Implementation of a teen sleep app in Canadian high schools: Preliminary evidence of acceptability, engagement, and capacity for supporting healthy sleep habits.

High school students suffer from mental health challenges and poorer academic performance resulting from sleep disturbances. Unfortunately, approaches to this problem sometimes focus on increasing sleep duration by going to bed early; a strategy with limited success because teens experience a phase delay in bedtimes. There is a need for approaches that leverage behavioural sleep science and are accessible, scalable, and easily disseminated to students. DOZE (Delivering Online Zzz's with Empirical Support) is a self-management app that is grounded in sleep and circadian basic science. Although initial testing supports it as a feasible and acceptable app in a research context, it has not been tested as a strategy to use in schools. The present study tested DOZE in private high schools in Canada. Two-hundred and twenty-three students downloaded the app and completed daily sleep diaries over 4 weeks. Students reported a more regularised routine for bedtime, Mdiff = -0.43 h, p < 0.001, 95% CI [-0.65, -0.21], and rise time, Mdiff = -0.61 h, p < 0.001, 95% CI [-0.84, -0.38], in addition to a higher total sleep time, Mdiff = 0.18 h, p < 0.008, 95% CI [0.05, 0.31]. Students also rated DOZE to be highly acceptable. The evidence suggests that students find DOZE to be acceptable and engagement in this nonclinical population was reasonably high under minimal researcher supervision. This makes DOZE an attractive option and a step towards broad-based sleep health services. High powered replications with control groups are needed to increase empirical rigour.

Conceptual overlap of negative thought processes in insomnia: A focus on catastrophizing, worry, and rumination in a student sample.

OBJECTIVES: The association and overlap between different forms of negative thought processes in insomnia is largely unknown. The purpose of the current investigation was to examine conceptual overlap between three insomnia-specific negative thought processes; catastrophizing, worry, and rumination, identify the underlying factors, and explore their associations with insomnia symptoms. METHODS: A total of 360 students completed three insomnia-related negative thought process scales (Catastrophic Thoughts about Insomnia Scale, Anxiety and Preoccupation about Sleep Questionnaire, Daytime Insomnia Symptom Response Scale) and two insomnia symptoms measures (the Insomnia Severity Index and Sleep Condition Indicator). RESULTS: The three scales and their subscales displayed acceptable reliabilities. Further, confirmatory factor analysis was supportive of the notion of catastrophizing, worry, and rumination measures as distinct. The catastrophizing and worry constructs were significantly associated with insomnia symptoms, but the rumination factor was not. CONCLUSIONS: The findings indicate that catastrophizing, worry, and rumination might be viewed as distinct constructs. Although more research is warranted on the topic of conceptual overlap, the current results might have implications for the development of models of insomnia, clinical research, and practice.

An Investigation of Further Strategies to Optimize Early Treatment Gains in Brief Therapies for Insomnia.

OBJECTIVES: Identifying those who are most (and least) likely to benefit from a stepped-care approach to cognitive behavioral therapy for insomnia (CBT-I) increases access to insomnia therapies while minimizing resource consumption. The present study investigates non-targeted factors in a single-session of CBT-I that may act as barriers to early response and remission. METHODS: Participants (N = 303) received four sessions of CBT-I and completed measures of subjective insomnia severity, fatigue, sleep-related beliefs, treatment expectations, and sleep diaries. Subjective insomnia severity and sleep diaries were completed between each treatment session. Early response was defined as a 50% reduction in Insomnia Severity Index (ISI) scores and early remission was defined by < 10 on the ISI after the first session. RESULTS: A single-session of CBT-I significantly reduced subjective insomnia severity scores and diary total wake time. Logistic regression models indicated that lower baseline fatigue was associated with increased odds of early remission (B = -.05, p = .02), and lower subjective insomnia severity (B = -.13, p = .049). Only fatigue was a significant predictor of early treatment response (B = -.06, p = .003). CONCLUSIONS: Fatigue appeared to be an important construct that dictates early changes in perceived insomnia severity. Beliefs about the relationship between sleep and daytime performance may hinder perceived improvements in insomnia symptoms. Incorporating fatigue management strategies and psychoeducation about the relationship between sleep and fatigue may target non-early responders. Future research would benefit from further profiling potential early insomnia responders/remitters.

Anxiolytic impact of cognitive behavioural therapy for insomnia in patients with co-morbid insomnia and generalized anxiety disorder.

