Behavioural therapy for shift work disorder improves shift workers' sleep, sleepiness and mental health: A pilot randomised control trial.

The present study evaluates the efficacy of behavioural therapy adapted for shift work disorder with a randomised control design in a healthcare population. Forty-three night shift workers (m. age: 34 years; 77% women) experiencing shift work disorder were randomised to either the behavioural therapy for shift work disorder (BT-SWD) or a waiting-list control group offered after the waiting period. Participants completed questionnaires on insomnia, sleepiness and mental health pre- and post-treatment, pre- and post-waiting, and at follow-up, and a sleep diary. As night shift workers alternate between sleeping during the day after their night shifts and transitioning to nighttime sleep on days off, insomnia severity and sleep variables were analysed for daytime and nighttime sleep. The BT-SWD involved sleep restriction therapy, stimulus control and fixed sleep periods in the dark. Statistical analyses were performed under intent-to-treat and per-protocol approaches. Repeated-measures two-way ANCOVA analysis, controlling for age, sex and pre-treatment daytime total sleep time, was performed with Bonferroni corrections, and between-group effect sizes computed. Fourteen participants dropped out after randomisation. Under the intent-to-treat analysis, BT-SWD participants had a significant greater decrease in daytime insomnia severity and an increase in daytime total sleep time at post-treatment than the control group, with large between-group effect sizes (-1.25 and 0.89). These corresponding results were also significant with large effect sizes under the per-protocol analysis. Sleepiness, anxiety and depression levels improved at post-treatment and maintained at follow-up when the BT-SWD treated controls were added to the BT-SWD group. The behavioural therapy for shift work disorder can be used to improve the sleep and mental health of healthcare night workers.

Insomnia.

Insomnia is highly prevalent in clinical practice, occurring in up to 50% of primary care patients. Insomnia can present independently or alongside other medical conditions or mental health disorders and is a risk factor for the development and exacerbation of these other disorders if not treated. In 2016, the American College of Physicians recommended that insomnia be specifically targeted for treatment. The recommended first-line treatment for insomnia, whether the underlying cause has been identified or not, is cognitive behavioural therapy for insomnia (CBT-I). Currently, there is no global consensus regarding which pharmacological treatment has the best efficacy or risk-benefit ratio. Both CBT-I and pharmacological intervention are thought to have similar acute effects, but only CBT-I has shown durable long-term effects after treatment discontinuation. Administering a combined treatment of CBT-I and medication could decrease the latency to treatment response, but might diminish the durability of the positive treatment effects of CBT-I.

Mechanisms of cognitive behavioural therapy for insomnia.

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

The effectiveness of stimulus control in cognitive behavioural therapy for insomnia in adults: A systematic review and network meta-analysis.

Stimulus control is part of the widely used cognitive behavioural therapy for insomnia. However, there is a lack of knowledge about its mechanisms of action and effectiveness when used alone. This systematic review with network meta-analysis aimed to evaluate stimulus control efficacy when used alone compared with cognitive behavioural therapy for insomnia or its components. The review also documented stimulus control mechanisms of action proposed by the authors. A search was conducted in several bibliographic databases (MEDLINE, PsycINFO, Embase, CINAHL, Psychology Behavioural Sciences Collection, Web of Science, and Cochrane Library) and in two registers from 1972 to June 2022. Randomised studies with adult participants presenting a diagnosis of insomnia and including at least one stimulus control instruction in a treatment group were included. Risk of bias was assessed with the Quality Assessment of Controlled Intervention Studies. Twenty-three studies were included and three network meta-analyses were conducted. The quality of included studies was generally poor. Results indicate that stimulus control is an effective intervention to improve insomnia compared with control conditions. Not all stimulus control instructions seem essential, especially those known to recondition the bedroom for sleep. The review challenges the classical conditioning hypothesis. Results should be interpreted cautiously given the small number of studies included, bias risk, and inconsistencies in the network meta-analysis. Rigorous research is needed in evaluating stimulus control efficacy and mechanisms.

