliminary findings. J Clin Sleep Med. 2024;20(7):1131-1140.

Managing non-24-hour sleep-wake rhythm disorder with ramelteon in a 12-year-old girl with Pierre Robin sequence and developmental delay: a case report

The author recently observed a case involving a 12-year-old sighted girl who exhibited symptoms typical of non-24-hour sleep-wake rhythm disorder (N24SWD). This disorder, more commonly found in blind individuals, presents a unique challenge when diagnosed in those with vision. Several interventions can be attempted, ranging from behavioral adjustments to light therapy. Although melatonin has been noted for its effectiveness in realigning the patient's sleep-wake cycle, the use of ramelteon, a melatonin receptor agonist, has seldom been reported in managing N24SWD. However, this case illuminates the potential of ramelteon as another therapeutic option for sighted individuals with N24SWD. Further study is suggested to determine the potential of ramelteon in managing this disorder among sighted individuals of varying age groups.

CITATION

Huang C-H. Managing non-24-hour sleep-wake rhythm disorder with ramelteon in a 12-year-old girl with Pierre Robin sequence and developmental delay: a case report. J Clin Sleep Med. 2024;20(6):995-997.

Quantum mechanics insights into melatonin and analogs binding to melatonin MT1 and MT2 receptors

Melatonin receptors MT1 and MT2 are G protein-coupled receptors that mediate the effects of melatonin, a hormone involved in circadian rhythms and other physiological functions. Understanding the molecular interactions between these receptors and their ligands is crucial for developing novel therapeutic agents. In this study, we used molecular docking, molecular dynamics simulations, and quantum mechanics calculation to investigate the binding modes and affinities of three ligands: melatonin (MLT), ramelteon (RMT), and 2-phenylmelatonin (2-PMT) with both receptors. Based on the results, we identified key amino acids that contributed to the receptor-ligand interactions, such as Gln181/194, Phe179/192, and Asn162/175, which are conserved in both receptors. Additionally, we described new meaningful interactions with Gly108/Gly121, Val111/Val124, and Val191/Val204. Our results provide insights into receptor-ligand recognition's structural and energetic determinants and suggest potential strategies for designing more optimized molecules. This study enhances our understanding of receptor-ligand interactions and offers implications for future drug development.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Melatonin attenuates chronic sleep deprivation-induced cognitive deficits and HDAC3-Bmal1/clock interruption

BACKGROUND AND AIMS

Sleep is predicted as a key modulator of cognition, but the underlying mechanisms are poorly understood. In this study, we investigated the effects of melatonin on chronic rapid eye movement sleep deprivation (CRSD)-induced cognitive impairment and circadian dysfunction in rat models.

METHODS

Thirty-six Sprague-Dawley male rats were divided into three groups: CRSD with saline treatment, CRSD with chronic melatonin injection (20 mg/kg/day), and non-sleep-deprived control. The cognitive behavioral tests as well as the expression of clocks and HDAC3 were evaluated in all groups.

RESULTS

CRSD significantly reduced recognition index in novel object location, increased escape latency and distance traveling in Morris water maze while melatonin treatment attenuated CRSD-induced hippocampal-dependent spatial learning and memory deficits. Furthermore, the mRNAs of brain and muscle aryl hydrocarbon receptor nuclear translocator-like 1(Bmal1) and circadian locomotor output cycles kaput (Clock) were globally down-regulated by CRSD with constant intrinsic oscillation in both hippocampus and peripheral blood. The protein levels of hippocampal Bmal1, Clock, and HDAC3 were also remarkably down-regulated following CRSD. Melatonin treatment reversed CRSD-induced alterations of Bmal1/Clock and HDAC3 on both mRNA levels and protein levels.

CONCLUSIONS

Our data indicate that melatonin treatment attenuates CRSD-induced cognitive impairment via regulating HDAC3-Bmal1/Clock interaction. These findings explore a broader understanding of the relationship between sleep and cognition and provide a potential new therapeutic target for cognitive impairment.

Delaying early morning workouts to protect sleep in two-a-day athletes

Two-a-day training is common for endurance athletes with training sessions typically beginning at 6 a.m. and 3 p.m. or 4 p.m. However, the early morning workouts could contribute to significant sleep loss, especially for night owls. Chronic sleep loss over a season could result in impaired performance, as well as an increased risk of physical and mental illness. It is hypothesized that shifting the early morning workout to later in the day could have beneficial effects for these athletes. A number of obstacles could make this hypothesis difficulty to test and implement. However, such a change could have dramatic benefits for some athletes.