BACKGROUND: Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia that also improves non-sleep symptoms, such as mood and anxiety. Identifying sleep-specific variables that predict anxiety change after CBT-I treatment may support alternative strategies when people with generalized anxiety disorder (GAD) do not improve from standard GAD treatment. AIMS: To investigate CBT-I on changes in anxiety and evaluate whether changes in sleep-specific variables predict anxiety outcomes. METHODS: Seventy-two participants presenting with insomnia and GAD (GAD-I) completed four sessions of CBT-I. Participants completed daily diaries and self-report measures at baseline and post-treatment. RESULTS: CBT-I in a co-morbid GAD-I sample was associated with medium reductions in anxiety, and large reductions in insomnia severity. Subjective insomnia severity and tendencies to ruminate in response to fatigue predicted post-treatment anxiety change, in addition to younger age and lower baseline anxiety. CONCLUSIONS: The findings suggest that younger GAD-I participants with moderate anxiety symptoms may benefit most from the anxiety-relieving impact of CBT-I. Reducing perceived insomnia severity and the tendency to ruminate in response to fatigue may support reductions in anxiety in those with GAD-I.

Cognitive factors and processes in models of insomnia: A systematic review.

Cognition is central to the experience of insomnia. Although unhelpful thoughts about and around insomnia are a primary treatment target of cognitive behaviour therapy for insomnia, cognitive constructs are termed and conceptualised differently in different theories of insomnia proposed over the past decades. In search of consensus in thinking, the current systematic review identified cognitive factors and processes featured in theoretical models of insomnia and mapped any commonality between models. We systematically searched PsycINFO and PubMed for published theoretical articles on the development, maintenance and remission of insomnia, from inception of databases to February, 2023. A total of 2458 records were identified for title and abstract screening. Of these, 34 were selected for full-text assessment and 12 included for analysis and data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified nine distinguishable models of insomnia published between 1982 and 2023 and extracted 20 cognitive factors and processes featured in these models; 39 if sub-factors were counted. After assigning similarity ratings, we observed a high degree of overlap between constructs despite apparent differences in terminologies and measurement methods. As a result, we highlight shifts in thinking around cognitions associated with insomnia and discuss future directions.

Examining whether Changes in Sleep Habits Predict Long-Term Sustainment of Treatment Gains in Individual Remitted from Insomnia after CBT-I.

OBJECTIVES: Providers of Cognitive-Behavioral Therapy for Insomnia (CBT-I) are often asked whether the behavioral recommendations (e.g., stimulus control, sleep restriction) must be adhered to ad infinitum. We examined whether changes in sleep habits/behaviors are a life sentence, or whether patients who remit can relax their adherence while maintaining their treatment gains at 1-year follow-up (FU). METHODS: Participants (N = 179) completed 2 weeks of sleep diaries and measures of insomnia severity and safety behaviors at baseline and following four sessions of CBT-I. Of the 137 patients that achieved remission, 77 completed these measures at 1-year FU. RESULTS: Improvements in insomnia severity and total wake time (TWT) at post-treatment were maintained at FU (ps ≥ .52). Similarly, reductions in safety behaviors were maintained at FU (p - 1.00), whereas lingering in bed reduced during treatment (p < .001) but increased at FU (p < .001). Changes in sleep habits after treatment did not predict insomnia severity at FU. However, increases in time in bed positively predicted TWT at FU (p = .001). CONCLUSIONS: Those who remit after CBT-I may generally relax their adherence to behavioral recommendations without significantly impacting their perceived insomnia symptoms 1 year after treatment despite some increases in TWT. Results increase our confidence in CBT-I as a brief and durable intervention.

Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause.

OBJECTIVES: Insomnia is frequently reported by women during menopause due to physiological changes and environmental factors and is associated with negative daytime sequelae. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments for menopausal insomnia. The primary objective of this review is to review the efficacy of cognitive-behavioral, behavioral, and mindfulness-based (CBBMB) therapies in treating insomnia in peri- and post-menopausal women. The secondary objective is to review the effect of CBBMB therapies on relevant secondary outcomes to gain a comprehensive understanding of their impacts. METHODS: We conducted a narrative review of the literature. A search of PubMed and Google Scholar was conducted between January 2020 and March 2021. RESULTS: Cognitive-behavioral therapy (CBT) for insomnia is efficacious, with corollary improvements in mood, functional outcomes and potential mechanistic factors (e.g., unhelpful beliefs). Sleep restriction therapy is also efficacious, with somewhat poorer effects on secondary outcomes relative to CBT. Mindfulness meditation and relaxation for insomnia demonstrated promise, but its long-term effects remain unknown. CONCLUSIONS: Research with more diverse samples and head-to-head comparisons is needed. Dissemination of CBBMBs for insomnia in clinics where menopausal women seek care is an important next step.

Insomnia Symptoms, Subjective Appraisals, and Fatigue: A Multiple Mediation Model.

