Group-delivered cognitive behavioural therapy versus waiting list in the treatment of insomnia in primary care: study protocol for a pragmatic, multicentre randomized controlled trial.

BACKGROUND: Insomnia is common in the general population and is a risk factor for ill-health, which highlights the importance of treating insomnia effectively and cost-efficiently. Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment due to its long-term effectiveness and few side-effects, but its availability is limited. The aim of this pragmatic, multicentre randomized controlled trial is to investigate the effectiveness of group-delivered CBT-I in primary care compared to a waiting-list control group. METHODS: A pragmatic multicentre randomized controlled trial will be conducted with about 300 participants recruited across 26 Healthy Life Centres in Norway. Participants will complete online screening and provide consent before enrolment. Those who meet the eligibility criteria will be randomized to a group-delivered CBT-I or to a waiting list according to a 2:1 ratio. The intervention consists of four two-hour sessions. Assessments will be performed at baseline, 4 weeks, 3- and 6 months post-intervention, respectively. The primary outcome is self-reported insomnia severity at 3 months post-intervention. Secondary outcomes include health-related quality of life, fatigue, mental distress, dysfunctional beliefs and attitudes about sleep, sleep reactivity, 7-day sleep diaries, and data obtained from national health registries (sick leave, use of relevant prescribed medications, healthcare utilization). Exploratory analyses will identify factors influencing treatment effectiveness, and we will conduct a mixed-method process evaluation to identify facilitators and barriers of participants' treatment adherence. The study protocol was approved by the Regional Committee for Medical and Health Research ethics in Mid-Norway (ID 465241). DISCUSSION: This large-scale pragmatic trial will investigate the effectiveness of group-delivered cognitive behavioural therapy versus waiting list in the treatment of insomnia, generating findings that are generalizable to day-to-day treatment of insomnia in interdisciplinary primary care services. The trial will identify those who would benefit from the group-delivered therapy, and will investigate the rates of sick leave, medication use, and healthcare utilization among adults who undergo the group-delivered therapy. TRIAL REGISTRATION: The trial was retrospectively registered in the ISRCTN registry (ISRCTN16185698).

Quantifying teenagers' sleep patterns and sex differences in social jetlag using at-home sleep monitoring.

Sleep plays an important role in the formative developmental processes occurring during the teenage years. At the same time, teenagers' changing bioregulatory mechanisms and psychosocial factors converge into the so-called social jetlag, a sleep timing misalignment between weekdays and weekends. The aim of this study was to quantify the course of day-to-day changes in sleep/wake patterns and sleep stage distributions, and the sex differences in social jetlag among teenagers. We observed the sleep of 156 teenagers (58.3% girls, 15-16 years) using a novel sleep monitor over the course of up to 10 consecutive days. 1323 nights of data were analyzed using multilevel modeling. On average, participants went to bed at 23:41, woke up at 07:48, slept for 7.7 h and had 85.5% sleep efficiency. Sleep stage distributions were in line with normative data. We found later sleep onset and offset, longer time in bed, sleep duration, and sleep onset latency (p = .001), greater proportion of light sleep and lower proportion of deep sleep, and poorer sleep efficiency (all p < .001) on weekend nights starting on Friday and Saturday. On Friday nights, girls had longer time awake after sleep onset (p = .020) than boys. On Friday and Saturday nights, girls fell asleep earlier (p < .001 and p = .006, respectively). On Saturday nights, girls had shorter sleep latency (p = .024), and better sleep efficiency (p = .019) than boys. In sum, teenagers' sleep patterns reflected healthy, albeit somewhat short sleep. There was convincing evidence of social jetlag, and girls exhibited less severe social jetlag than boys.

The Influence of Menstrual-Cycle Phase on Measures of Recovery Status in Endurance Athletes: The Female Endurance Athlete Project.