Delayed melatonin circadian timing, lower melatonin output, and sleep disruptions in myopic, or short-sighted, children

STUDY OBJECTIVES

This study investigated the differences in melatonin circadian timing and output, sleep characteristics, and cognitive function in myopic and non-myopic (or emmetropic) children, aged 8-15 years.

METHODS

Twenty-six myopes (refractive error [mean ± standard error mean] -2.06 ± 0.23 diopters) and 19 emmetropes (-0.06 ± 0.04 diopters), aged 11.74 ± 2.31 years were recruited. Circadian timing was assessed using salivary dim-light melatonin onset (DLMO), collected half-hourly for 7 hours, beginning 5 hours before and finishing 2 hours after individual average sleep onset in a sleep laboratory. Nocturnal melatonin output was assessed via aMT6s levels from urine voids collected from 05:30 pm to 8:00 am the following morning. Actigraphy-derived objective sleep timing were acquired for a week prior to the sleep laboratory visit. Cognitive assessments of sustained attention (using psychomotor vigilance task [PVT]) and working memory (using digit spans) were performed on the night of sleep laboratory.

RESULTS

Myopic children (9:07 pm ± 14 minutes) exhibited a DLMO phase-delay of 1 hour 8 minutes compared to emmetropes (7:59 pm ± 13 minutes), p = 0.002. aMT6s melatonin levels were significantly lower among myopes (18.70 ± 2.38) than emmetropes (32.35 ± 6.93, p = 0.001). Myopes also exhibited significantly delayed sleep onset, delayed wake-up time, poor and reduced sleep, and more evening-type diurnal preference than emmetropes (all p < 0.05). Finally, myopes showed a slower reaction time in the PVT (p < 0.05), but not digit span tasks at night.

CONCLUSIONS

These findings suggest a potential association between circadian rhythm dysfunction and myopia in children.

Circadian light therapy and light dose for depressed young people: a systematic review and meta-analysis

Background

Empirical evidence has shown that light therapy (LT) can reduce depression symptoms by stimulating circadian rhythms. However, there is skepticism and inconclusive results, along with confusion regarding dosing. The purpose of this study is to quantify light as a stimulus for the circadian system and create a dose-response relationship that can help reduce maladies among adolescents and young adults (AYAs). This will provide a reference for light exposure and neural response, which are crucial in the neuropsychological mechanism of light intervention. The study also aims to provide guidance for clinical application.

Methods

The latest quantitative model of CLA (circadian light) and CSt,f (circadian stimulus) was adopted to quantify light dose for circadian phototransduction in youth depression-related light therapy. Articles published up to 2023 through Web of Science, Cochrane Library, Medline (OVID), CINAHL, APA PsycINFO, Embase, and Scholars were retrieved. A meta-analysis of 31 articles (1,031 subjects) was performed using Stata17.0, CMA3.0 (comprehensive meta-analysis version 3.0) software, and Python 3.9 platform for light therapy efficacy comparison and dose-response quantification.

Results

Under various circadian stimulus conditions (0.1 < CSt,f < 0.7) of light therapy (LT), malady reductions among AYAs were observed (pooled SMD = -1.59, 95%CI = -1.86 to -1.32; z = -11.654, p = 0.000; I2 = 92.8%), with temporal pattern (p = 0.044) and co-medication (p = 0.000) suggested as main heterogeneity sources. For the efficacy advantage of LT with a higher circadian stimulus that is assumed to be influenced by visualization, co-medication, disease severity, and time pattern, sets of meta-analysis among random-controlled trials (RCTs) found evidence for significant efficacy of circadian-active bright light therapy (BLT) over circadian-inactive dim red light (SMD = -0.65, 95% CI = -0.96 to -0.34; z = -4.101, p = 0.000; I2 = 84.9%) or circadian-active dimmer white light (SMD = -0.37, 95% CI = -0.68 to -0.06; z = -2.318, p = 0.02; I2 = 33.8%), whereas green-blue, circadian-active BLT showed no significant superiority over circadian-inactive red/amber light controls (SMD = -0.21, 95% CI = -0.45 to 0.04; z = -2.318, p = 0.099; I2 = 0%). Overall, circadian-active BLT showed a greater likelihood of clinical response than dim light controls, with increased superiority observed with co-medication. For pre-to-post-treatment amelioration and corresponding dose-response relationship, cumulative duration was found more influential than other categorical (co-medication, severity, study design) or continuous (CSt,f) variables. Dose-response fitting indicated that the therapeutic effect would reach saturation among co-medicated patients at 32-42 days (900-1,000 min) and 58-59 days (1,100-1,500 min) among non-medicated AYAs. When exerting high circadian stimulus of light therapy (0.6 < CSt,f < 0.7), there was a significantly greater effect size in 1,000-1,500 min of accumulative duration than <1,000 or >1,500 min of duration, indicating a threshold for practical guidance.