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

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Nightmare content during the COVID-19 pandemic: Influence of COVID-related stress and sleep disruption in the United States.

Nightmares are often associated with psychiatric disorders and acute stress. This study explores how the COVID-19 pandemic may have influenced the content of nightmares. A sample of N = 419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked about the degree to which they agreed with statements linking greater general stress, worse overall sleep and more middle-of-the-night insomnia with the COVID-19 pandemic. They were also asked if, during the pandemic, they experienced nightmares related to various themes. Logistic regression analyses examined each nightmare content as outcome and increased stress, worse sleep and more middle-of-the-night insomnia as predictors, adjusted for age, sex and race/ethnicity. Those who reported greater general COVID-related stress were more likely to have nightmares about confinement, failure, helplessness, anxiety, war, separation, totalitarianism, sickness, death, COVID and an apocalypse. Those who reported worsened sleep were more likely to have nightmares about confinement, oppression, failure, helplessness, disaster, anxiety, evil forces, war, domestic abuse, separation, totalitarianism, sickness, death, COVID and an apocalypse. Those who reported worsened middle-of-the-night insomnia were more likely to have nightmares about confinement, oppression, failure, helplessness, disaster, anxiety, war, domestic abuse, separation, totalitarianism, sickness, death, COVID and an apocalypse. These results suggest that increased pandemic-related stress may induce negatively-toned dreams of specific themes. Future investigation might determine whether (and when) this symptom indicates an emotion regulation mechanism at play, or the failure of such a mechanism.

Pandémie COVID-19, sommeil et séquelles psychologiques: au nom du Réseau canadien du sommeil et des rythmes circadiens* et de la Société canadienne du sommeil*.

Les données recueillies lors de crises et tragédies passées prouvent que les problèmes de sommeil survenant durant ou peu de temps après un événement traumatique sont reliés à une probabilité accrue de développer des symptômes psychiatriques durables. Or la pandémie COVID-19 et ses conséquences à moyen et long-terme combinent plusieurs facteurs de risque pour le sommeil, tant pour les intervenants de la santé que la population générale. Notre relevé mensuel des publications scientifiques qui combinent COVID-19 et sommeil/insomnie entre janvier et juillet 2020 révèle un taux de croissance comparable pour les articles qui portent plus précisément sur la santé mentale mais aucune ne porte sur les résultats d'une intervention. Nous proposons qu'il faille agir rapidement sur les difficultés de sommeil en cette période de pandémie afin de protéger l'équilibre psychologique individuel à moyen et long terme, d'autant plus que les outils nécessaires à la prévention de l'insomnie, sa détection et son traitement sont à la portée de tous les professionnels de la santé mentale.

Managing Insomnia Using Lucid Dreaming Training: A Pilot Study.

Objectives/Background: Despite Cognitive Behavioral Therapy for Insomnia (CBT-I) being considered the first-line treatment for insomnia, it is not without its challenges. As such it is worthwhile to consider, and test, alternative or adjuvant management options. Methods/Participants: The aim of the present study was to examine whether Lucid Dreaming Training for insomnia (LDT-I) impacted on insomnia, depressive and anxious symptomology in an open label trial of 48 adults with Insomnia Disorder. Participants completed the Insomnia Severity Index, General Anxiety Disorder-7 and Patient Health Questionnaire at baseline then one month following LDT-I. Training consisted of four modules delivered over a period of two consecutive weeks. Results: The results suggest, albeit preliminarily, that LDT-I may have a place within the non-pharmacological management of insomnia, as there were significant reductions in insomnia severity (t(46) = 8.16,p <.001), anxious symptomology (t(46) = 4.75,p <.001) and depressive symptomology (t(46) = 5.87,p <.001). Further, the effect size in terms of pre-post reductions on ISI scores was large (dz 1.17). Conclusions: Whilst the results are promising, further testing of LDT-I is needed to inform its place amongst the non-pharmacological treatments for insomnia.

