Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

Sleep disturbance and menopause

PURPOSE OF REVIEW

Sleep problems are among the most prevalent and bothersome symptoms of menopause. This review characterizes menopausal sleep disturbances, describes biopsychosocial predictors, and summarizes the evidence supporting pharmacological and nonpharmacological treatment options.

RECENT FINDINGS

Recent studies found that sleep changes are early indicators of perimenopause and sought to disentangle the respective impacts of menopausal status, hot flashes (HFs), and changes in reproductive hormones on peri-/postmenopausal sleep problems. Both HFs and reproductive hormones predicted sleep problems, but neither solely accounted for the myriad changes in sleep, thus highlighting the contribution of additional biopsychosocial risk factors. Inconsistencies across studies were likely due to differences in study design and methodology, participants' menopausal stage, and the presence of sleep complaints. Recent studies support the use of psychological (cognitive-behavioral therapy for insomnia) and pharmacological (e.g., neurokinin B antagonists) treatments in addition to hormone therapy.

SUMMARY

Sleep problems are common and of critical import to women during the menopausal transition, significantly influencing treatment preferences and satisfaction. Thus, sleep problems should be routinely assessed from a biopsychosocial perspective and treated with evidence-based interventions throughout menopause. Treatment selection should be based on diagnosis and careful assessment.

Sleep Deficiency and Fatigue in Adults with Inflammatory Bowel Disease: A Systematic Review

PURPOSE

Fatigue is one of the most common and disabling symptoms experienced by people with inflammatory bowel disease; however, interventions to treat fatigue are limited. The purpose of this systematic review is to examine the relationship between sleep deficiency and fatigue in adults with inflammatory bowel disease and to describe the demographic and clinical factors associated with fatigue to inform future intervention work.

METHODS

We conducted a systematic review and reported the results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL on 3/7/24. We included studies with adults (≥18 years of age) who had a diagnosis of inflammatory bowel disease (Crohn's disease, ulcerative colitis, or indeterminate colitis) and measured fatigue and sleep using a validated self-report questionnaire or objective measurement.

RESULTS

Twenty-two studies met inclusion criteria for a total sample of 16 927, of whom 58.7% (n = 9937) had Crohn's disease, and 66.3% (n = 11 226) were female. 56.1% of the participants experienced fatigue and 66.3% experienced sleep deficiency. Sleep quality and insomnia were consistently associated with fatigue. Baseline poor sleep quality was associated with persistent and worsening fatigue over 12 to 24 months. Clinical but not objective assessment of disease activity, anxiety, depression, female gender/sex, and younger age were also associated with more severe fatigue.

CONCLUSIONS

Sleep quality and insomnia represent important modifiable contributors to fatigue. Future research should explore whether sleep interventions can improve fatigue in this population.

Determinants of treatment response to cognitive behavioral therapy in veterans presenting with comorbid insomnia and sleep apnea

PURPOSE

Although cognitive behavioral therapy for insomnia (CBT-I) is considered the preferred treatment for insomnia in patients with comorbid insomnia and obstructive sleep apnea (COMISA), the remission rate with CBT-I is generally considered lower than in insomnia-only populations. There is also a sizable variability in individual treatment responses. Due to the limited availability of CBT-I, we sought to identify specific clinical attributes that predict benefit from Brief Behavioral Therapy for Insomnia (BBTI)-an adaptation of CBT-I-in patients with COMISA.

METHODS

We conducted a retrospective analysis of the National Veterans Health Administration (VHA) electronic medical records covering veterans diagnosed with COMISA between January 2021 and December 2023. Insomnia Severity Index (ISI) scores were recorded at baseline and after 12±1 weeks after BBTI. A positive response to BBTI was defined as a reduction in ISI score of ≥ 8 from baseline. A multivariate generalized linear model analysis was performed to delineate predictive factors of BBTI responsiveness.

RESULTS

131 eligible cases received BBTI over 6 weeks, 56 (43%) of whom did not respond. Non-whites (OR 3.5, 95% CI [1.4, 8.8]) and shorter sleep time (OR 0.98, 95% CI [0.98, 0.99] were independent predictors of blunted response to BBTI. These findings remained true even when depression and AHI were forced into the regression model. Patients with a total sleep duration of < 4.1 h were at greatest risk of being nonresponsive to BBTI.

CONCLUSION

These findings indicate that identifying insomnia phenotypes in patients with COMISA would help deliver personalized care while maximizing BBTI treatment resources.

Depression, sleep and pain affect instrumental activities of daily living through cognitive functioning in adults with sickle cell disease: A report from the Sickle Cell Disease Implementation Consortium

Depression, disrupted sleep and pain are common comorbidities in sickle cell disease. We tested (1) if these comorbidities are associated with attention/executive functioning, processing speed and instrumental activities of daily living (IADLs), which describe complex skills that support independence, and (2) if cognitive symptoms mediate the relationship between comorbidities and IADLs. Participants (n = 2417) completed patient-reported outcome measures through the Sickle Cell Disease Implementation Consortium. Mean age of participants was 28 years and HbSS/Sβ0 genotypes were prevalent (73%). Comorbidities of depression, pain frequency and disrupted sleep were associated with processing speed and attention/executive functioning (all p < 0.01) when controlling for stroke and demographics. IADLs were associated with depression, pain, sleep, attention/executive functioning, income (<$25 000) (all p < 0.001) and genotype (p = 0.0025) after controlling for covariates. The indirect effects of attention/executive functioning and processing speed were both significant (p < 0.001) in mediation models that examined pathways between comorbidities and IADLs. Attention/executive functioning accounted for 17.5% of the relationship between depression and IADLs and sleep and IADLs. Processing speed explained 10% of the relationship between sleep and IADLs and 8% of the relationship between depression and IADLs. Managing comorbidities should be prioritized to mitigate cognitive symptoms and improve complex daily living skills.

Comparing the efficacy of technology-enabled treatments for insomnia: study protocol for a randomized controlled trial

Chronic insomnia is a prevalent sleep disorder where <1% of patients receive the recommended first-line treatment; Cognitive Behavioural Therapy for Insomnia. Digital technologies and self-managed therapies are scalable solutions to address this critical gap in patient care, but it is presently difficult to know which therapies are best. This study will test the comparative efficacy and cost-benefits of Intensive Sleep Retraining administered by the THIM sleep tracker, Sleep Healthy Using the Internet (SHUTi) treatment program, and their combination (THIM then SHUTi) versus a waitlist control group. This study is a 4 (treatment: +/- THIM and +/- SHUTi) × 3 (time: pretreatment, posttreatment, and 2-month follow-up) randomized controlled trial. Participants who meet the diagnostic criteria for Chronic Insomnia Disorder will be randomized to one of four groups. Sleep and daytime functioning symptoms will be assessed via self-report daily and weekly questionnaires, and objective sleep trackers during treatment and for 2 weeks at pre-treatment, post-treatment, and 2-month follow-up. The primary outcome is total wake time, with a reduction of ≥30 minutes considered a clinically meaningful difference. For the primary analysis, the interaction between the treatment group and time on total wake time will be analyzed using repeated measures analyses of variance (ANOVA). This project was approved by the Southern Adelaide Clinical Human Research Ethics Committee (2021/HRE00414) and registered in the Australian and New Zealand Clinical Trials Registry (ACTRN12622000778785). As the first study to investigate the comparative efficacy of two different technology-enabled treatments for insomnia, this study will help inform clinicians and public health policy regarding the use cases for public and private health-funded technology-enabled options for insomnia.

Investigating the efficacy of digital cognitive behavioural therapy in comparison to a sleep-monitoring application via integrated diary and actigraphy: A randomised-controlled trial

Dissemination of digital cognitive behavioural therapy is a promising approach for treating insomnia in the broad population. Current evidence supports the effectiveness of the digital format, but clinical findings are often limited by the choice of control group and lack of in-depth therapeutic measures. This study was designed to investigate the specific effects of digital cognitive behavioural therapy in comparison to a self-monitoring application. Participants meeting criteria for insomnia were randomly allocated (1:1) to 8 weeks of digital cognitive behavioural therapy or 8 weeks of digital sleep monitoring (control application). The primary outcome, insomnia severity, was assessed at baseline, 8- and 16-weeks post-randomisation. Secondary outcomes included the assessment of sleep via application-integrated sleep diaries and actigraphy. Linear-mixed models were fitted to assess between-group differences. Fifty-six participants (48 females, mean age: M = 45.55 ± 13.70 years) were randomised to either digital cognitive behavioural therapy (n = 29) or digital sleep monitoring (n = 27). At 8- and 16-weeks post-randomisation, large treatment effects (d = 0.87-1.08) indicated robust reductions (-3.70 and -2.97, respectively; p ≤ 0.003) in insomnia severity in the digital cognitive behavioural therapy arm, relative to digital sleep monitoring. Treatment effects in favour of digital cognitive behavioural therapy were also found for self-reported and actigraphy-derived sleep continuity variables, indicating that sleep improved throughout the 8-week intervention period. Our study reinforces the role of digital cognitive behavioural therapy in achieving clinical improvements for patients with insomnia, affirming previous findings and supporting the specific effects of cognitive behavioural therapy.

Promoting sustained access to cognitive behavioral therapy for insomnia in Australia: a system-level implementation program

STUDY OBJECTIVES

Insomnia is a highly prevalent and debilitating disorder. Cognitive behavioral therapy for insomnia (CBTi) is the recommended "first line" treatment, but is accessed by a minority of people with insomnia. This paper describes a system-level implementation program to improve access to CBTi in Australia to inform CBTi implementation in other locations.