Limitations

The results have been based on limited samples and influenced by a small sample effect. The placebo effect could not be ignored.

Conclusions

Although the superiority of LT with higher circadian stimulus over dimmer light controls remains unproven, greater response potentials of circadian-active BLT have been noticed among AYAs, taking co-medication, disease severity, time pattern, and visual characteristics into consideration. The dose-response relationship with quantified circadian stimulus and temporal pattern had been elaborated under various conditions to support clinical depression treatment and LT device application in the post-pandemic era.

The Safety and Comparative Effectiveness of Non-Psychoactive Cannabinoid Formulations for the Improvement of Sleep: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Clinical evidence on the use of cannabidiol (CBD) for sleep remains limited. Even fewer studies have tested the comparative effectiveness of cannabinoid formulations found within CBD products used for sleep or how they compare to other complementary therapies such as melatonin.

METHODS

Participants (N = 1,793 adults experiencing symptoms of sleep disturbance) were randomly assigned to receive a 4-week supply of 1 of 6 products (all capsules) containing either 15 mg CBD or 5 mg melatonin, alone or in combination with minor cannabinoids. Sleep disturbance was assessed over a period of 5 weeks (baseline week and 4 weeks of product use) using Patient-Reported Outcomes Measurement Information System (PROMIS™) Sleep Disturbance SF 8A, administered via weekly online surveys. A linear mixed-effects regression model was used to assess the differences in the change in sleep disturbance through time between each active product arm and CBD isolate.

RESULTS

All formulations exhibited a favorable safety profile (12% of participants reported a side effect and none were severe) and led to significant improvements in sleep disturbance (p < 0.001 in within-group comparisons). Most participants (56% to 75%) across all formulations experienced a clinically important improvement in their sleep quality. There were no significant differences in effect, however, between 15 mg CBD isolate and formulations containing 15 mg CBD and 15 mg cannabinol (CBN), alone or in combination with 5 mg cannabichromene (CBC). There were also no significant differences in effect between 15 mg CBD isolate and formulations containing 5 mg melatonin, alone or in combination with 15 mg CBD and 15 mg CBN.

CONCLUSIONS

Our findings suggest that chronic use of a low dose of CBD is safe and could improve sleep quality, though these effects do not exceed that of 5 mg melatonin. Moreover, the addition of low doses of CBN and CBC may not improve the effect of formulations containing CBD or melatonin isolate.

An independent comparison of the Novolytix salivary melatonin radioimmunoassay with the new Novolytix salivary melatonin enzyme-linked immunosorbent assay

The dim light melatonin onset (DLMO) is the current gold standard biomarker of the timing of the central circadian clock in humans and is often assessed from saliva samples. To date, only one commercially available salivary melatonin assay is considered accurate at the low daytime levels required to accurately detect the DLMO (Novolytix RIA RK-DSM2). The aim of this study was to conduct the first independent evaluation of a newly improved enzyme-linked immunosorbent assay (ELISA; Novolytix MLTN-96) and compare it with the recommended radioimmunoassay (RIA)-both in terms of melatonin concentrations and derived DLMOs. Twenty participants (15 females, 18-59 years old) provided saliva samples every 30 min in dim light starting 6 h before their habitual bedtime, yielding a total of 260 saliva samples. Both the RIA and ELISA yielded daytime melatonin concentrations <2 pg/mL, indicating adequate accuracy to detect the DLMO. The melatonin concentrations from the two assays were highly correlated (r = .94, p < .001), although the RIA yielded lower levels of melatonin concentration than the ELISA, on average by 0.70 pg/mL (p = .006). Seventeen DLMOs were calculated from the melatonin profiles and the DLMOs from both assays were not statistically different (p = .36) and were highly correlated (r = .97, p < .001). Two DLMOs derived from the RIA occurred more than 30 min earlier than the DLMO derived from the ELISA. These results indicate that the new Novolytix ELISA is an appropriate assay to use if the Novolytix RIA is not feasible or available.