PURPOSE: To investigate the influence of menstrual-cycle (MC) phase on measures of recovery status, that is, resting heart rate, perceived sleep quality, and physical and mental readiness to train, among female endurance athletes. METHODS: Daily data were recorded during 1 to 4 MCs (ie, duration ≥21 and ≤35 d, ovulatory, luteal phase ≥10 d) of 41 trained-to-elite-level female endurance athletes (mean [SD]: age 27 [8] y, weekly training: 9 [3] h). Resting heart rate was assessed daily using a standardized protocol, while perceived sleep quality and physical and mental readiness to train were assessed using a visual analog scale (1-10). Four MC phases (early follicular phase [EFP], late follicular phase, ovulatory phase, and midluteal phase [MLP]) were determined using the calendar-based counting method and urinary ovulation-prediction test. Data were analyzed using linear mixed-effects models. RESULTS: Resting heart rate was significantly higher in MLP (1.7 beats·min-1, P = .006) compared with EFP without significant differences between the other MC phases. Perceived sleep quality was impaired in MLP compared with late follicular phase (-0.3, P = .035). Physical readiness to train was lower both in ovulatory phase (-0.6, P = .015) and MLP (-0.5, P = .026) compared with EFP. Mental readiness to train did not show any significant differences between MC phases (P > .05). CONCLUSIONS: Although significant, the findings had negligible to small effect sizes, indicating that MC phase is likely not the main determinant of changes in measures of recovery status but, rather, one of the many possible stressors.

App-Delivered Cognitive-Behavioral Therapy for Insomnia Among Patients with Comorbid Musculoskeletal Complaints and Insomnia Referred to 4-Week Inpatient Multimodal Rehabilitation: Protocol for a Randomized Clinical Trial.

Background: Insomnia is prevalent among patients receiving treatment for long-term musculoskeletal complaints in inpatient rehabilitation settings. Cognitive-behavioral therapy for insomnia (CBT-I) is effective for improving sleep quality in patients with pain, but a lack of therapists often limits the capacity to use this therapy in rehabilitation programs. The aim of this randomized clinical trial (RCT) is to evaluate the effectiveness of app-delivered CBT-I adjunct to inpatient multimodal rehabilitation for individuals with comorbid musculoskeletal complaints and insomnia, compared with rehabilitation (usual care) only. Methods: This RCT has two parallel arms: 1) inpatient multimodal rehabilitation and 2) app-delivered CBT-I adjunct to inpatient multimodal rehabilitation. Patients referred to Unicare Helsefort (Norway) with long-term chronic musculoskeletal complaints are invited to the study. Eligible and consenting participants will be randomized to the intervention and usual care at a ratio of 2:1. Assessments will be carried out at baseline (prior to randomization), 6 weeks (at the end of rehabilitation), 3 months (primary outcome), as well as 6 and 12 months after the rehabilitation. The primary outcome is insomnia severity measured at 3 months. Secondary outcomes include pain intensity, health-related quality of life, fatigue, physical function, work ability, expectations about sick leave length, sick leave, and prescribed medication. Exploratory analyses are planned to identify moderators and mediators of the effect of the app-delivered intervention. Discussion: This RCT will provide novel knowledge about the effectiveness of app-delivered CBT-I as an adjunct to usual care among patients participating in inpatient multimodal pain rehabilitation. Regardless of the results from this trial, the results will improve our understanding of the utility of dCBT-I in the field of rehabilitation and the importance of adding sleep therapy to this patient group. Trial Registration: This trial was prospectively registered in ClinicalTrials.gov October 10, 2022 (ClinicalTrials.gov identifier: NCT05572697).

NREM Sleep Parasomnias Commencing in Childhood: Trauma and Atopy as Perpetuating Factors.