Insomnia does not affect heart rate changes when young adults watch humorous films: An exploratory study.

Emotional reactivity in insomnia is affected both subjectively and on a physiological level for negative emotional material, but little is known about reactions to positive stimuli. We here investigated whether in younger adult insomnia patients, presentation of short humorous films would lead to heart rate decreases during and after film viewing, as compared to heart rate changes when falling asleep. Investigating 20 participants with DSM-5-diagnosed insomnia and 18 participants without insomnia, we found that heart rate decreased when falling asleep, increased when watching humorous films and returned to normal values afterwards for all participants. Film-related heart rate increases were strongly related to humour ratings of the films. No differences were found between those with and without insomnia on subjective ratings of the films, film-related heart rate changes or when falling asleep. We conclude that the experience of positive daily life stimuli in younger adults is not affected by insomnia in our study, despite insomnia having a known more profound effect on negative stimuli. Future studies exploring insomnia-related autonomous nervous system responses combining different neurophysiological modalities should confirm our findings.

The key role of insomnia and sleep loss in the dysregulation of multiple systems involved in mood disorders: A proposed model.

Mood disorders are amongst the most prevalent and severe disorders worldwide, with a tendency to be recurrent and disabling. Although multiple mechanisms have been hypothesized to be involved in their pathogenesis, just a few integrative theoretical frameworks have been proposed and have yet to integrate comprehensively all available findings. As such, a comprehensive framework would be quite useful from a clinical and therapeutic point of view in order to identify elements to evaluate and target in the clinical practice. Because conditions of sleep loss, which include reduced sleep duration and insomnia, are constant alterations in mood disorders, the aim of this paper was to review the literature on their potential role in the pathogenesis of mood disorders and to propose a novel theoretical model. According to this hypothesis, sleep should be considered the main regulator of several systems and processes whose dysregulation is involved in the pathogenesis of mood disorders. The model may help explain why sleep disturbances are so strikingly linked to mood disorders, and underscores the need to evaluate, assess and target sleep disturbances in clinical practice, as a priority, in order to prevent and treat mood disorders.

Using heart rate profiles during sleep as a biomarker of depression.

BACKGROUND: Abnormalities in heart rate during sleep linked to impaired neuro-cardiac modulation may provide new information about physiological sleep signatures of depression. This study assessed the validity of an algorithm using patterns of heart rate changes during sleep to discriminate between individuals with depression and healthy controls. METHODS: A heart rate profiling algorithm was modeled using machine-learning based on 1203 polysomnograms from individuals with depression referred to a sleep clinic for the assessment of sleep abnormalities, including insomnia, excessive daytime fatigue, and sleep-related breathing disturbances (n = 664) and mentally healthy controls (n = 529). The final algorithm was tested on a distinct sample (n = 174) to categorize each individual as depressed or not depressed. The resulting categorizations were compared to medical record diagnoses. RESULTS: The algorithm had an overall classification accuracy of 79.9% [sensitivity: 82.8, 95% CI (0.73-0.89), specificity: 77.0, 95% CI (0.67-0.85)]. The algorithm remained highly sensitive across subgroups stratified by age, sex, depression severity, comorbid psychiatric illness, cardiovascular disease, and smoking status. CONCLUSIONS: Sleep-derived heart rate patterns could act as an objective biomarker of depression, at least when it co-occurs with sleep disturbances, and may serve as a complimentary objective diagnostic tool. These findings highlight the extent to which some autonomic functions are impaired in individuals with depression, which warrants further investigation about potential underlying mechanisms.

Sleep Spindles Characteristics in Insomnia Sufferers and Their Relationship with Sleep Misperception.