Sleep Disorders and Aging in Women

Women of advancing age can suffer from an array of sleep disorders. We review the changes in sleep architecture, the impact of hormonal changes on sleep, and the various sleep disorders in women of advancing age. A focused history in this population should include the temporal relation to menopause and comorbid conditions. Treatment options should involve patient preference and review of current medications and comorbid conditions to optimize sleep in this population.

Current Considerations in the Diagnosis and Treatment of Circadian Rhythm Sleep-Wake Disorders in Children

Circadian Rhythm Sleep-Wake Disorders (CRSWDs) are important sleep disorders whose unifying feature is a mismatch between the preferred or required times for sleep and wakefulness and the endogenous circadian drives for these. Their etiology, presentation, and treatment can be different in pediatric patients as compared to adults. Evaluation of these disorders must be performed while viewed through the lens of a patient's comorbid conditions. Newer methods of assessment promise to provide greater diagnostic clarity and critical insights into how circadian physiology affects overall health and disease states. Effective clinical management of CRSWDs is multimodal, requiring an integrated approach across disciplines. Therapeutic success depends upon appropriately timed nonpharmacologic and pharmacologic interventions. A better understanding of the genetic predispositions for and causes of CRSWDs has led to novel clinical opportunities for diagnosis and improved therapeutics.

A seasonal switch hypothesis for the neuroendocrine control of aggression

Aggression is a well-studied social behavior that is universally exhibited by animals across a wide range of contexts. Prevailing knowledge suggests gonadal steroids primarily mediate aggression; however, this is based mainly on studies of male-male aggression in laboratory rodents. When males and females of other species, including humans, are examined, a positive relationship between gonadal steroids and aggression is less substantiated. For instance, hamsters housed in short 'winter-like' days show increased aggression compared with long-day housed hamsters, despite relatively low circulating gonadal steroids. These results suggest alternative, non-gonadal mechanisms controlling aggression. Here, we propose the seasonal switch hypothesis, which employs a multidisciplinary approach to describe how seasonal variation in extra-gonadal steroids, orchestrated by melatonin, drives context-specific changes in aggression.

Twenty-four-hour rhythmicities in disorders of consciousness are associated with a favourable outcome

Fluctuations of consciousness and their rhythmicities have been rarely studied in patients with a disorder of consciousness after acute brain injuries. 24-h assessment of brain (EEG), behaviour (eye-opening), and circadian (clock-controlled hormones secretion from urine) functions was performed in acute brain-injured patients. The distribution, long-term predictability, and rhythmicity (circadian/ultradian) of various EEG features were compared with the initial clinical status, the functional outcome, and the circadian rhythmicities of behaviour and clock-controlled hormones. Here we show that more physiological and favourable patterns of fluctuations are associated with a higher 24 h predictability and sharp up-and-down shape of EEG switches, reminiscent of the Flip-Flop model of sleep. Multimodal rhythmic analysis shows that patients with simultaneous circadian rhythmicity for brain, behaviour, and hormones had a favourable outcome. Finally, both re-emerging EEG fluctuations and homogeneous 24-h cycles for EEG, eye-opening, and hormones appeared as surrogates for preserved functionality in brainstem and basal forebrain, which are key prognostic factors for later improvement. While the recovery of consciousness has previously been related to a high short-term complexity, we suggest in this exploratory study the importance of the high predictability of the 24 h long-term generation of brain rhythms and highlight the importance of circadian body-brain rhythms in awakening.

Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition

Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.

Development of indirect competitive ELISA and CLEIA for quantitative analysis of melatonin in health products