METHODS

From 2019-2023, we conducted a program of work to promote sustained change in access to CBTi in Australia. Three distinct phases included (1) scoping and mapping barriers to CBTi access, (2) analysis and synthesis of barriers and facilitators to devise change goals, and (3) structured promotion and coordination of change. We used a system-level approach, knowledge brokerage, and codesign, and drew on qualitative, quantitative, and implementation science methods.

RESULTS

We identified barriers to CBTi access from the perspectives of people with insomnia, primary care clinicians, and the health system. A stakeholder advisory committee was convened to codesign change goals, identify modifiable barriers, devise program logic, and drive change strategies. We commenced a program to promote system-level change in CBTi access via: improved awareness and education of insomnia among primary care clinicians, self-guided interventions, and advocating to Government for additional CBTi funding mechanisms.

CONCLUSIONS

This implementation program made significant progress toward improving access to CBTi in Australia. Ongoing work is required to continue this program, as long-term system-level change requires significant and sustained time, effort, and resources from multiple stakeholders. This program may be used to inform CBTi implementation activities in other locations.

CITATION

Sweetman A, McEvoy RD, Frommer MS, et al. Promoting sustained access to cognitive behavioral therapy for insomnia in Australia: a system-level implementation program. J Clin Sleep Med. 2025;21(2):325-335.

A scoping review of self-help cognitive behavioural therapy for insomnia

Uptake of cognitive behavioural therapy for insomnia (CBTI) as first-line therapy of chronic insomnia has been restricted by a shortage of trained therapists, access barriers, and limited awareness of self-help alternatives. Self-help CBTI has emerged as a practical alternative, offering ready access, convenience, and dissemination and scalability efficiency. Yet, evidence syntheses of limited data have suggested its effectiveness and acceptability may be inferior to face-to-face CBTI and others have questioned its fidelity with CBTI standards. We conducted a scoping review to map and characterize self-help CBTI research, focusing on its core components, delivery methods, use of coaching support, and growth. Our review included 174 reports of 145 unique studies, 106 of which were randomized trials, with 65 published since 2020. Findings revealed that self-help CBTI maintained the essential core components (time-in-bed restriction, stimulus control, relaxation techniques, cognitive therapy, and sleep hygiene/education) and structure of conventional CBTI with many, but not all, including different types and formats of coaching support. The expanding body of evidence suggests that self-help CBTI is an evolving field, warranting further analysis to delineate its role in filling the treatment gap for chronic insomnia.

An Expert Consensus Statement for Implementing Cognitive Behavioral Therapy for Nightmares in Adults

OBJECTIVES

Research supports cognitive behavioral therapies for nightmares (CBT-N) in adults. However, the nuances of implementation and unstandardized nomenclature for treatment components has created confusion in the field. To provide clarification, an expert consensus panel convened to review treatment manual components and to develop guidelines for the standardized implementation and terminology of CBT-N. The aims of this paper are to report on the expert panel recommendations.

METHODS

A literature review was conducted for nightmare treatment manuals that have been tested in randomized clinical trials with adults. the panel of experts evaluated the content and the main controversies regarding treatment components. The panel then established recommended treatment guidelines based on the literature and clinical experience.

RESULTS

Recommendations pertain to which patient symptom presentations are appropriate for CBT-N and considerations for implementing treatment components including session length, relaxation training, stimulus control, sleep efficiency training, sleep hygiene, nightmare exposure, nightmare rescripting, and imagery rehearsal of rescripted dreams. The panel evaluated treatment components to inform the development of a consensus CBT-N treatment manual.

CONCLUSIONS

Using a comprehensive treatment manual based on expert recommendations will not only help disseminate nightmare treatment but also advance the field by providing clarity. These recommendations are based on the status of the field and will need to be revised to incorporate developing research evidence in nightmare treatment.

Applying Natural Language Processing Techniques to Map Trends in Insomnia Treatment Terms on the r/Insomnia Subreddit: Infodemiology Study

BACKGROUND

People share health-related experiences and treatments, such as for insomnia, in digital communities. Natural language processing tools can be leveraged to understand the terms used in digital spaces to discuss insomnia and insomnia treatments.

OBJECTIVE

The aim of this study is to summarize and chart trends of insomnia treatment terms on a digital insomnia message board.

METHODS

We performed a natural language processing analysis of the r/insomnia subreddit. Using Pushshift, we obtained all r/insomnia subreddit comments from 2008 to 2022. A bag of words model was used to identify the top 1000 most frequently used terms, which were manually reduced to 35 terms related to treatment and medication use. Regular expression analysis was used to identify and count comments containing specific words, followed by sentiment analysis to estimate the tonality (positive or negative) of comments. Data from 2013 to 2022 were visually examined for trends.

RESULTS

There were 340,130 comments on r/insomnia from 2008, the beginning of the subreddit, to 2022. Of the 35 top treatment and medication terms that were identified, melatonin, cognitive behavioral therapy for insomnia (CBT-I), and Ambien were the most frequently used (n=15,005, n=13,461, and n=11,256 comments, respectively). When the frequency of individual terms was compared over time, terms related to CBT-I increased over time (doubling from approximately 2% in 2013-2014 to a peak of over 5% of comments in 2018); in contrast, terms related to nonprescription over-the-counter (OTC) sleep aids (such as Benadryl or melatonin) decreased over time. CBT-I-related terms also had the highest positive sentiment and showed a spike in frequency in 2017. Terms with the most positive sentiment included "hygiene" (median sentiment 0.47, IQR 0.31-0.88), "valerian" (median sentiment 0.47, IQR 0-0.85), and "CBT" (median sentiment 0.42, IQR 0.14-0.82).

CONCLUSIONS

The Reddit r/insomnia discussion board provides an alternative way to capture trends in both prescription and nonprescription sleep aids among people experiencing sleeplessness and using social media. This analysis suggests that language related to CBT-I (with a spike in 2017, perhaps following the 2016 recommendations by the American College of Physicians for CBT-I as a treatment for insomnia), benzodiazepines, trazodone, and antidepressant medication use has increased from 2013 to 2022. The findings also suggest that the use of OTC or other alternative therapies, such as melatonin and cannabis, among r/insomnia Reddit contributors is common and has also exhibited fluctuations over time. Future studies could consider incorporating alternative data sources in addition to prescription medication to track trends in prescription and nonprescription sleep aid use. Additionally, future prospective studies of insomnia should consider collecting data on the use of OTC or other alternative therapies, such as cannabis. More broadly, digital communities such as r/insomnia may be useful in understanding how social and societal factors influence sleep health.

Cognitive-behavioural therapy for insomnia mechanism of action: Exploring the homeostatic K-complex involvement

Investigating the mechanisms of action of cognitive-behavioural therapy for insomnia (CBT-I), the first-line treatment for chronic insomnia disorder (ID), can contribute to the overall understanding of insomnia and its treatment. To date, no study has examined the relationship between K-complexes (KC) and CBT-I, despite the known homeostatic and protective function of this relevant sleep brainwave. This retrospective multicentre study aims to explore the relationship between electroencephalographic (EEG) indices and CBT-I, with a particular focus on evaluating an index of sleep homeostasis identified by KC. This research is designed to assess the predictive value of this index for treatment outcomes and to examine its variations before and after intervention. Ninety eight patients with ID underwent a 6-8 week in-person CBT-I programme, with pre-and post-treatment evaluation conducted using polysomnography (PSG) and the Insomnia Severity Index (ISI). The main outcome was determined by calculating the slope of the linear equation indexing the KC density (number of KC/minutes of N2) in each non-artifacted NREM stage 2 epoch throughout the night (KCSlope). Furthermore, the sample was categorised into Responders (ISIdecrease ≥8) and non-Responders (ISIdecrease <8). The results indicate that the KC Slope is effective not only to predict treatment response (one-way ANOVA, F = 7.831 p = 0.007; Responders = -2.954*10-5 ± 3.346*10-5, non-Responders = -5.583*10-5 ± 5.305*10-5; adjusted for PSG wake after sleep onset at the baseline), but also to detect a statistically significant improvement in sleep pressure following CBT-I (Wilcoxon signed-rank test W = 3074.000 p = 0.022; KCSlope pre-treatment = -4.054*10-5 ± 4.446*10-5, KCSlope post-treatment = -4.797*10-5 ± 5.710*10-5). These findings suggest that CBT-I increases sleep pressure in patients with chronic insomnia, highlighting a novel and relevant biomarker in this context.

Exploring the impact and mechanisms of behavioral activation on sleep disorders in colorectal cancer: a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) patients frequently experience sleep disturbances, significantly impacting their quality of life. Cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line treatment but is often complex, costly, and requires highly trained therapists. Behavioral activation (BA), derived from cognitive behavioral therapy (CBT), offers a flexible, simple, and cost-effective alternative. BA highlights the importance of activation, a strategy that encourages active participation in positive, meaningful activities to boost positive experiences and reduce negative emotions, which may have potential benefits for individuals with sleep disorders. This study explores the effects of BA on sleep disturbances, quality of life, and psychological distress in CRC patients and investigates potential underlying mechanisms.

METHODS

The study included 101 CRC patients with sleep disturbances, who were randomly assigned to either the BA group (n = 53) or the usual care (UC) group (n = 48). Assessments of quality of life, sleep disturbances, psychological distress, activation, avoidance, and physical activity levels were conducted at baseline (T0), four weeks later (T1), and post-intervention (T2). Generalized estimating equation (GEE) analysis was used to evaluate the intervention's impact and potential mediating effects.