Objective/Background: Phenotyping of non-rapid-eye-movement (NREM) parasomnias is currently poorly undertaken. This study aimed to determine whether there are differences phenotypically among childhood-, adolescent-, and adult-onset NREM parasomnias continuing into and presenting in adulthood. Patients/Methods: A retrospective, cohort study of patients presenting with NREM parasomnia between 2008 and 2019 (n = 307) was conducted. Disorders included sleepwalking (n = 231), night terrors (n = 150), sexualised behaviour in sleep (n = 50), and sleep-related eating disorder (n = 28). Results: Compared to the adult-onset NREM behaviours group, the childhood- and adolescent-onset groups were more likely to have a family history of NREM behaviours (p < 0.001), experience a greater spectrum of NREM disorders (p = 0.001), and report a history of sleep-talking significantly more frequently (p = 0.014). Atopy was most prevalent in the childhood-onset group (p = 0.001). Those with childhood-onset NREM parasomnias were significantly more likely to arouse from N3 sleep on video polysomnography (p = 0.0003). Psychiatric disorders were more likely to be comorbid in the adult-onset group (p = 0.012). A history of trauma coinciding with onset of NREM behaviours was significantly more common in the childhood- and adolescent-onset groups (p < 0.001). Conclusions: Significant differences exist across childhood-, adolescent-, and adult-onset NREM parasomnia presenting in adulthood. This study suggests that adult-onset slow-wave sleep disorders may be confounded by psychiatric disorders resulting in nocturnal sleep disruption and that unresolved traumatic life experiences perpetuate NREM disorders arising in childhood and comprise one of the strongest external risk factors for triggering and perpetuating these disorders in adolescence.

Variations in Elite Female Soccer Players' Sleep, and Associations With Perceived Fatigue and Soccer Games.

The current study investigated the associations between female perceived fatigue of elite soccer players and their sleep, and the associations between the sleep of players and soccer games. The sample included 29 female elite soccer players from the Norwegian national soccer team with a mean age of ~26 years. Perceived fatigue and sleep were monitored over a period of 124 consecutive days. In this period, 12.8 ± 3.9 soccer games per player took place. Sleep was monitored with an unobtrusive impulse radio ultra-wideband Doppler radar (Somnofy). Perceived fatigue was based on a self-report mobile phone application that detected daily experienced fatigue. Multilevel analyses of day-to-day associations showed that, first, increased perceived fatigue was associated with increased time in bed (3.6 ± 1.8 min, p = 0.037) and deep sleep (1.2 ± 0.6 min, p = 0.007). Increased rapid eye movement (REM) sleep was associated with subsequently decreased perceived fatigue (-0.21 ± 0.08 arbitrary units [AU], p = 0.008), and increased respiration rate in non-REM sleep was associated with subsequently increased fatigue (0.27 ± 0.09 AU, p = 0.002). Second, game night was associated with reduced time in bed (-1.0 h ± 8.4 min, p = <0.001), total sleep time (-55.2 ± 6.6 min, p = <0.001), time in sleep stages (light: -27.0 ± 5.4 min, p = <0.001; deep: -3.6 ± 1.2 min, p = 0.001; REM: -21.0 ± 3.0 min, p = <0.001), longer sleep-onset latency (3.0 ± 1.2 min, p = 0.013), and increased respiration rate in non-REM sleep (0.32 ± 0.08 respirations per min, p = <0.001), compared to the night before the game. The present findings show that deep and REM sleep and respiration rate in non-REM sleep are the key indicators of perceived fatigue in female elite soccer players. Moreover, sleep is disrupted during game night, likely due to the high physical and mental loads experienced during soccer games. Sleep normalizes during the first and second night after soccer games, likely preventing further negative performance-related consequences.

"When I Sleep Poorly, It Impacts Everything": An Exploratory Qualitative Investigation of Stress and Sleep in Junior Endurance Athletes.

On their journeys toward senior athletic status, junior endurance athletes are faced with a multitude of stressors. How athletes react to stressors plays a vital part in effective adaptation to the demanding, ever-changing athletic environment. Sleep, the most valued recovery strategy available to athletes, has the potential to influence and balance athletic stress, and enable optimal functioning. However, sleep is sensitive to disturbances by stress, which is described by the concept of sleep reactivity. Among athletes, poor sleep quality is frequently reported, but our understanding of the associations between stress and sleep in junior athletes is currently incomplete. The present study therefore investigated the themes of stress and sleep, and the associations between these variables with the use of in-depth semi-structured interviews in six junior endurance athletes (three men and three women, mean age 17.7 ± 0.5 years). Data was analyzed qualitatively based on the Grounded Theory. The qualitative material was supplemented with quantitative data on subjective sleep quality (Pittsburg Sleep Quality Index), sleep reactivity (Ford Insomnia Response to Stress Test), and mental strain (visual analog scale). The main results showed that stress could be differentiated into relevant stressors (encompassing poor performance, uncertainty in relation to training, school, daily hassles, and sleep) and reactions to stress (with sub-categories facilitative and maladaptive). Sleep could be differentiated into sleep benefits (encompassing energy levels and athletic functioning) and sleep quality (with sub-categories satisfactory and inadequate). All athletes identified relevant stressors, and all athletes were aware of the benefits of sleep for athletic functioning. However, athletes formed two distinctive categories based on the interactions between stress and sleep: three exhibited facilitative reactions to stress and good sleep quality, as well as low sleep reactivity, and low mental strain. The remaining participants exhibited maladaptive reactions to stress and poor sleep quality, as well as high sleep reactivity and high mental strain. Conceptualizing sleep quality based on the evaluation of stressors, reactions to stress, degree of mental strain, and the propensity to stress-related sleep disturbance may offer a plausible explanation for why the occurrence of stressors leads to poor sleep quality in some athletes, but not others.