Cortical hyperarousal is higher in insomnia sufferers (INS) than in good sleepers (GS) and could be related to an alteration in sleep protection mechanisms, like reduced density or altered characteristics in sleep spindles. The deficient sleep protection mechanisms might in turn enhance underestimation of sleep. This study's objective was to document sleep spindles characteristics in INS compared with GS and to investigate their potential role in sleep consolidation and misperception. Seventeen individuals with paradoxical insomnia (PARA-I), 24 individuals with psychophysiological insomnia (PSY-I), and 29 GS completed four consecutive polysomnographic nights in laboratory. Sleep spindles were detected automatically during stage 2 and SWS (3-4) on night 3. Number, density, duration, frequency, and amplitude of sleep spindles were calculated. A misperception index was used to determine the degree of discrepancy between subjective and objective total sleep times. Kruskal-Wallis H tests and post hoc tests revealed that PARA-I had significantly shorter sleep spindles than GS but that PSY-I and GS did not differ on spindles length. A standard multiple regression model revealed that neither sleep spindles characteristics nor objective sleep measures were predictive of sleep misperception. A longer duration of spindles could reflect a higher gating process but this hypothesis still needs to be confirmed in replication studies.

Sleep spindles and rapid eye movement sleep as predictors of next morning cognitive performance in healthy middle-aged and older participants.

Spindles and slow waves are hallmarks of non-rapid eye movement sleep. Both these oscillations are markers of neuronal plasticity, and play a role in memory and cognition. Normal ageing is associated with spindle and slow wave decline and cognitive changes. The present study aimed to assess whether spindle and slow wave characteristics during a baseline night predict cognitive performance in healthy older adults the next morning. Specifically, we examined performance on tasks measuring selective and sustained visual attention, declarative verbal memory, working memory and verbal fluency. Fifty-eight healthy middle-aged and older adults (aged 50-91 years) without sleep disorders underwent baseline polysomnographic sleep recording followed by neuropsychological assessment the next morning. Spindles and slow waves were detected automatically on artefact-free non-rapid eye movement sleep electroencephalogram. All-night stage N2 spindle density (no./min) and mean frequency (Hz) and all-night non-rapid eye movement sleep slow wave density (no./min) and mean slope (µV/s) were analysed. Pearson's correlations were performed between spindles, slow waves, polysomnography and cognitive performance. Higher spindle density predicted better performance on verbal learning, visual attention and verbal fluency, whereas spindle frequency and slow wave density or slope predicted fewer cognitive performance variables. In addition, rapid eye movement sleep duration was associated with better verbal learning potential. These results suggest that spindle density is a marker of cognitive functioning in older adults and may reflect neuroanatomic integrity. Rapid eye movement sleep may be a marker of age-related changes in acetylcholine transmission, which plays a role in new information encoding.

Subjective sleep quality in non-demented older adults with and without cognitive impairment.

OBJECTIVE: Sleep problems are prevalent among older adults who are at risk of developing dementia. Until now, there have been relatively few studies investigating subjective sleep quality in these individuals. The first objective of this study was to compare seniors with cognitive impairment no dementia (CIND) and older adults without cognitive impairment (non-CIND) on several subjective sleep measures. The second objective was to verify whether sleep parameters associated with CIND differ between men and women. METHODS: The population sample consisted of 2287 French-speaking older adults from Québec (Canada) aged between 65 and 96 years. Participants were classified as CIND or non-CIND on the basis of their mini mental state examination score using sex, age, and education-stratified normative data. All participants completed the Pittsburgh Sleep Quality Index, and responses of CIND and non-CIND individuals were compared. A series of confounding variables (age, education, chronic diseases, mood disorders, anxiety disorders, and use of psychotropic drugs) were statistically controlled for. Student's t-tests were performed to compare characteristics of CIND and non-CIND individuals; data from male and female participants were analyzed separately. Moreover, the association between each sleep variable and CIND was measured by odds ratios based on logistic regression. RESULTS: On the whole, analyses revealed no significant association between subjective sleep parameters and CIND. Moreover, no difference was observed between men and women regarding subjective sleep quality. CONCLUSIONS: Overall, these results suggest that subjective measures of sleep do not allow differentiating cognitively impaired older individuals from those with normal cognition.