RESULTS

The BA group experienced significant improvements in sleep disturbances (Wald's χ2 = 7.979, P = 0.019), enhanced quality of life (Wald's χ2 = 6.435.P = 0.04), and reduced psychological distress (Wald's χ2 = 56.728, P < 0.001) compared to the UC group. Physical activity (P < 0.001) partially mediated the intervention effects of BA on sleep disturbances, while activation (P = 0.073) demonstrated marginal mediating effects.

CONCLUSION

BA is an effective psychological intervention that significantly improves sleep disturbances, enhances quality of life, and alleviates psychological distress in CRC patients. Mediator analysis indicates that physical activity partially mediates the effects of BA on sleep disturbances, with activation showing marginal significance. Future research should further investigate the underlying mechanisms and long-term effects of BA on sleep disturbances.

Impact of associated factors and adherence to Mediterranean diet on insomnia among Arab men living in Jordan

The detrimental health and economic burdens associated with insomnia have led to investigations examining its prevalence and potential predictors to utilize this information in insomnia prevention/treatment. Ethnicity, gender, and lifestyle habits are among the important predictors associated with insomnia. The aim of this study was to examine the prevalence of insomnia and potential predictors of insomnia among Arab men living in Jordan, including Mediterranean diet (MD) adherence. The inclusion criteria of this cross-sectional, correlational study were: (1) being a male; (2) aged 18 and older; and (3) able to read, write, and speak the Arabic language. Online questionnaires were used to assess participants' sociodemographic information, adherence to the MD, physical activity, and insomnia. Results demonstrated that there was a high prevalence of insomnia (53.9%) among the study's participants (N = 529). Moreover, in the unadjusted model, the study revealed that being unemployed (OR = 1.90, p = 0.018), categorized as dehydrated (OR = 1.20, p = 0.020), overweight (OR = 1.30, p = 0.035), sleeping less than 6 hours/day (OR = 2.10, p < 0.001), and having high adherence to the MD (OR = 1.60, p = 0.010) were predictors of insomnia. Meanwhile, the adjusted multivariate logistic regression model indicated that being married (OR = 1.20, p = 0.020) played a significant protective role against developing insomnia among Arab men. While high adherence to MD (OR = 1.642, p = 0.028) and sleeping less than 6 hours/day (OR = 2.760, p < 0.001) were relative risk factors for experiencing insomnia. The high prevalence of insomnia in this population and the identification of possible predictors associated with insomnia, and the unexpected relationship between adherence to the MD and insomnia warrant further in-depth investigations that may help promote the understanding of the factors associated with insomnia and facilitate the development of interventions to target it.

Internet-based cognitive behavioural therapy for insomnia comorbid with chronic benign pain - A randomized controlled trial

Background

Comorbid sleep disturbances are common among individuals with chronic pain, and Cognitive Behavioural Therapy for Insomnia (CBT-i) has proven effective for such individuals. Nonetheless, research on web-based CBT-i tailored for patients with both chronic pain and insomnia is limited. This study aimed to evaluate the feasibility and efficacy of internet-based CBT-i and to explore potential mechanisms underlying treatment outcomes.

Methods

In this study, 85 participants suffering from comorbid insomnia and chronic pain were randomized into two groups: Internet-based CBT for Insomnia (ICBT-i) and Internet-based Applied Relaxation (IAR). Both interventions spanned eight weeks, supported by therapeutic guidance throughout.

Results

Participation was modest, with an average module completion of 2.0 out of 8 for ICBT-i and 2.4 for IAR. Both interventions significantly alleviated insomnia symptoms on one of the insomnia measures post-treatment, without notable differences between them. Directly after treatment, IAR outperformed ICBT-i in reducing pain interference, anxiety, and in enhancing self-rated health, though these differences lessened at the 6-month follow-up. Potential therapeutic mechanisms may involve attenuating maladaptive sleep beliefs and augmenting sleep-related willingness.

Conclusions

The study encountered low engagement rates, with approximately one-third of participants not completing any module. The limited efficacy of ICBT-i may be due to low treatment involvement, with few patients completing key techniques like sleep compression and stimulus control. Despite the low adherence, both interventions yielded post-treatment improvements in insomnia symptoms, but to establish internet-based treatments for insomnia as a viable option in chronic pain management, patient engagement must be improved.

Network meta-analysis examining efficacy of components of cognitive behavioural therapy for insomnia

Cognitive behavioural therapy for insomnia (CBTI) is recommended as first-line treatment for insomnia. CBT-I is a multi-component intervention comprising psychoeducation, sleep restriction, stimulus control, cognitive, and relaxation therapy. The relative efficacy of its components has yet to be investigated with state-of-the-art meta-analytic methods. PubMed, MEDLINE, PsycINFO, PsycARTICLES, and CINAHL were searched according to a pre-registered protocol using search terms indicative of insomnia and CBTI. Baseline-to-post-treatment effect sizes (Cohen's d) were calculated in a component network meta-analysis. Eighty studies representing 15,351 participants (mean age 44.9 years, 70.1 % female) were included. For the primary outcome insomnia severity, a significant positive effect for sleep restriction therapy (d = -0.45; 95 % CI: [-0.63; -0.36]) was found. Overall, the results suggest that sleep restriction therapy improves self-reported sleep continuity and sleep quality, and stimulus control therapy improves self-reported and objective total sleep time. No significant effects of psychoeducation, relaxation therapy, and cognitive therapy, and no further significant effects of any CBT-I component on objective sleep parameters were found. The most common sources of bias were a lack of blinding, missing outcome data, and the absence of study protocols. The current results suggest that sleep restriction therapy and stimulus control therapy are the most effective components of CBT-I.

Sleep Treatment Education Program for Cancer Survivors: Protocol for an Efficacy Trial

BACKGROUND

Cancer survivors are at increased risk for chronic insomnia, even years after treatment completion. As insomnia is associated with a variety of long-term health consequences, access to insomnia treatment is critically important for the survivor population. Cognitive behavioral therapy for insomnia (CBTI) is the recommended first-line treatment for insomnia but remains largely unavailable to survivors. Treatment barriers include geographic limitations, a shortage of trained providers, and demanding treatment regimens. Designed with these limitations in mind, the Sleep Treatment Education Program (STEP-1) delivers components of CBTI in a low-intensity educational intervention delivered online.

OBJECTIVE

This is a phase II pilot randomized controlled trial. The primary aims are to test the efficacy of STEP-1 to improve (1) insomnia symptoms and (2) mood in cancer survivors compared to a control condition. The secondary aims will (1) explore participant factors associated with clinically significant response, (2) evaluate acceptability of the control intervention, (3) explore feasibility of delivering individualized coaching sessions for participants who do not have a significant response to STEP-1, and (4) describe participants' satisfaction with STEP-1 and suggestions for improvement.

METHODS

This 2-arm randomized controlled trial enrolled 70 off-treatment cancer survivors aged 40-89 years with clinically significant insomnia. Participants are randomized to receive either the STEP-1 intervention or control condition (relaxation education); interventions are delivered in one-on-one, synchronous, virtual videoconference sessions by trained interventionists. The STEP-1 intervention presents educational information on the development of insomnia after cancer and offers suggestions for improving insomnia symptoms based on the CBTI elements of sleep hygiene, stimulus control, and cognitive restructuring. With the interventionist, participants review the suggestions and develop a personalized sleep action plan for implementation. The relaxation education session provides information on the potential benefits of relaxation and how to independently access online relaxation exercises. The Insomnia Severity Index is used to measure insomnia symptoms, and the Profile of Mood States Short Form is used to measure mood at baseline and 4 and 8 weeks after intervention. The primary end point is change in the Insomnia Severity Index score at 8 weeks, and the secondary end point is change in mood symptoms (Profile of Mood States Short Form) at 8 weeks.

RESULTS

This trial was funded in July 2022. Enrollment and data collection began in February 2023 and concluded in October 2024, with 70 participants enrolled. The analysis will begin in fall 2024, and the results are expected in winter 2025.

CONCLUSIONS

Trial results will determine if STEP-1 effects go beyond those that could be attributed to placebo and other nonspecific treatment factors. Should results support the efficacy of STEP-1 to improve mood and insomnia symptoms, we anticipate developing efficacy and implementation trials of STEP-1 in larger and more diverse samples.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05519982; https://clinicaltrials.gov/study/NCT05519982.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60762.

Association between sleep quality and weight gain in pregnancy: a cross-sectional study

INTRODUCTION

There are grounds for the hypothesis that poor sleep quality, regardless of the pre-gestational nutritional status, is a risk factor for inadequate gestational weight gain.

OBJECTIVE

To investigate the association between sleep quality and insufficient or excessive gestational weight gain in Brazilian pregnant women without gestational complications and monitored in public prenatal care units.

METHODS

This is a cross-sectional study nested within a cohort study that reviewed pregnant women's mental health, sleep, and nutritional outcome. Data collection was carried out from May 2018 to June 2019 through face-to-face and telephone interviews and consultation of pregnant women's medical records. Sleep quality was assessed using the Mini-sleep Questionnaire. The pregnancy weight gain was measured based on the Institute of Medicine's recommendations. Univariate and multivariate Poisson regression analysis was used for the two outcomes: insufficient or excessive weight gain, using pregnant women with adequate weight gain as the reference category. Associations were considered significant when p < 0.05.

RESULTS

The prevalence of severe sleep disorders was high: 63.4% of pregnant women experienced this condition. Severe sleep disorders enhanced independently the risk of insufficient gestational weight gain (PR = 2.40; 95% CI = 1.06-5.42, p = 0.035). There was no association between sleep disorders and excessive gestational weight gain.