OBJECTIVE AND BACKGROUND: Fatigue and insomnia are common debilitating symptoms associated with multiple sclerosis (MS). Negative subjective appraisals of symptoms may influence both insomnia and fatigue severity, but this relationship has not been examined among those with MS. The relationship between insomnia symptoms and both physical and cognitive fatigue were examined. Health-related self-efficacy, fatigue catastrophization, and rumination were examined as potential mediators of the relationship between insomnia symptoms and fatigue. PARTICIPANTS: Participants diagnosed with MS (N = 115) were recruited from hospital and community settings in a large metropolitan city. METHODS: Participants completed self-report questionnaires, including: Modified Fatigue Impact, Insomnia Severity Index, MS Quality of Life Questionnaire-54, Fatigue Catastrophizing Scale, Multidimensional Health Locus of Control Scale, and the Rumination-Reflection Questionnaire. Two multiple mediation analyses were performed using bootstrapping techniques, examining the cognitive and physical domains of fatigue as separate outcomes. RESULTS AND CONCLUSIONS: Mediation analyses revealed a significant association between insomnia symptom severity and the cognitive and physical domains of fatigue. Fatigue catastrophizing was the only significant mediator, accounting for 25% of the variance in the relationship between insomnia symptoms and the cognitive fatigue. However, fatigue catastrophizing did not significantly mediate the relationship between insomnia symptoms and physical fatigue, indicating physical and cognitive fatigue may reflect distinct processes in fatigue expression in those with MS.

Psychometric Properties of the Consensus Sleep Diary in Those With Insomnia Disorder.

The Consensus Sleep Diary (CSD) is a standardized, prospective tool for tracking nightly subjective sleep. The current study evaluated the validity and utility of the CSD, with consideration for challenges inherent to psychometric evaluation of diary measures. Results showed that the CSD indices differentiated good sleepers from those with insomnia and were associated with similar objective indices and a subjective insomnia severity measure. The ability to detect treatment improvements after cognitive behavior therapy for insomnia (CBT-I) was tested by comparing pre- and post-CBT-I CSD indices with a subjective rating of insomnia symptom severity. Improvement in insomnia symptom severity was significantly related to improvement on the CSD indices. Completion rate of the CSD amongst participants across all 14 days was 99.8%. These findings provide support for the validity, clinical utility, and usability of the CSD.

Daytime rumination as a feature of Insomnia Disorder: sleep related cognition is not merely a problem of the night.

Night-time sleep related cognitions have been shown to play a perpetuating role in insomnia. According to the cognitive model of insomnia day time cognitions (i.e. worry, rumination, etc.) may also contribute to it. The aim of this study was to investigate the possible role of daytime sleep-related rumination in Insomnia Disorder (n= 55, mean age 49.7±16.7 years), Obstructive Sleep Apnea Syndrome (OSAS) (n=33, mean age 58.1±10.2 years) and healthy subjects (n=33, mean age 49.8±13.9), using a set of sleep related variables which included the Daytime Insomnia Symptom Response Scale (DISRS), the Dysfunctional Beliefs about Sleep Scale (DBAS), the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). Daytime sleep related rumination was higher in insomnia when compared to both OSAS (p<.001) and good sleepers (p<.001). In insomnia, elevated sleep related daytime rumination was best determined by unhelpful sleep related beliefs (coeff=0.3 p=.004), while in OSAS by insomnia symptoms (coeff=0.9, p=.02). These findings suggest that the association between insomnia-specific daytimerumination and unhelpful beliefs may be considered a cognitive feature of insomnia. In insomnia, sleep related cognition may dominate the 24-hour period. This finding might be of use for further investigations studying therapeutic strategies acting on cognitive processes to prevent and treat insomnia disorder and its comorbid conditions.

Understanding mental and physical fatigue complaints in those with depression and insomnia.

Fatigue is a concern for both people with insomnia and with depression, yet it remains poorly understood. Participants (N = 62) included those meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) criteria for insomnia and major depressive disorder (MDD). Multiple regression examined sleep, mood, activity, and cognitive factors as predictors of mental and physical fatigue. Only the cognitive factors (i.e., unhelpful beliefs about sleep and symptom-focused rumination) were predictive of both physical and mental fatigue. Beliefs about not being able to function and needing to avoid activities after a poor night of sleep were related to both types of fatigue. Targeting these beliefs via cognitive therapy and encouraging patients to test maladaptive beliefs about sleep may enhance fatigue response in those with MDD and insomnia.

Comparing patients treated with CBT for insomnia with healthy sleepers and sleepers with past insomnia on dimensions of sleep health.