Melatonin (MT), as a hormone regulating the rhythm of sleep, is widely used in health products. However, illicit and excessive use of MT might cause undesirable effects. Therefore, it is essential to establish highly sensitive and specific rapid methods for MT analysis in health products. In this study, we established indirect competitive enzyme-linked immunosorbent assay (ic-ELISA) and indirect competitive chemiluminescent enzyme immunoassay (ic-CLEIA) for sensitive and selective detection of MT in health products. Under optimal conditions, half-maximum inhibitory concentration (IC50 value) and limit of detection (LOD, IC10 value) for MT by ic-ELISA were 0.25 ng mL-1 and 0.03 ng mL-1 respectively, while the IC50 and LOD of ic-CLEIA were lower at 0.17 ng mL-1 and 0.03 ng mL-1 respectively. Three MT-free Chinese patent medicines were spiked with MT and the recovery rates ranged from 71.89% to 117% (ic-ELISA) and 83.66% to 107.17% (ic-CLEIA). The level of MT in six MT-containing health products was assessed in parallel using the developed methods and HPLC. Both ic-ELISA and ic-CLEIA showed good consistencies (R2 = 0.999 and 0.993, respectively) with HPLC, indicating that the two methods developed were sensitive, fast, and reliable for application in MT analysis.

Nightmares and Sleep Disturbances in Children with PTSD: A Polysomnographic and Actigraphy Approach Evaluation

RATIONALE

Sleep disturbances (insomnia and nightmare symptoms) are the most sensitive and persistent symptoms of pediatric post-traumatic stress disorder (PTSD). Untreated, these sleep disturbances (SD) associated with PTSD are predictive of PTSD persistence and increased psychiatric complications. The aim of this study was to evaluate sleep and circadian rhythms in children with PTSD under both laboratory and ecological conditions in comparison with a control population and to test for the first time the hypothesis that SD and circadian rhythms are positively correlated with PTSD severity and its comorbidities.

METHOD

This prospective pilot study evaluated PTSD, SD (insomnia, nightmares), and sleep-wake rhythms in 11 children with PTSD (aged 3-18), compared with the age and sex-matched control groups. Assessment of PTSD and subjective and objective measures of sleep and sleep-wake rhythms (questionnaires, 24-h in-laboratory video-polysomnography, 15-day at-home actigraphy recording) were performed between 1 and 6 months after the traumatic event.

RESULTS

Children with PTSD had higher sleep fragmentation (increased wake-after-sleep onset, increased number of sleep stage changes) compared to controls, with a change in sleep microarchitecture (micro-arousal index at 14.8 versus 8.2, p = 0.039). Sleep fragmentation parameters correlated with PTSD symptomatology, insomnia, and post-traumatic nightmare severity. The within-group comparison revealed a better sleep architecture in the controlled (sleep laboratory) than in the ecological condition (at home) (total sleep time 586 versus 464 min, p = 0.018).

CONCLUSIONS

Sleep and rhythm disturbances are strongly associated with PTSD in children. The assessment of SD in children with PTSD should be carried out systematically and preferentially under ecological conditions, and management of SD should integrate the environment (environmental design, psycho-education for the children and their parents) more fully into therapy focused on sleep and trauma.

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

The optimal dose of Ramelteon for the better treatment adherence of delayed sleep-wake phase disorder: a dropout rate study

Background

Evidence regarding the effectiveness of melatonin receptor agonists in treating delayed sleep-wake phase disorder (DSWPD) remains limited. This study aimed to determine the optimal dose of ramelteon, a melatonin receptor agonist, for the better treatment adherence of DSWPD.

Methods

The patients who were diagnosed definitely as having DSWPD by board-certified physicians specialized in sleep medicine and started to receive strategically timed ramelteon medications after the diagnosis were included. Data on the initial ramelteon dose and follow-up duration (up to 24 months) were collected retrospectively. Patients with treatment discontinuation, changes in ramelteon dose, or the addition of other sleep-related medications were considered dropouts. Kaplan-Meier estimates, log-rank tests, and Cox regression analyses were performed.

Results

Overall, 373 patients were analyzed. The findings revealed that the 2 mg dose of ramelteon was associated with a lower dropout rate compared to the other doses (8 mg, 4 mg, and 1 mg). The dropout rate for the 2 mg group was estimated to have a hazard ratio (HR) of 0.5762 when compared with the 8 mg dose group. Sex did not reveal a significant HR, whereas older age exhibited a small but significant HR (0.9858).

Conclusion

For achieving better adherence, a dosing regimen of strategically timed 2 mg ramelteon may be the best for the treatment of DSWPD. The therapeutic dose window for better adherence seems to center approximately 2 mg of ramelteon. Furthermore, caution should be exercised when treating younger patients to prevent dropouts.

Therapist training in treating sleep problems: A survey study of clinical practice

OBJECTIVES

Mental health care clinicians' training in treating sleep problems was investigated. We examined clinicians' (1) prior training in providing treatment for sleep problems, (2) interest in receiving training in treatment for sleep problems, and (3) perceptions of the importance of treating sleep problems and interest in incorporating sleep treatments into their practices.