CONCLUSION

The hypothesis that poor sleep quality influences gestational weight gain was confirmed. Severe sleep disorders, a highly prevalent condition, significantly increased the prevalence of insufficient gestational weight gain, yet it was not associated with excessive weight gain. Thus, educational actions should be included in the preconception and prenatal periods, in order to encourage the adoption of habits that favor sleep quality, an intervention that may have positive effects in reducing insufficient gestational weight gain.

Digital cognitive behavioural therapy for insomnia versus digital sleep education control in an Australian community-based sample: a randomised controlled trial

BACKGROUND

Insomnia is a prevalent condition in Australia that increases the risk of depression and anxiety symptoms. Cognitive behaviour therapy for insomnia (CBT-i) is the recommended 'first line' treatment but is accessed by a minority of people with insomnia.

AIMS

To improve CBT-i access in Australia, we aimed to develop and test a self-guided interactive digital CBT-i program.

METHODS

An online randomised controlled trial was conducted from August 2022 to August 2023 to investigate the effect of digital CBT-i, versus digital sleep education control, on symptoms of insomnia (ISI), depression (PHQ-9), anxiety (GAD-7), fatigue, sleepiness and maladaptive beliefs about sleep at 8-week follow-up. The control group accessed the intervention after the 8-week follow-up. Questionnaires were additionally administered at 16 and 24 weeks. Intent-to-treat mixed models and complete-case chi-squared analyses were used.

RESULTS

Participants included 62 adults with insomnia symptoms (age M (SD) = 52.5 (16.3), 82% female, ISI = 18.6 (2.9)). There were no between-group differences in baseline characteristics or missing 8-week data (14.5%). After adjusting for baseline scores, CBT-i was associated with lower insomnia (Diffadj (95% CI) = 7.32 (5.0-9.6), P < 0.001, d = 1.64), depression (3.36 (1.3-5.4), p = 0.002, d = 0.84), fatigue (5.2 (2.5-7.9), P < 0.001, d = 1.00) and maladaptive beliefs about sleep (11.0 (4.1-18.0), P = 0.002, d = 0.82), but not anxiety symptoms at 8 weeks (1.84 (-0.1 to 3.8), p = 0.060, d = 0.50). Compared to control, CBT-i was associated with greater rates of insomnia remission (ISI <8; 0.0%, vs 40.0%, P < 0.001) and response at 8 weeks (ISI reduction ≥6; 7.1% vs 72.0%, P < 0.001). Improvements in insomnia and depression were maintained at 24 weeks in the CBT-i group.

CONCLUSIONS

This interactive digital CBT-i program resulted in large and sustained improvements in symptoms of insomnia, depression, fatigue and maladaptive beliefs about sleep in Australian adults with insomnia symptoms. Implementation programs are required to increase digital CBT-i access and uptake.

Patient perceptions of digital and therapist-led CBT for insomnia: A qualitative study

OBJECTIVES

Technology has the potential to increase access to evidence-based insomnia treatment. Patient preferences/perceptions of automated digital cognitive behavior therapy for insomnia (CBTI) and telehealth-delivered CBTI remain largely unexplored among middle-aged and older adults. Using a qualitative approach, the current study describes patients' reasons for participating in the clinical trial, preferences for digital CBTI (dCBTI) versus therapist-led CBTI, patient attitudes toward dCBTI, and patient attitudes toward telehealth-delivered therapist-led CBTI.

METHOD

Middle-aged and older adults (N = 80) completed a semi-structured interview before CBTI exposure. Qualitative responses were coded, and themes were inductively extracted.

RESULTS

Most (62.5%) of the participants expressed a preference for therapist-led CBTI to dCBTI. Convenience was the most commonly reported advantage of dCBTI (n = 55) and telehealth-delivered CBTI (n = 65). Decreasing transit time and pandemic-related health concerns were identified as advantages to dCBTI and telehealth-delivered CBTI. Lack of human connection and limited personalization were perceived as disadvantages of dCBTI. Only three participants reported technological barriers to dCBTI and telehealth-delivered CBTI.

CONCLUSION

Findings suggest that, despite an overall preference for therapist-led treatment, most middle-aged and older adults are open to dCBTI. As both dCBTI and telehealth-delivered CBTI are perceived as convenient, these modalities offer the potential to increase access to insomnia care.

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.

Chronic pain management and sleep disorders

Chronic pain affects the quality of life for millions of people worldwide. There is a bidirectional link between pain and sleep: poor sleep quality exacerbates pain, and pain disrupts sleep. Addressing this cycle is crucial for effective pain management and improving patients' overall health outcomes.

Empowerment-based cognitive behavioural therapy for insomnia in persons with mild cognitive impairment: A sequential explanatory mixed-method pilot study

Insomnia is an emerging risk factor for the onset of mild cognitive impairment (MCI) and its progression to dementia. Impaired cognition and neuropsychiatric symptoms create challenges for persons with MCI to participate actively in non-pharmacological interventions. This study examined the feasibility and preliminary effects of empowerment-based cognitive-behavioural therapy for insomnia (CBT-I) on sleep, cognitive function, and health-related quality of life (HRQoL) in persons with MCI and sleep problems. Sixty participants were randomly allocated to the intervention or control group to receive empowerment-based CBT-I or usual care, respectively. The 12 week intervention comprised all core CBT-I techniques delivered through a group and individualised face-to-face approach. An empowerment approach with interactive teaching methods, goal setting, and action planning was used to deliver the intervention. Outcome measures included subjective and objective sleep quality and pattern, and a battery of neuropsychological tests and the 12-item Short Form Survey were administered 3 months (T1) and 6 months post-randomisation (T2). This intervention is feasible and highly acceptable for persons with MCI. The intervention group showed significant improvements in subjective and objective sleep-related outcomes compared with the control group. Moreover, the intervention group showed greater improvements in global cognition, processing speed, attention, and mental flexibility than the control group at T1 and/or T2. No significant between-group differences were observed in memory or HRQoL scores. The qualitative data converged with the quantitative data. In conclusion, empowerment-based CBT-I was well received by persons with MCI and had potential positive effects on improving sleep and cognition in this cohort.

Lectin YKL-40 Level and Telomere Length are Indicators of Insomnia Disorder

OBJECTIVE

To explore the relationship between YKL-40 level, telomere length, and different subtypes of insomnia disorder.

METHODS

A total of 145 individuals suffering from insomnia were enrolled and divided into four groups according to the insomniac subtypes: difficulty initiating sleep, early morning awakening, difficulty maintaining sleep, and mixed symptoms. Eighty healthy controls were also collected at the same time. Peripheral leukocyte genomic DNA was extracted, relative telomere lengths were measured using the real-time quantitative polymerase chain reaction method, and YKL-40 levels were determined using enzyme-linked immunoassay. Logistic regression modeling was used to analyze the correlation between different insomnia subtypes, YKL-40 level, and telomere length.

RESULTS

People with telomere lengths in the lowest tertile were more likely to have trouble falling asleep (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.22-3.63; p = 0.03) and had a higher frequency of mixed symptoms (OR 1.49, 95% CI 1.30-2.81; p = 0.04). People in the highest tertile of YKL-40 level had an increased chance of waking up early (OR 2.98, 95% CI 1.54-5.33; p = 0.01) and more mixed symptoms (OR 1.47, 95% CI 1.22-2.79; p = 0.02). Furthermore, using receiver operating characteristic curve analysis, the area under the curve of YKL-40 level and telomere length was 0.806 and 0.746, respectively.

CONCLUSIONS

Telomere length in patients with difficulty initiating sleep and mixed symptoms was significantly shortened and the level of YKL-40 in people who have early morning awakening and mixed symptoms was significantly increased. Our findings provide the first evidence that leukocyte telomere length and YKL-40 level are individually linked to mixed symptoms.

A nationwide analysis of 350 million patient encounters reveals a high volume of mental-health conditions in primary care

How many primary-care encounters are devoted to mental-health conditions compared with physical-health conditions? Here we analyzed Norway's nationwide administrative primary-care records, extracting all doctor-patient encounters occurring during 14 years (2006-2019) for the population aged 0-100 years. Encounters were recorded according to the International Classification of Primary Care. We compared the volume of mental-health encounters against volumes for conditions in multiple different body systems. A total of 4,875,722 patients generated 354,516,291 encounters. One in 9 encounters (11.7%) involved a mental-health condition. Only musculoskeletal conditions accounted for a greater share of primary-care physicians' attention. The volume of mental-health encounters in primary care equaled encounters for infections, cardiovascular and respiratory conditions and exceeded encounters for pain, injuries, metabolic, digestive, skin, urological, reproductive and sensory conditions. Primary-care physicians frequently treat complex mental-health conditions in patients of every age. These physicians may have a more important role in preventing the escalation of mental-health problems than heretofore appreciated.

Voice-Activated Cognitive Behavioral Therapy for Insomnia: A Randomized Clinical Trial

Importance

Insomnia symptoms affect an estimated 30% to 50% of the 4 million US breast cancer survivors. Previous studies have shown the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), but high insomnia prevalence suggests continued opportunities for delivery via new modalities.

Objective

To determine the efficacy of a CBT-I-informed, voice-activated, internet-delivered program for improving insomnia symptoms among breast cancer survivors.

Design, Setting, and Participants

In this randomized clinical trial, breast cancer survivors with insomnia (Insomnia Severity Index [ISI] score >7) were recruited from advocacy and survivorship groups and an oncology clinic. Eligible patients were females aged 18 years or older who had completed curative treatment more than 3 months before enrollment and had not undergone other behavioral sleep treatments in the prior year. Individuals were assessed for eligibility and randomized between March 2022 and October 2023, with data collection completed by December 2023.