An observational study of sleep characteristics in elite endurance athletes during an altitude training camp at 1800 m.

OBJECTIVES: To observe changes in sleep from baseline and during an altitude training camp in elite endurance athletes. DESIGN: Prospective, observational. SETTING: Baseline monitoring at <500 m for 2 weeks and altitude monitoring at 1800 m for 17-22 days. PARTICIPANTS: Thirty-three senior national-team endurance athletes (mean age 25.8 ± S.D. 2.8 years, 16 women). MEASUREMENTS: Daily measurements of sleep (using a microwave Doppler radar at baseline and altitude), oxygen saturation (SpO2), training load and subjective recovery (at altitude). RESULTS: At altitude vs. baseline, sleep duration (P = .036) and light sleep (P < .001) decreased, while deep sleep (P < .001) and respiration rate (P = .020) increased. During the first altitude week vs. baseline, deep sleep increased (P = .001). During the first vs. the second and third altitude weeks, time in bed (P = .005), sleep duration (P = .001), and light sleep (P < .001) decreased. Generally, increased SpO2 was associated with increased deep sleep while increased training load was associated with increased respiration rate. CONCLUSION: This is the first study to document changes in sleep from near-sea-level baseline and during a training camp at 1800 m in elite endurance athletes. Ascending to altitude reduced total sleep time and light sleep, while deep sleep and respiration rate increased. SpO2 and training load at altitude were associated with these responses. This research informs our understanding of the changes in sleep occurring in elite endurance athletes attending training camps at competition altitudes.

Sex differences in sleep and influence of the menstrual cycle on women's sleep in junior endurance athletes.

Previous research shows that female athletes sleep better according to objective parameters but report worse subjective sleep quality than male athletes. However, existing sleep studies did not investigate variations in sleep and sleep stages over longer periods and have, so far, not elucidated the role of the menstrual cycle in female athletes' sleep. To address these methodological shortcomings, we investigated sex differences in sleep and sleep stages over 61 continuous days in 37 men and 19 women and examined the role of the menstrual cycle and its phases in 15 women. Sleep was measured by a non-contact radar, and menstrual bleeding was self-reported. Associations were investigated with multilevel modeling. Overall, women tended to report poorer subjective sleep quality (p = .057), but objective measurements showed that women obtained longer sleep duration (p < .001), more light (p = .013) and rapid eye movement sleep (REM; hours (h): p < .001, %: p = .007), shorter REM latency (p < .001), and higher sleep efficiency (p = .003) than men. R2 values showed that sleep duration, REM and REM latency were especially affected by sex. Among women, we found longer time in bed (p = .027) and deep sleep (h: p = .036), and shorter light sleep (%: p = .021) during menstrual bleeding vs. non-bleeding days; less light sleep (h: p = .040), deep sleep (%: p = .013) and shorter REM latency (p = .011) during the menstrual than pre-menstrual phase; and lower sleep efficiency (p = .042) and more deep sleep (%: p = .026) during the follicular than luteal phase. These findings indicate that the menstrual cycle may impact the need for physiological recovery, as evidenced by the sleep stage variations. Altogether, the observed sex differences in subjective and objective sleep parameters may be related to the female athletes' menstrual cycle. The paper provides unique data of sex differences in sleep stages and novel insights into the role of the menstrual cycle in sleep among female athletes.