The relationships between insomnia, nightmares, and dreams: A systematic review.

Insomnia and nightmares are both prevalent and debilitating sleep difficulties. The present systematic review aims to document the relationships between insomnia and nightmares in individuals without a concomitant psychopathology. The relationships between insomnia and dreams are also addressed. PsycINFO and Medline were searched for papers published in English or French from 1970 to March 2023. Sixty-seven articles were included for review. Most results support positive relationships between insomnia variables and nightmare variables in individuals with insomnia, individuals with nightmares, the general population, students, children and older adults, and military personnel and veterans. These positive relationships were also apparent in the context of the COVID-19 pandemic. Some psychological interventions, such as Imagery Rehearsal Therapy, might be effective in alleviating both nightmares and insomnia symptoms. Regarding the relationships between insomnia and dreams, compared with controls, the dreams of individuals with insomnia are characterized by more negative contents and affects. The results show that insomnia and nightmares are connected and may be mutually aggravating. A model is proposed to explain how insomnia might increase the likelihood of experiencing nightmares, and how nightmares can in turn lead to sleep loss and nonrestorative sleep.

Reduced rapid eye movement sleep in late middle-aged and older apolipoprotein E ɛ4 allele carriers.

STUDY OBJECTIVES: Apolipoprotein E ɛ4 (APOE4) is the strongest genetic risk factor for Alzheimer's disease (AD). In addition, APOE4 carriers may exhibit sleep disturbances, but conflicting results have been reported, such that there is no clear consensus regarding which aspects of sleep are impacted. Our objective was to compare objective sleep architecture between APOE4 carriers and non-carriers, and to investigate the modulating impact of age, sex, cognitive status, and obstructive sleep apnea (OSA). METHODS: A total of 198 dementia-free participants aged >55 years old (mean age: 68.7 ± 8.08 years old, 40.91% women, 41 APOE4 carriers) were recruited in this cross-sectional study. They underwent polysomnography, APOE4 genotyping, and a neuropsychological evaluation. ANCOVAs assessed the effect of APOE4 status on sleep architecture, controlling for age, sex, cognitive status, and the apnea-hypopnea index. Interaction terms were added between APOE4 status and covariates. RESULTS: Rapid eye movement (REM) sleep percentage (F = 9.95, p = .002, ηp2 = 0.049) and duration (F = 9.23, p = .003, ηp2 = 0.047) were lower in APOE4 carriers. The results were replicated in a subsample of 112 participants without moderate-to-severe OSA. There were no significant interactions between APOE4 status and age, sex, cognitive status, and OSA in the whole sample. CONCLUSIONS: Our results show that APOE4 carriers exhibit lower REM sleep duration, including in cognitively unimpaired individuals, possibly resulting from early neurodegenerative processes in regions involved in REM sleep generation and maintenance.

Information processing varies between insomnia types: measures of N1 and P2 during the night.

This study compared cortical arousal mechanisms during the night using event-related potentials (N1 and P2), and compared sleep misperception in 30 adults with psychophysiological insomnia (Psy-I), 28 adults with paradoxical insomnia (Para-I), and 30 good sleepers (GS). Participants (age range = 25-55 years) spent 4 consecutive nights in the laboratory, and Night-4 data were used for analysis. N1 amplitude was generally larger in both insomnia groups compared to GS, and P2 amplitude was larger in Para-I than in the 2 other groups, especially in REM sleep. Results suggest that, although hyperarousal appears to persist during sleep in adults with insomnia, inhibition deficits are more likely to be present in Para-I compared to Psy-I.

Partner Alliance to Enhance Efficacy and Adherence of CBT-I.