Intervention

Participants were randomized 1:1 to a smart speaker with a voice-interactive CBT-I program or educational control for 6 weeks.

Main Outcomes and Measures

Linear mixed models and Cohen d estimates were used to evaluate the primary outcome of changes in ISI scores and secondary outcomes of sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and sleep efficiency.

Results

Of 76 women enrolled (38 each in the intervention and control groups), 70 (92.1%) completed the study. Mean (SD) age was 61.2 (9.3) years; 49 (64.5%) were married or partnered, and participants were a mean (SD) of 9.6 (6.8) years from diagnosis. From baseline to follow-up, ISI scores changed by a mean (SD) of -8.4 (4.7) points in the intervention group compared with -2.6 (3.5) in the control group (P < .001) (Cohen d, 1.41; 95% CI, 0.87-1.94). Sleep diary data showed statistically significant improvements in the intervention group compared with the control group for sleep quality (0.56; 95% CI, 0.39-0.74), wake after sleep onset (9.54 minutes; 95% CI, 1.93-17.10 minutes), sleep onset latency (8.32 minutes; 95% CI, 1.91-14.70 minutes), and sleep efficiency (-0.04%; 95% CI, -0.07% to -0.01%) but not for total sleep time (0.01 hours; 95% CI, -0.27 to 0.29 hours).

Conclusions and Relevance

This randomized clinical trial of an in-home, voice-activated CBT-I program among breast cancer survivors found that the intervention improved insomnia symptoms. Future studies may explore how this program can be taken to scale and integrated into ambulatory care.

Trial Registration

ClinicalTrials.gov Identifier: NCT05233800.

Sleep effects of psychological therapies for menopausal symptoms in women with hot flashes and night sweats: A systematic review

Sleep disturbance is frequently reported by women during the menopausal transition due to various physiological changes and environmental factors. Insomnia is a critical treatment target for its deleterious effects on daytime functioning and quality of life and increased risk of developing a depressive disorder. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments that address the myriad of menopausal symptoms, including cognitive-behavioural therapy, clinical hypnosis and mindfulness-based therapies. The objective of this article is to review the effects of psychological treatments for menopausal symptoms on sleep disturbance in peri-/postmenopausal women. We conducted a systematic review of the literature using PubMed and reference lists from inception until May 2023, including 12 studies that evaluated sleep as a secondary outcome. Most studies found that group and self-help (guided and unguided) cognitive-behavioural therapies and clinical hypnosis for menopausal symptoms have positive effects on sleep among women with significant vasomotor symptoms. There was preliminary support for mindfulness-based stress reduction. Future research including more diverse samples and women with sleep disorders is needed. Evaluating the implementation of psychological therapies in clinics where menopausal women seek care is an important next step.

Efficacy of eHealth Versus In-Person Cognitive Behavioral Therapy for Insomnia: Systematic Review and Meta-Analysis of Equivalence

BACKGROUND

Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive behavioral therapy for insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person-delivered CBTI (ipCBTI), electronically delivered eHealth CBTI (eCBTI), ranging from telephone- and videoconference-delivered interventions to fully automated web-based programs and mobile apps, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined.

OBJECTIVE

This study aims to test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized controlled trials directly comparing the 2 delivery formats.

METHODS

A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and nonsleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences. Supplementary Bayesian analyses were conducted to determine the strength of the available evidence.

RESULTS

The meta-analysis included 15 studies with a total of 1083 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the 2 delivery formats were statistically significantly equivalent (P<.05) for most sleep and nonsleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements (P<.05) in insomnia severity; sleep quality; and secondary outcomes such as fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and dropout rates as potential moderators of the differences in treatment efficacy.

CONCLUSIONS

eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and dropout rates on efficacy.

TRIAL REGISTRATION

PROSPERO CRD42023390811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=390811.

Level 2 Polysomnography for the Diagnosis of Sleep Disorders: A Health Technology Assessment

Background

It is estimated that half of Canadians have insufficient sleep, which over time is associated with poor physical and mental health. Currently, the only publicly funded option for the diagnosis of sleep disorders in Ontario is an in-person overnight sleep study, performed in a hospital or independent health facility (known as a level 1 polysomnography). Level 2 polysomnography has been proposed as an alternative that can be conducted at home for the diagnosis of suspected sleep disorders, if considered to have sufficient diagnostic accuracy. We conducted a health technology assessment of level 2 polysomnography for the diagnosis of suspected sleep disorders in adults and children, which included an evaluation of the test performance, cost-effectiveness, and budget impact of publicly funding level 2 polysomnography, and the experiences, preferences, and values of people with suspected sleep disorders.

Methods

We performed a systematic literature search of the clinical evidence to identify diagnostic accuracy, test failures and subjective measures of patient preferences. We assessed the risk of bias of each included study (using the Quality Assessment of Diagnostic Accuracy Studies [QUADAS-2] tool) and the quality of the body of evidence (according to Grading of Recommendations Assessment, Development, and Evaluation [GRADE] Working Group criteria). We performed a systematic literature search of economic evidence and conducted a primary economic evaluation and budget impact analysis to determine the cost-effectiveness and additional costs of publicly funding level 2 polysomnography for adults and children with suspected sleep disorders in Ontario. To contextualize the potential value of using level 2 polysomnography, we spoke with people with sleep disorders.

Results

We included 10 studies that reported on diagnostic accuracy and found level 2 polysomnography had sensitivity ranging between 0.76-1.0 and specificity ranging between 0.40-1.0 (GRADE: Moderate to Very low) when compared with level 1 polysomnography. Studies reported test failure rates from 0% to 20%, with errors present in both level 1 and level 2 tests conducted (GRADE: Very low). As well, some of these studies reported patients were found to have mixed opinions about their experiences, with more people preferring their experience with level 2 testing at home and having better quality of sleep compared with when they underwent level 1 testing (GRADE not conducted).Our primary economic evaluation showed that for adults with suspected sleep disorders, the new diagnostic pathway with level 2 polysomnography was equally effective (outcome: confirmed diagnosis at the end of the pathway) as the current practice diagnostic pathway with level 1 polysomnography. With the assumption of a lower technical fee for level 2 polysomnography, the new diagnostic pathway with level 2 polysomnography was less costly than the current practice diagnostic pathway (a saving of $27 per person with a wide 95% credible interval [95% CrI, -$137 to $121]), indicating that the results are highly uncertain. For children, a new diagnostic pathway with level 2 polysomnography was associated with additional costs (mean, $9.70; 95% CrI, -$125 to $190), and similarly, this estimate was highly uncertain.We estimated that the budget impact of publicly funding level 2 polysomnography for adults is uncertain and could range from savings of $22 million to additional costs of $43 million. Publicly funding a diagnostic pathway with level 2 polysomnography for children could result in additional costs of about $0.005 million over the next 5 years.People with whom we spoke reported that their sleep disorder negatively impacted their day-to-day lives, mental health, social and family relationships, and work. Participants who had experience with in-clinic (level 1) polysomnography described negative experiences they had at the clinic. Most people said they would prefer at-home (level 2) polysomnography over in-clinic (level 1) polysomnography, citing comfort and convenience as the main reasons; however, some people who have physical limitations preferred level 1 (in-clinic) polysomnography because they needed assistance to set up the equipment.

Conclusions

Level 2 polysomnography may have good test performance for adults and children, with adequate diagnostic accuracy, compared with level 1 polysomnography. The economic analyses showed that level 2 polysomnography for adults with suspected sleep disorders could be potentially cost saving but there is high uncertainty in the cost-effectiveness results. Given very limited information, the cost-effectiveness of this technology is also highly uncertain for children and young adults with suspected sleep disorders. The budget impact of publicly funding level 2 polysomnography for adults could range from savings of $22 million to additional costs of $43 million. Publicly funding level 2 polysomnography in children would require additional costs of about $0.005 million over the next 5 years. A clearer understanding of uptake of the technology, test costs, and the implementation pathway for adopting the technology is needed to improve the certainty of the cost-effectiveness and budget impact estimates. People with sleep disorders highlighted how important getting a diagnosis had been in order to be able to seek proper treatment for their sleep disorder and improve their lives. For many people with suspected sleep disorders, undergoing a sleep study at home would be a more comfortable and convenient option than undergoing a sleep study in clinic.

Daytime symptom trajectories among adults with stable heart failure and insomnia: evidence from a randomised controlled trial of cognitive behavioural therapy for insomnia

People with heart failure (HF) experience a high symptom burden and prevalent insomnia. However, little is known about daytime symptom trajectories after cognitive behavioural therapy for insomnia (CBT-I). In this study we describe: (1) daytime symptom trajectories among adults with insomnia and stable HF over 1 year, (2) how symptom trajectories differ between CBT-I versus HF self-management interventions, and (3) associations between demographic, clinical, and sleep characteristics, perceived stress, health-related quality of life (HRQoL), functional performance and daytime symptoms trajectories. We retrospectively analysed data from a randomised controlled trial of CBT-I versus HF self-management (NCT0266038). We measured sleep, perceived stress, HRQoL, and functional performance at baseline and symptoms at baseline, 3, 6, and 12 months. We conducted group-based trajectory modelling, analysis of variance, chi-square, and proportional odds models. Among 175 participants (mean [standard deviation] age 63.0 [12.9] years, 57.1% male, 76% White), we found four daytime symptom trajectories: (A) low improving symptoms (38.3%); (B) low psychological symptoms and high improving physical symptoms (22.8%); (C) high improving symptoms (24.0%); and (D) high not improving symptoms (14.9%). The CBT-I versus the HF self-management group had higher odds of belonging to Group A compared to other trajectories after controlling for baseline fatigue (odds ratio = 3.27, 95% confidence interval 1.39-7.68). The difference between the CBT-I and the HF self-management group was not statistically significant after controlling for baseline characteristics. Group D had the highest body mass index, perceived stress, and insomnia severity and the lowest cognitive ability, HRQoL, and functional performance. Research is needed to further evaluate factors contributing to symptom trajectories.