Associations Between Sleep Patterns and Performance Development Among Norwegian Chess Players.

An inherent part of elite-level chess are high emotional and cognitive stress loads related to performance development. Sleep is a crucial recovery strategy, previously implicated in athletic performance. The main purpose of the current study was to investigate the associations between performance development and objectively measured sleep in a sample of 14 Norwegian chess players over a period of 120 consecutive days. Seven of the chess players in the current sample had negative development in their International Chess Federation (FIDE) ranking score in the period of sleep monitoring, while 7 had positive development. The sleep patterns of the chess players with positive performance development were different from the players with negative development - with higher amounts of deep sleep, less rapid eye movement (REM) sleep and lower respiration rate in the positive performance development group compared to the negative performance development group. The findings are discussed in terms of existing knowledge on the importance of sleep stage distribution and sleep durations for athlete functioning, and in light of applied implications and possible future research.

Validation of sleep stage classification using non-contact radar technology and machine learning (Somnofy®).

OBJECTIVE: To validate automatic sleep stage classification using deep neural networks on sleep assessed by radar technology in the commercially available sleep assistant Somnofy® against polysomnography (PSG). METHODS: Seventy-one nights of overnight sleep in healthy individuals were assessed by both PSG and Somnofy at two different institutions. The Somnofy unit was placed in two different locations per room (nightstand and wall). The sleep algorithm was validated against PSG using a 25-fold cross validation technique, and performance was compared to the inter-rater reliability between the PSG sleep scored by two independent sleep specialists. RESULTS: Epoch-by-epoch analyses showed a sensitivity (accuracy to detect sleep) and specificity (accuracy to detect wake) for Somnofy of 0.97 and 0.72 respectively, compared to 0.99 and 0.85 for the PSG scorers. The sleep stage differentiation for Somnofy was 0.75 for N1/N2, 0.74 for N3 and 0.78 for R, whilst PSG scorers ranged between 0.83 and 0.96. The intraclass correlation coefficient revealed excellent and good reliability for total sleep time and sleep efficiency, while sleep onset and R latency had poor agreement. Somnofy underestimated total wake time by 5 min and N1/N2 by 3 min. N3 was overestimated by 4 min and R by 3 min. Results were independent of institution and sensor location. CONCLUSION: Somnofy showed a high accuracy staging sleep in healthy individuals and has potential to assess sleep quality and quantity in a sample of healthy, mostly young adults. More research is needed to examine performance in children, older individuals and those with sleep disorders.

Reciprocal Associations Between Sleep, Mental Strain, and Training Load in Junior Endurance Athletes and the Role of Poor Subjective Sleep Quality.

The importance of adequate sleep for athletic functioning is well established. Still, the literature shows that many athletes report sleep of suboptimal quality or quantity. To date, no research has investigated how bidirectional variations in mental and physiological states influence sleep patterns. The present study, therefore, investigates reciprocal associations between sleep, mental strain, and training load by utilizing a prospective, observational design. In all, 56 junior endurance athletes were followed over 61 consecutive days. Unobtrusive, objective measurements of sleep with novel radar technology were obtained, and subjective daily reports of mental strain and training load were collected. The role of subjective sleep quality was investigated to identify whether the reciprocal associations between sleep, mental strain, and training load depended on being a good versus poor sleeper. Multilevel modeling with Bayesian estimation was used to investigate the relationships. The results show that increases in mental strain are associated with decreased total sleep time (TST, 95% CI = -0.12 to -0.03), light sleep (95% CI = -0.08 to -0.00), and sleep efficiency (95% CI = -0.95 to -0.09). Further, both mental strain and training load are associated with subsequent deceased rapid eye movement (REM, respectively, 95% CI = -0.05 to -0.00 and 95% CI = -0.06 to -0.00) sleep. Increases in TST, light, deep, and REM sleep are all associated with subsequent decreased training load (respectively, 95% CI = -0.09 to -0.03; 95% CI = -0.10 to -0.01; 95% CI = -0.22 to -0.02; 95% CI = -0.18 to -0.03). Finally, among poor sleepers, increases in sleep onset latency are associated with increases in subsequent mental strain (95% CI = 0.09-0.46), and increases in deep sleep are associated with decreases in subsequent training load (95% CI = -67.65 to 11.43). These results offer novel insight into the bidirectional associations between sleep, mental strain, and training load in athletes and demonstrate the detrimental effects of mental strain on sleep, likely caused by mental activation incompatible with sleep. An increased need for recovery, suggested by increased TST and time in different sleep stages, is associated with subsequent self-regulatory reduction of training loads by the athletes. In poor sleepers, increases in deep sleep may suggest an elevated need for physiological recovery.