METHODS

An online survey was completed by 137 clinicians.

RESULTS

The majority of clinicians (61.31%) reported receiving prior training in treating sleep problems, most commonly in the form of a workshop and after receiving a graduate degree. Most clinicians reported interest in receiving further training in treating sleep problems. Clinicians reported that the majority (66.67%) of their clients experience sleep problems, yet reported that they address sleep with fewer than half of clients. Addressing sleep in treatment was rated as "somewhat" to "very" important and most clinicians indicated further interest in receiving training in treating sleep.

CONCLUSIONS

Mental health care clinicians receive limited training in treating sleep problems. As clinicians are interested in gaining further training to address sleep concerns within their clinical practice, training programs and continuing education programs should consider increasing the amount of programming in sleep treatment and assessment.

Neurological Insights into Sleep Disorders in Parkinson's Disease

Parkinson's disease (PD) is a common multidimensional neurological disorder characterized by motor and non-motor features and is more prevalent in the elderly. Sleep disorders and cognitive disturbances are also significant characteristics of PD. Sleep is an important physiological process for normal human cognition and physical functioning. Sleep deprivation negatively impacts human physical, mental, and behavioral functions. Sleep disturbances include problems falling asleep, disturbances occurring during sleep, abnormal movements during sleep, insufficient sleep, and excessive sleep. The most recognizable and known sleep disorders, such as rapid-eye-movement behavior disorder (RBD), insomnia, excessive daytime sleepiness (EDS), restless legs syndrome (RLS), sleep-related breathing disorders (SRBDs), and circadian-rhythm-related sleep-wake disorders (CRSWDs), have been associated with PD. RBD and associated emotional disorders are common non-motor symptoms of PD. In individuals, sleep disorders and cognitive impairment are important prognostic factors for predicting progressing neurodegeneration and developing dementia conditions in PD. Studies have focused on RBD and its associated neurological changes and functional deficits in PD patients. Other risks, such as cognitive decline, anxiety, and depression, are related to RBD. Sleep-disorder diagnosis is challenging, especially in identifying the essential factors that disturb the sleep-wake cycle and the co-existence of other concomitant sleep issues, motor symptoms, and breathing disorders. Focusing on sleep patterns and their disturbances, including genetic and other neurochemical changes, helps us to better understand the central causes of sleep alterations and cognitive functions in PD patients. Relations between α-synuclein aggregation in the brain and gender differences in sleep disorders have been reported. The existing correlation between sleep disorders and levels of α-synuclein in the cerebrospinal fluid indicates the risk of progression of synucleinopathies. Multidirectional approaches are required to correlate sleep disorders and neuropsychiatric symptoms and diagnose sensitive biomarkers for neurodegeneration. The evaluation of sleep pattern disturbances and cognitive impairment may aid in the development of novel and effective treatments for PD.

Sleep problems and referral intentions in mental health services: service user self-report and staff proxy report surveys

BACKGROUND

Sleep problems are common in mental health service users, but few non-pharmacological therapies are offered. Therapies are being developed and tested, but there may be barriers to these therapies reaching those who need them.

METHODS

Light-Dark and Activity Rhythm Therapy (L-DART), is a new sleep therapy delivered by an occupational therapist, which has been feasibility tested in people with schizophrenia spectrum diagnoses. This paper presents two surveys, conducted with mental health staff and service users, on sleep problems, treatment wishes; and barriers and facilitators to uptake of L-DART or similar therapies. Descriptive statistics, single-level and multi-level ordinal logistic regression were used to examine factors associated with sleep problems and referral intentions.

FINDINGS

Sleep problems were commonly identified by staff and service users, there was demand for non-pharmacological intervention across diagnostic and demographic categories, but staff readiness to refer differed according to NHS Trust and service user diagnosis. Staff and service user reports differed in awareness of sleep disordered breathing and parasomnias, and wish for referral. Staff were more confident identifying sleep problems than addressing them, but more training was associated with greater confidence concerning both assessment and treatment.

CONCLUSIONS

A range of sleep problems are prevalent and recognised in mental health service users, and there is an unmet need for non-pharmacological sleep interventions. Improving suitable resources to support self-management in this group may help; Staff and service users also reported a high readiness to refer or be referred for sleep interventions. Staff training to improve identification of sleep problems, and differentiation between types of sleep problems, would support access to the most appropriate treatments.