Kinesin binding as a shared pathway underlying the genetic basis of male factor infertility and insomnia

OBJECTIVE

To study whether male factor infertility and insomnia share genetic risk variants and identify any molecular, cellular, and biologic interactions between these traits.

DESIGN

The in silico study was performed. Two lists of genetic variants were manually curated through a literature review, one of those associated with male factor infertility and the other with insomnia. Genes were assigned to these variants to compose male factor infertility-associated (454 genes) and insomnia-associated (921 genes) gene lists.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Enrichment of biologic pathways and protein-protein interaction analysis.

RESULT(S)

Twenty-eight genes were common to both lists, representing a greater overlap than would be expected by chance. In the 28 genes contained in the intersection list, there was a significant enrichment of pathways related to kinesin binding. A protein-protein interaction analysis using the intersection list as input retrieved 25 nodes and indicated that two of them were kinesin-related proteins (PLEKHM2 and KCL1).

CONCLUSION(S)

The shared male factor infertility and insomnia genes, and the biologic pathways highlighted in this study, suggest that further functional investigations into the interplay between fertility and sleep are warranted.

'Let's talk about sleep health' within primary care: a qualitative study of patients' willingness to engage in psychological interventions for insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia yet remains underutilised in general practice. Understanding patient motivations and barriers to engaging in psychological interventions for insomnia is critical. Theoretical frameworks, such as the theory of planned behaviour, are needed to identify variables related to intentions and behaviour change.

AIM

To explore key influences that motivate individuals' intention to engage with psychological interventions for insomnia.

DESIGN AND SETTING

Qualitative study consisting of an online survey and interviews with 20 community-dwelling participants with insomnia aged 26-75 years residing in Victoria, Australia.

METHOD

Guided by the theory of planned behaviour, reflexive thematic analysis was used to identify factors influencing participants' intention to engage with psychological interventions for insomnia.

RESULTS

Participants reported positive attitudes towards psychological interventions for insomnia, stemming from negative beliefs about pharmacological sleep aids and the perceived benefits of a structured and evidence-based intervention. Important others positively influenced participants' intention to engage; however, the GP influence was less consistent and often indirect. Participants believed in the efficacy of psychological interventions, but several barriers hampered their ability to benefit from them. Accessibility was identified as a key facilitator, whereas lack of knowledge and clear referral pathways were the main barriers having an impact on uptake.

CONCLUSION

This study highlights key factors influencing patients' intention to engage in psychological interventions for insomnia as well as opportunities for GPs to support uptake and engagement. Routine conversations about sleep health are essential to reduce the burden of untreated insomnia in the community, and the active promotion of evidence-based psychological interventions is needed.

Nurse-delivered sleep restriction therapy to improve insomnia disorder in primary care: the HABIT RCT

Background

Insomnia is a prevalent and distressing sleep disorder. Multicomponent cognitive-behavioural therapy is the recommended first-line treatment, but access remains extremely limited, particularly in primary care where insomnia is managed. One principal component of cognitive-behavioural therapy is a behavioural treatment called sleep restriction therapy, which could potentially be delivered as a brief single-component intervention by generalists in primary care.

Objectives

The primary objective of the Health-professional Administered Brief Insomnia Therapy trial was to establish whether nurse-delivered sleep restriction therapy in primary care improves insomnia relative to sleep hygiene. Secondary objectives were to establish whether nurse-delivered sleep restriction therapy was cost-effective, and to undertake a process evaluation to understand intervention delivery, fidelity and acceptability.

Design

Pragmatic, multicentre, individually randomised, parallel-group, superiority trial with embedded process evaluation.

Setting

National Health Service general practice in three regions of England.

Participants

Adults aged ≥ 18 years with insomnia disorder were randomised using a validated web-based randomisation programme.

Interventions

Participants in the intervention group were offered a brief four-session nurse-delivered behavioural treatment involving two in-person sessions and two by phone. Participants were supported to follow a prescribed sleep schedule with the aim of restricting and standardising time in bed. Participants were also provided with a sleep hygiene leaflet. The control group received the same sleep hygiene leaflet by e-mail or post. There was no restriction on usual care.

Main outcome measures

Outcomes were assessed at 3, 6 and 12 months. Participants were included in the primary analysis if they contributed at least one post-randomisation outcome. The primary end point was self-reported insomnia severity with the Insomnia Severity Index at 6 months. Secondary outcomes were health-related and sleep-related quality of life, depressive symptoms, work productivity and activity impairment, self-reported and actigraphy-defined sleep, and hypnotic medication use. Cost-effectiveness was evaluated using the incremental cost per quality-adjusted life-year. For the process evaluation, semistructured interviews were carried out with participants, nurses and practice managers or general practitioners. Due to the nature of the intervention, both participants and nurses were aware of group allocation.

Results

We recruited 642 participants (n = 321 for sleep restriction therapy; n = 321 for sleep hygiene) between 29 August 2018 and 23 March 2020. Five hundred and eighty participants (90.3%) provided data at a minimum of one follow-up time point; 257 (80.1%) participants in the sleep restriction therapy arm and 291 (90.7%) participants in the sleep hygiene arm provided primary outcome data at 6 months. The estimated adjusted mean difference on the Insomnia Severity Index was -3.05 (95% confidence interval -3.83 to -2.28; p < 0.001, Cohen's d = -0.74), indicating that participants in the sleep restriction therapy arm [mean (standard deviation) Insomnia Severity Index = 10.9 (5.5)] reported lower insomnia severity compared to sleep hygiene [mean (standard deviation) Insomnia Severity Index = 13.9 (5.2)]. Large treatment effects were also found at 3 (d = -0.95) and 12 months (d = -0.72). Superiority of sleep restriction therapy over sleep hygiene was evident at 3, 6 and 12 months for self-reported sleep, mental health-related quality of life, depressive symptoms, work productivity impairment and sleep-related quality of life. Eight participants in each group experienced serious adverse events but none were judged to be related to the intervention. The incremental cost per quality-adjusted life-year gained was £2075.71, giving a 95.3% probability that the intervention is cost-effective at a cost-effectiveness threshold of £20,000. The process evaluation found that sleep restriction therapy was acceptable to both nurses and patients, and delivered with high fidelity.

Limitations

While we recruited a clinical sample, 97% were of white ethnic background and 50% had a university degree, which may limit generalisability to the insomnia population in England.

Conclusions

Brief nurse-delivered sleep restriction therapy in primary care is clinically effective for insomnia disorder, safe, and likely to be cost-effective.

Future work

Future work should examine the place of sleep restriction therapy in the insomnia treatment pathway, assess generalisability across diverse primary care patients with insomnia, and consider additional methods to enhance patient engagement with treatment.

Trial registration

This trial is registered as ISRCTN42499563.

Funding

The award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/84/01) and is published in full in Health Technology Assessment; Vol. 28, No. 36. See the NIHR Funding and Awards website for further award information.

The role of arousal in maintaining the relationship between insomnia and gastrointestinal conditions

The relationship between gastrointestinal (GI) conditions and sleep disturbance has been well established. With a higher-than-average prevalence of sleep disturbance in individuals with GI conditions, it is imperative to better understand the maintaining factors driving this comorbidity. Although there are separate, ongoing investigations into both the biological mechanisms and interventions for the sleep and GI relationship, there is a considerable need to further specify common and mutually influential pathways. In our review, we highlight arousal as both a unifying feature of insomnia and various GI conditions as well as a possible mechanism for action for the bidirectional relationship. This review aims to summarize the relationship between arousal, insomnia, and GI conditions, specifically examining sources of arousal across four broad domains: psychosocial factors, physical health factors, daily living factors, and sociocultural factors. Online databases, including PubMed, PsychInfo, and Google Scholar, were searched for full-text English language articles focused on patients with insomnia and/or GI conditions and involving mental health, physical comorbidities, and social factors. Understanding the nature of this bidirectional relationship between sleep and GI through the lens of arousal as a common mechanism will lend itself to using a multidisciplinary approach to treatment and care.

Shared genetic mechanisms underlying association between sleep disturbances and depressive symptoms

OBJECTIVES

Polygenic scores (PGS) for sleep disturbances and depressive symptoms in an epidemiological cohort were contrasted. The overlap between genes assigned to variants that compose the PGS predictions was tested to explore the shared genetic bases of sleep problems and depressive symptoms.

METHODS

PGS analysis was performed on the São Paulo Epidemiologic Sleep Study (EPISONO, N = 1042), an adult epidemiological sample. A genome wide association study (GWAS) for depression grounded the PGS calculations for Beck Depression Index (BDI), while insomnia GWAS based the PGS for Insomnia Severity Index (ISI) and Pittsburg Sleep Quality Index (PSQI). Pearson's correlation was applied to contrast PGS and clinical scores. Fisher's Exact and Benjamin-Hochberg tests were used to verify the overlaps between PGS-associated genes and the pathways enriched among their intersections.