Adult NREM Parasomnias: An Update.

Our understanding of non-rapid eye movement (NREM) parasomnias has improved considerably over the last two decades, with research that characterises and explores the causes of these disorders. However, our understanding is far from complete. The aim of this paper is to provide an updated review focusing on adult NREM parasomnias and highlighting new areas in NREM parasomnia research from the recent literature. We outline the prevalence, clinical characteristics, role of onset, pathophysiology, role of predisposing, priming and precipitating factors, diagnostic criteria, treatment options and medico-legal implications of adult NREM parasomnias.

Unique Predictors of Sleep Quality in Junior Athletes: The Protective Function of Mental Resilience, and the Detrimental Impact of Sex, Worry and Perceived Stress.

Since athletic development and functioning are heavily dependent on sufficient recuperation, sleep in athletes is becoming a topic of increasing interest. Still, existing scientific evidence points to inadequate sleep in athletes, especially in females. This may be due to the fact that sleep is vulnerable to disturbances caused by stress and cognitive and emotional reactions to stress, such as worry and negative affect, which may exacerbate and prolong the stress response. Such disturbing factors are frequently experienced by junior athletes aiming for performance development and rise in the rankings, but may be damaging to athletic progression. Based on limited research in non-athletic samples, mental resilience may protect individuals against the detrimental effects of stress on sleep. Therefore, the present study aimed to investigate the extent to which sex, mental resilience, emotional (negative affect) and cognitive (worry) reactions to stress, and perceived stress, uniquely contributed to sleep quality in a cross-sectional study including 632 junior athletes. A multiple hierarchical linear regression showed that females had poorer sleep quality than males, while the mental resilience sub-components Social Resources and Structured Style were positively associated with sleep quality, providing a protective function and thus preventing sleep quality from deteriorating. Simultaneously, worry, as well as perceived stress, were negatively associated with sleep quality. Together, the independent variables explained 28% of the variance in sleep quality. A dominance analysis showed that perceived stress had the largest relative relationship with sleep quality. Based on these results, close attention should be paid to athletes' abilities to manage worry and perceived stress, and the potential of mental resilience as a protective factor that could prevent sleep from deteriorating. The latter might be especially relevant for female athletes. Since performance margins are progressively becoming smaller and smaller, every improvement that adequate sleep can provide will be beneficial in terms of improved functioning and athletic performance.

Identifying Unique Contributions of the Coach-Athlete Working Alliance, Psychological Resilience and Perceived Stress on Athlete Burnout among Norwegian Junior Athletes.

The main purpose of the current study was to examine how the coach-athlete working alliance, psychological resilience and perceived stress are uniquely associated with burnout among junior athletes in sport. A sample of 670 Norwegian junior athletes practicing a variety of sports participated in the study. A hierarchical multiple regression analysis showed that the bond dimension of the working alliance, the protective factors 'planned future' and 'structured style', as well as perceived stress, all contributed uniquely to the explanation of athlete burnout. A dominance analysis identified perceived stress to have the strongest relative influence on athlete burnout among the set of variables investigated in this study. The findings are discussed in terms of applied implications and possible future research.

Burnout and Perceived Performance Among Junior Athletes-Associations with Affective and Cognitive Components of Stress.

The current study investigated associations between cognitive components such as psychological resilience and perceived stress, and affective components such as positive and negative affect, and athlete burnout and perceived performance among 670 Norwegian junior athletes attending high schools specialized for sports. A hypothesized model of the relations between the constructs was analyzed by structural equation modeling (SEM). The results in the current study show that athlete resilience is a key in understanding athlete burnout and perceived performance, and that cognitive (perceived stress) and affective reactions (negative and positive affect) are important mediators in this process.