Seizure control with treatment of delayed sleep-wake phase disorder in juvenile myoclonic epilepsy: A case report

Juvenile Myoclonic Epilepsy (JME) is an idiopathic generalized epilepsy associated with a characteristic sleep/wake rhythm, with the tendency to go to bed later at night, to get up later in the morning. In the pediatric population, we have previously observed specific circadian and sleep/wake patterns of generalized seizures (6 am-12 pm) and myoclonic seizures (in wakefulness, 6 am to noon). Delayed Sleep-Wake Phase Disorder (DSWPD) is characterized by sleep initiation insomnia when attempting sleep at conventional times and difficulty waking at the required time. Here we present the case of a 20-year-old man with JME, diagnosed DSWPD (sleep schedule 3 am to 11 am), presenting with nocturnal seizures out of sleep, always between 5 and 6am. Improvements in seizure control (seizure frequency from 8 per month to 0 per month) were achieved with timed evening melatonin, combined with behavioral sleep-wake scheduling (sleep schedule 10 pm to 6 am) and morning light therapy. Recognition and characterization of DSWPD in JME, together with assessment of circadian and diurnal seizure patterns, may offer therapeutic consideration for better control of seizures.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Updates and confounding factors in delayed sleep-wake phase disorder

Delayed sleep-wake phase disorder (DSWPD) is a circadian rhythm sleep disorder characterised by a delay in the main sleep period, with patients experiencing difficulty getting to sleep and waking up at socially appropriate times. This often causes insomnia and compromised sleep, results in impairment to daytime function and is associated with a range of comorbidities. Besides interventions aimed at ameliorating symptoms, there is good evidence supporting successful phase advancement with bright light therapy or melatonin administration. However, no treatment to date addresses the tendency to phase delay, which is a common factor amongst the various contributing causes of DSWPD. Circadian phase markers such as core body temperature and circulating melatonin typically correlate well with sleep timing in healthy patients, but numerous variations exist in DSWPD patients that can make these unpredictable for use in diagnostics. There is also increasing evidence that, on top of problems with the circadian cycle, sleep homeostatic processes actually differ in DSWPD patients compared to controls. This naturally has ramifications for management but also for the current approach to the pathogenesis itself in which DSWPD is considered a purely circadian disorder. This review collates what is known on the causes and treatments of DSWPD, addresses the pitfalls in diagnosis and discusses the implications of current data on modified sleep homeostasis, making clinical recommendations and directing future research.

Delayed sleep-wake phase disorder and its related sleep behaviors in the young generation

Delayed sleep-wake phase disorder (DSWPD) is a sleep disorder in which the habitual sleep-wake timing is delayed, resulting in difficulty in falling asleep and waking up at the desired time. Patients with DSWPD frequently experience fatigue, impaired concentration, sleep deprivation during weekdays, and problems of absenteeism, which may be further complicated by depressive symptoms. DSWPD is typically prevalent during adolescence and young adulthood. Although there are no studies comparing internationally, the prevalence of DSWPD is estimated to be approximately 3% with little racial differences between Caucasians and Asians. The presence of this disorder is associated with various physiological, genetic and psychological as well as behavioral factors. Furthermore, social factors are also involved in the mechanism of DSWPD. Recently, delayed sleep phase and prolonged sleep duration in the young generation have been reported during the period of COVID-19 pandemic-related behavioral restrictions. This phenomenon raises a concern about the risk of a mismatch between their sleep-wake phase and social life that may lead to the development of DSWPD after the removal of these restrictions. Although the typical feature of DSWPD is a delay in circadian rhythms, individuals with DSWPD without having misalignment of objectively measured circadian rhythm markers account for approximately 40% of the cases, wherein the psychological and behavioral characteristics of young people, such as truancy and academic or social troubles, are largely involved in the mechanism of this disorder. Recent studies have shown that DSWPD is frequently comorbid with psychiatric disorders, particularly mood and neurodevelopmental disorders, both of which have a bidirectional association with the pathophysiology of DSWPD. Additionally, patients with DSWPD have a strong tendency toward neuroticism and anxiety, which may result in the aggravation of insomnia symptoms. Therefore, future studies should address the effectiveness of cognitive-behavioral approaches in addition to chronobiological approaches in the treatment of DSWPD.