RESULTS

All PGS models were significant when individuals were divided as cases or controls according to BDI (R2 = 1.2%, p = 0.00026), PSQI (R2 = 3.3%, p = 0.007) and ISI (R2 = 3.4%, p = 0.021) scales. When clinical scales were used as continuous variables, the PGS models for BDI (R2 = 1.5%, p = 0.0004) and PSQI scores (R2 = 3.3%, p = 0.0057) reached statistical significance. PSQI and BDI scores were correlated, and the same observation was applied to their PGS. Genes assigned to variants that compose the best-fit PGS predictions for sleep quality and depressive symptoms were significantly overlapped. Pathways enriched among the intersect genes are related to synapse function.

CONCLUSIONS

The genetic bases of sleep quality and depressive symptoms are correlated; their implicated genes are significantly overlapped and converge on neural pathways. This data suggests that sleep complaints accompanying depressive symptoms are not secondary issues, but part of the core mental illness.

Sleep hygiene - What do we mean? A bibliographic review

There is no consensus on the definition of sleep hygiene and its components. We examined the definition of sleep hygiene based on its use in published studies. Four databases (Medline, EMBASE, PsycINFO and CINAHL) were searched from inception until December 31, 2021 for the phrase 'sleep hygiene' in the title or abstract. We identified 548 relevant studies in adults: 250 observational and 298 intervention studies. A definition of sleep hygiene was provided in only 44% of studies and converged on three themes: behavioural factors, environmental factors, and an aspect of control. Sleep hygiene components were explicitly defined in up to 70% of observational studies, but in only 35% of intervention studies. The most commonly considered components of sleep hygiene were caffeine (in 51% of studies), alcohol (46%), exercise (46%), sleep timing (45%), light (42%), napping (39%), smoking (38%), noise (37%), temperature (34%), wind-down routine (33%), stress (32%), and stimulus control (32%), although the specific details of each component varied. Lack of consistency in definitions of sleep hygiene and its components may hinder communication between researchers, clinicians, and the public, and likely limits the utility of sleep hygiene as an intervention.

Sleep disorders and orofacial pain: insights for dental practice

In dental sleep medicine several sleep disorders commonly coexist with pain, contributing to complex clinical presentations which might affect the provision of appropriate and timely treatment. There are associations between sleep disorders and pain in general, as well as with specific orofacial pain conditions. As many as five of six patients with orofacial pain can present with sleep problems. The comorbidity of orofacial pain and sleep disorders overlays a complex web of altered neurobiological mechanisms that predispose to the chronification of orofacial pain. This review discusses the relationship between orofacial pain and sleep disorders and highlights their interactions and the neurobiological mechanisms underlying those relationships.

Clinico-demographic factors associated with the treatment response to cognitive behavioral therapy for insomnia

BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) is among the recommended non-pharmacological treatments for patients with insomnia. While there are multiple reports on the effects of CBT-I treatment, few studies evaluating the factors associated with the treatment response to CBT-I have been reported. The present study aimed to confirm the effects of CBT-I in patients with insomnia and to examine the clinico-demographic factors that can predict the outcomes of CBT-I in these patients.

METHODS

Overall, 62 patients were included in the present study. To confirm the effectiveness of CBT-I, we compared the pre- and post-CBT-I therapy values of several sleep parameters. Furthermore, to identify the clinico-demographic factors that could be predictive of the treatment response to CBT-I, we performed generalized linear model (GLM) analysis.

RESULTS

The values of several sleep parameters were significantly lower after treatment than at baseline. The results of the GLM analysis revealed that sex and occupation were significantly associated with the treatment response to CBT-I.

CONCLUSIONS

The present results suggest that several clinico-demographic factors should be considered in the treatment of patients with insomnia.

Psychiatric comorbidities and prescribing tendencies of sleep medications and related medications in young people with insomnia: a United States commercial claims-based analysis

STUDY OBJECTIVES

To characterize children and youth newly diagnosed with insomnia and to describe their use of sleep and other related prescription medications.

METHODS

Within a commercial claims database (January 1, 2016-December 31, 2021), we identified children and youth (2-24 years) with a newly recorded insomnia diagnosis (G47.0x; F51.0x) and examined psychiatric diagnoses in the prior 6 months. We evaluated sleep and related prescription medications dispensed in the week after new insomnia diagnoses (i.e. trazodone, other antidepressants, hydroxyzine, alpha-agonists, benzodiazepines, non-benzodiazepine hypnotics "z-drugs," antipsychotics, and others). Analyses were stratified by age and psychiatric comorbidities.

RESULTS

Among 68 698 children and 108 118 older youth (18-24 years) with a new insomnia diagnosis, three-quarters had a diagnosed comorbid psychiatric condition; anxiety disorders, depression, and ADHD were the most common. Among those without comorbid psychiatric diagnoses, 20.2% of children and 37.4% of older youth had a sleep or related medication dispensed in the following week. In children without a comorbid psychiatric diagnosis, alpha-agonists, hydroxyzine, and trazodone were the most common medications; in older youth, trazodone was the most common medication followed by hydroxyzine, z-drugs, and SSRIs. Sleep and related prescription medications were more commonly dispensed to those with psychiatric comorbidities. From 2017 to 2021, there was an increase in hydroxyzine prescriptions following a new insomnia diagnosis and decline in z-drug and benzodiazepine prescriptions.

CONCLUSIONS

Our findings from a nationwide sample of young people with insomnia highlight the high prevalence of psychiatric comorbidities and variety of sleep and related medications they receive. Characterizing prescribing tendencies informs guideline development and future research.

Relationship between insomnia and pain in patients with chronic orofacial pain

OBJECTIVE

Few studies have investigated specific associations between insomnia and orofacial pain (OFP). The aim of this cross-sectional study was to examine relationships of insomnia with pain, mental health, and physical health variables among treatment-seeking patients with chronic OFP.

METHODS

OFP diagnosis, demographics, insomnia symptoms, pain intensity, interference, and duration, mental health measures, and number of medical comorbidities were extracted from the medical records of 450 patients receiving an initial appointment at a university-affiliated tertiary OFP clinic. T-tests compared differences between patients with and without insomnia symptomatology, and between patients with different insomnia subtypes (delayed onset/early wakening).

RESULTS

Compared to patients without insomnia, those with elevated insomnia symptomatology (45.1%) reported higher pain intensity (60.70 ± 20.61 vs 44.15 ± 21.69; P < .001) and interference (43.81 ± 29.84 vs 18.40 ± 23.43; P < 0.001), depression/anxiety symptomatology (5.53 ± 3.32 vs 2.72 ± 2.66; P < 0.001), dissatisfaction with life (21.63 ± 6.95 vs 26.50 ± 6.21; P < .001), and number of medical comorbidities (6.72 ± 5.37 vs 4.37 ± 4.60; P < .001). Patients with Sleep Onset Latency insomnia (SOL-insomnia) (N = 76) reported higher pain intensity (t = 3.57; P < 0.001), and pain interference (t = 4.46; P < .001) compared to those without SOL-insomnia. Those with Early Morning Awakening insomnia (EMA-insomnia) (N = 71) did not significantly differ from those without EMA-insomnia on any of the variables. Differences remained significant after adjusting for age, sex, primary OFP diagnosis, and pain intensity.

CONCLUSIONS

Insomnia is associated with pain outcomes and should be appropriately managed when treating patients with chronic OFP.

The screening and management of sleep disturbances in people living with HIV: Delphi consensus

Sleep disturbances in people living with HIV (PLHIV) are frequent but their management remains insufficient. In the absence of specific recommendations, a DELPHI consensus research project was conducted in France to establish best practice. A multidisciplinary Steering Committee (STC) undertook a literature review and used it with clinical expertise to create statements that were voted on. Two profiles of healthcare professionals with significant experience in monitoring PLHIV were selected for the voting: physicians and nurses/psychologists. Votes were collected electronically, independently, and anonymously. The STC created 27 statements covering six areas: Screening of sleep disturbances, Investigation, First-line management, Referral to a specialist, Antiretroviral treatment (ARV), and Prevention. Two rounds of votes included 42 physicians and 32 nurses/psychologists. Consensus was reached for 24 out of 27 statements (89%) including: to assess quantity and quality of sleep among PLHIV at least annually, ideally using a common methodology within the medical department; to consider the temporary addition of a hypnotic treatment in cases of acute insomnia not improved by the rules of sleep hygiene, with full awareness of potential drug-drug interactions and risk of dependence; to correct ferritinaemia if <100 ng/mL before referral to a specialist when restless legs syndrome is suspected; to consider changing the time of ARV administration or an ARV switch within the same class when sleep disturbances are caused by an ARV. This DELPHI Consensus provides best practice for screening and managing sleep disturbances in PLHIV and optimising their quality of life.

Healthy Sleep Practices for Consumers of Home Total Parenteral Nutrition: A Mixed-Methods Community-Based Participatory Study

Background

Consumers of overnight home parenteral nutrition (HPN) often experience sleep disruption; however, existing healthy sleep recommendations are widely inapplicable to consumers.

Objectives

The aim of this mixed-methods, community-based participatory research study was to develop tailored recommendations on healthy sleep practices for HPN consumers.

Methods

The multipart study involved the following: 1) an initial draft of sleep recommendations based on the evaluation of existing general sleep hygiene guidelines by an expert panel of clinicians and consumers with lived experience; 2) semi-structured focus groups with consumers and clinicians; 3) pre- and post-knowledge tests completed by consumers, and 4) final approval of the recommendations by the expert panel.