Cognitive behavioral therapy for insomnia (CBT-I) is now widely recognized as the first-line management strategy for insomnia, both for insomnia in its "pure" form, and when comorbid with a physical or psychological illness. However, there is a definite need to develop and test both alternative and adjunct interventions to CBT-I, before implementing them into routine practice. The aim of this article is to provide a narrative review of the literature with regard to what is known about the influence of partners on sleep, insomnia, and its management.

REM sleep is associated with the volume of the cholinergic basal forebrain in aMCI individuals.

BACKGROUND: Rapid-eye movement (REM) sleep highly depends on the activity of cholinergic basal forebrain (BF) neurons and is reduced in Alzheimer's disease. Here, we investigated the associations between the volume of BF nuclei and REM sleep characteristics, and the impact of cognitive status on these links, in late middle-aged and older participants. METHODS: Thirty-one cognitively healthy controls (66.8 ± 7.2 years old, 13 women) and 31 participants with amnestic Mild Cognitive Impairment (aMCI) (68.3 ± 8.8 years old, 7 women) were included in this cross-sectional study. All participants underwent polysomnography, a comprehensive neuropsychological assessment and Magnetic Resonance Imaging examination. REM sleep characteristics (i.e., percentage, latency and efficiency) were derived from polysomnographic recordings. T1-weighted images were preprocessed using CAT12 and the DARTEL algorithm, and we extracted the gray matter volume of BF regions of interest using a probabilistic atlas implemented in the JuBrain Anatomy Toolbox. Multiple linear regressions were performed between the volume of BF nuclei and REM sleep characteristics controlling for age, sex and total intracranial volume, in the whole cohort and in subgroups stratified by cognitive status. RESULTS: In the whole sample, lower REM sleep percentage was significantly associated to lower nucleus basalis of Meynert (Ch4) volume (ß = 0.32, p = 0.009). When stratifying the cohort according to cognitive status, lower REM sleep percentage was significantly associated to both lower Ch4 (ß = 0.48, p = 0.012) and total BF volumes (ß = 0.44, p = 0.014) in aMCI individuals, but not in cognitively unimpaired participants. No significant associations were observed between the volume of the BF and wake after sleep onset or non-REM sleep variables. DISCUSSION: These results suggest that REM sleep disturbances may be an early manifestation of the degeneration of the BF cholinergic system before the onset of dementia, especially in participants with mild memory deficits.

Sleep Health, Individual Characteristics, Lifestyle Factors, and Marathon Completion Time in Marathon Runners: A Retrospective Investigation of the 2016 London Marathon.

Despite sleep health being critically important for athlete performance and well-being, sleep health in marathoners is understudied. This foundational study explored relations between sleep health, individual characteristics, lifestyle factors, and marathon completion time. Data were obtained from the 2016 London Marathon participants. Participants completed the Athlete Sleep Screening Questionnaire (ASSQ) along with a brief survey capturing individual characteristics and lifestyle factors. Sleep health focused on the ASSQ sleep difficulty score (SDS) and its components. Linear regression computed relations among sleep, individual, lifestyle, and marathon variables. The analytic sample (N = 943) was mostly male (64.5%) and young adults (66.5%). A total of 23.5% of the sample reported sleep difficulties (SDS ≥ 8) at a severity warranting follow-up with a trained sleep provider. Middle-aged adults generally reported significantly worse sleep health characteristics, relative to young adults, except young adults reported significantly longer sleep onset latency (SOL). Sleep tracker users reported worse sleep satisfaction. Pre-bedtime electronic device use was associated with longer SOL and longer marathon completion time, while increasing SOL was also associated with longer marathon completion. Our results suggest a deleterious influence of pre-bedtime electronic device use and sleep tracker use on sleep health in marathoners. Orthosomnia may be a relevant factor in the relationship between sleep tracking and sleep health for marathoners.