Results

The literature synthesis resulted in 51 recommendations evaluated for relevance for HPN consumers. Focus groups with 20 HPN consumers and clinicians contributed additional recommendations based on lived experience. Ultimately, the final resource included recommendations spanning 4 sections: getting ready for bed, preparing the bedroom for sleep, daytime behaviors, and overall strategies for better sleep. Of the 36 recommendations, 58% were derived from existing general sleep hygiene guidelines, and the remaining 42% addressed sleep challenges experienced uniquely by consumers, including nocturnal polyuria, noise/light from medical equipment, and infusion schedules. Knowledge tests completed by 10 additional consumers indicated a modest increase in sleep health knowledge.

Conclusions

The curated healthy sleep resource tailored for HPN consumers was facilitated by a multidisciplinary expert panel, a strategic collaboration with members of the HPN community and their clinicians, and in partnership with patient advocacy and support organizations. The wide distribution of these resources may improve the overall well-being of HPN consumers.

Components and Delivery Formats of Cognitive Behavioral Therapy for Chronic Insomnia in Adults: A Systematic Review and Component Network Meta-Analysis

Importance

Chronic insomnia disorder is highly prevalent, disabling, and costly. Cognitive behavioral therapy for insomnia (CBT-I), comprising various educational, cognitive, and behavioral strategies delivered in various formats, is the recommended first-line treatment, but the effect of each component and delivery method remains unclear.

Objective

To examine the association of each component and delivery format of CBT-I with outcomes.

Data Sources

PubMed, Cochrane Central Register of Controlled Trials, PsycInfo, and International Clinical Trials Registry Platform from database inception to July 21, 2023.

Study Selection

Published randomized clinical trials comparing any form of CBT-I against another or a control condition for chronic insomnia disorder in adults aged 18 years and older. Insomnia both with and without comorbidities was included. Concomitant treatments were allowed if equally distributed among arms.

Data Extraction and Synthesis

Two independent reviewers identified components, extracted data, and assessed trial quality. Random-effects component network meta-analyses were performed.

Main Outcomes and Measures

The primary outcome was treatment efficacy (remission defined as reaching a satisfactory state) posttreatment. Secondary outcomes included all-cause dropout, self-reported sleep continuity, and long-term remission.

Results

A total of 241 trials were identified including 31 452 participants (mean [SD] age, 45.4 [16.6] years; 21 048 of 31 452 [67%] women). Results suggested that critical components of CBT-I are cognitive restructuring (remission incremental odds ratio [iOR], 1.68; 95% CI, 1.28-2.20) third-wave components (iOR, 1.49; 95% CI, 1.10-2.03), sleep restriction (iOR, 1.49; 95% CI, 1.04-2.13), and stimulus control (iOR, 1.43; 95% CI, 1.00-2.05). Sleep hygiene education was not essential (iOR, 1.01; 95% CI, 0.77-1.32), and relaxation procedures were found to be potentially counterproductive(iOR, 0.81; 95% CI, 0.64-1.02). In-person therapist-led programs were most beneficial (iOR, 1.83; 95% CI, 1.19-2.81). Cognitive restructuring, third-wave components, and in-person delivery were mainly associated with improved subjective sleep quality. Sleep restriction was associated with improved subjective sleep quality, sleep efficiency, and wake after sleep onset, and stimulus control with improved subjective sleep quality, sleep efficiency, and sleep latency. The most efficacious combination-consisting of cognitive restructuring, third wave, sleep restriction, and stimulus control in the in-person format-compared with in-person psychoeducation, was associated with an increase in the remission rate by a risk difference of 0.33 (95% CI, 0.23-0.43) and a number needed to treat of 3.0 (95% CI, 2.3-4.3), given the median observed control event rate of 0.14.

Conclusions and Relevance

The findings suggest that beneficial CBT-I packages may include cognitive restructuring, third-wave components, sleep restriction, stimulus control, and in-person delivery but not relaxation. However, potential undetected interactions could undermine the conclusions. Further large-scale, well-designed trials are warranted to confirm the contribution of different treatment components in CBT-I.

Reliability and validity of the cancer-related dysfunctional beliefs and attitudes about sleep scale in cancer patients

BACKGROUND

Insomnia is a common health problem among cancer patients, which is not only a physical problem but also a psychological problem. Sleep plays an important role in the mental and somatic rehabilitation of cancer patients, and the sleep beliefs and attitudes of cancer patients are key factors in improving their sleep situation and quality of life. The aim of this study was to translate the Cancer-Related Dysfunctional Beliefs and Attitudes about Sleep (C-DBAS-14) scale into Chinese and to validate its reliability and validity in cancer patients.

METHOD

The C-DBAS-14 scale was translated into Chinese using the backward and forward translation procedure. The reliability of the scale was measured by internal consistency, split-half reliability and retest reliability. The validity of the scale was assessed through the content validity indicators, exploratory factor analysis and validation factor analysis.

RESULT

The Cronbach's ɑ coefficient of the Chinese version of the C-DBAS-14 was 0.932 while the McDonald's omega coefficient (ω t) was 0.934. The split-half reliability coefficient was 0.908, and the test-retest reliability was 0.857. The four-factor model was obtained using exploratory factor analysis, explaining 72.7% of the variance, with each item loading greater than 0.4 on the common factor. The results of the confirmatory factor analysis revealed that all indicators of model fit were within an acceptable range, indicating a well-fitting model.

CONCLUSION

The Chinese version of the C-DBAS-14 has good reliability and validity among cancer patients. It can be used to measure the sleep beliefs and attitudes of Chinese cancer patients.

Stimulus control for insomnia: A systematic review and meta-analysis

Stimulus control (SC) is commonly viewed as an evidence-based treatment for insomnia, but it has not been evaluated comprehensively with modern review and meta-analytic techniques. The aim of the current study was thus to perform a systematic review and meta-analysis of trials that examine the efficacy of stimulus control for insomnia. A systematic search for eligible articles and dissertations was conducted in six online bibliographic databases. The 11 included studies, with the majority published between 1978 and 1998, were randomised controlled and experimental studies in adults, comparing stimulus control for insomnia with passive and active comparators and assessing insomnia symptoms as outcomes. A random effects model was used to determine the standardised mean difference Hedge's g at post-treatment and follow-up for three sleep diary measures: the number of awakenings, sleep onset latency, and total sleep time. A test for heterogeneity was conducted, forest plots were produced, the risk of publication bias was estimated, and the study quality was assessed. In the trials identified, stimulus control resulted in small to large improvements on sleep onset latency and total sleep time, relative to passive comparators (g = 0.38-0.85). Compared with active comparators, the improvements following stimulus control were negligible (g = 0.06-0.30). Although methodological uncertainties were observed in the included trials, stimulus control appears to be an efficacious treatment for insomnia when compared with passive comparators and with similar effects to active comparators. More robust studies are, however, warranted before stronger conclusions are possible to infer.

Self-reported sleep status and influencing factors: a web-based national cross-sectional survey in China

OBJECTIVES

To investigate self-reported sleep duration, sleep timing, sleep status and influencing factors in the Chinese population.

METHODS

This web-based cross-sectional survey was conducted in 2022, covering 31 provinces (91%) in China. 11,000 questionnaires were collected, of which 8970 were valid for analysis. Self-reported sleep habits, problems and quality were investigated. Good or fair sleep ratings, enough duration, regular, with no sleep disturbances and <30 min sleep latency was defined as a composite variable: 'Good sleep'. Factors influencing sleep patterns and 'Good sleep' were analyzed by multivariate logistic regression.

RESULTS

Most participants sleep less than 7 h per night (55.13%), usually go to bed at 10-12 pm (47.99%), wake up at 6-8 am (49.86%), and take less than 30 min to fall asleep (66.30%) with regular sleep schedule (76.01%). Only 12.36% have 'Good sleep'. In the past 3 months, 46.80% of the participants reported symptoms of insomnia, and 21.54% had snoring problems. Among the adults, the young, males, college students, freelancers, and those who resided in urban areas and pandemic-free areas slept later, and the northerners woke up earlier. The adults with low-moderate and moderate income and the minors at elementary and middle school slept earlier and woke up earlier. Mid-aged adults who often napped at noon were more likely to have 'Good sleep' than any other age group, and urban dwellers with the same habit were more likely to have 'Good sleep' than people dwelled in other regions. While people who slept late, woke up too early or too late, slept too little or too much, resided at GMT 7-8 area or pandemic area, had high income, or took up some occupations (entrepreneurs/individuals, professionals, manual and non-manual workers, housewives) were less likely to get a 'Good sleep'.

CONCLUSIONS

The national survey provided a sleep profile of the Chinese population. Both socio-economic status and personal sleep hygiene habits had an impact on 'Good sleep'.

The efficacy of intensive sleep retraining for insomnia: A systematic review and research agenda

Intensive sleep retraining (ISR) is a brief behavioural treatment for sleep onset insomnia, administered in just a single overnight treatment session. This systematic review evaluates existing trials about the efficacy of intensive sleep retraining for treating insomnia, to inform whether there is enough evidence to recommend its use for clinical practice. A systematic literature search was conducted across three databases, yielding 108 results. Of these studies, three were deemed suitable for inclusion in this review. The included studies consistently reported significant reductions in insomnia symptoms following intensive sleep retraining, particularly decreases in sleep diary-derived sleep latency and increases in total sleep time. Based on these inconclusive but promising findings, a research agenda is proffered to test intensive sleep retraining as a treatment for insomnia. Large randomised controlled trials are needed to elucidate the potential benefits of intensive sleep retraining for different populations with insomnia, as are mechanistic trials to test which components underlie its seemingly therapeutic effects. Since more practical modalities of intensive sleep retraining administration have been developed, such trials are more feasible to conduct now than ever before.