OBJECTIVES: To compare patients treated with cognitive behavioral therapy for insomnia (CBT-I) with healthy sleepers and individuals with past but not current insomnia on multidimensional sleep health. METHODS: The study evaluates CBT-I on six dimensions of sleep health (regularity, satisfaction, alertness, timing, efficiency, duration) in a sample of individuals with insomnia compared to two other unique sleep samples. Participants were in one of three groups: insomnia (CUR, n = 299), healthy sleeper (HS, n = 122), or past insomnia (PAST, n = 35). Daily diaries and validated measures were employed to capture six dimensions of sleep health. The CUR group received four 60-minute sessions of CBT-I every 2weeks, and sleep health indices were measured at baseline and post-treatment. The HS and PAST groups were measured only at baseline. RESULTS: Results of the pairwise t tests indicated improvements in sleep satisfaction, alertness (fatigue but not sleepiness), timing, efficiency, and duration (Cohen's d=0.22 to 1.55). ANCOVA models revealed significant differences in sleep health scores between treated insomnia patients and the other two sleep groups. Treated patients demonstrated less bedtime and risetime variability, in addition to lower napping duration. Overall, the study observed significant changes in various domains of sleep health after four sessions of cognitive behavioral therapy for insomnia; however, differences remain when compared to the other groups in the study. CONCLUSION: There may be ongoing sleep vulnerability in patients treated with cognitive behavioral therapy for insomnia though future inclusion of a control group would increase internal validity. Borrowing from transdiagnostic sleep modules may be helpful to support remaining deficits after cognitive behavioral therapy for insomnia.

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.

Examining sleep characteristics in Canada through a diversity and equity lens.

OBJECTIVE: To examine specific sleep characteristics of adults living in Canada according to sex, gender, ethnoracial background, socioeconomic status, immigration status, sexual orientation, and language spoken at home. METHODS: This cross-sectional and nationally representative study used self-reported data from the 2021 Canadian Community Health Survey (n = 39,346 adults aged 18 years and older). Sleep characteristics (sleep duration, nighttime insomnia symptoms, unrefreshing sleep, and difficulty staying awake) were assessed and compared across groups. RESULTS: Females were more likely than males to report nighttime insomnia symptoms (23.1% vs. 14.8%) and unrefreshing sleep (17.2% vs. 13.5%). The same was also observed for gender identity. Although White respondents were more likely to meet sleep duration recommendations (58.3%), they had the highest prevalence of nighttime insomnia symptoms (20.9%) compared to respondents with other ethnoracial backgrounds. Respondents coming from lower socioeconomic backgrounds were more likely to report poorer sleep compared to those coming from higher socioeconomic backgrounds. Insomnia symptoms were lower among immigrants (13.9%) compared to nonimmigrants (21.1%). Respondents with a sexual orientation not classified as heterosexual, gay, or lesbian reported poorer sleep. Finally, for language spoken at home, those who responded "French only" were more likely to meet sleep duration recommendations (64.1%) and were less likely to report unrefreshing sleep (8.8%). Nighttime insomnia symptoms were the lowest among those who reported speaking a language other than French or English at home (9.5%). CONCLUSION: This study highlights important sleep disparities among Canadians. Future intervention strategies should aim to reduce sleep health disparities.

Social problem-solving attitudes and performance as a function of differences in trait and state worry.

BACKGROUND AND OBJECTIVES: This study investigated problem-solving attitudes and state-dependent, performance-based problem-solving abilities of individuals with high trait worry as compared to those low in trait worry. Secondary objectives involved investigating the relationship between problem-solving effectiveness and processes hypothesized to influence worry and problem-solving (i.e., working memory, attentional control, emotional dysregulation, and concreteness of thought). METHODS: A 2 (group: high worry, n = 68, vs. low worry, n = 66) X 2 (induction type: worry vs. neutral mentation) factorial design was employed to investigate the differential effects of state worry, and neutral mentation for comparison, on performance-based problem-solving effectiveness. Independent samples t-tests tested for group differences in self-reported problem-solving attitudes. Multiple regression analyses were used to investigate if aforementioned processes predict problem-solving effectiveness. RESULTS: Previous findings that individuals with high trait worry endorse greater tendencies to self-report unconstructive problem-solving attitudes were replicated. Contrary to predictions, there were no significant within or between group differences on problem-solving performance. Concreteness of problem solutions was the only consistent predictor of problem-solving effectiveness. LIMITATIONS: Study did not directly assess problem-solving for personal problems. CONCLUSIONS: Disparities in self-appraisal may account for lack of worry-related performance differences. Findings suggest that when employing problem-solving interventions with a high worry population, emphasis should be placed on changing maladaptive problem attitudes. Nonclinical and clinical populations alike may benefit from incorporating training in concreteness in problem-solving therapy.

What are patients completing Cognitive Behavioral Insomnia Therapy telling us with their post-treatment Insomnia Severity Index scores?

STUDY OBJECTIVE: Cognitive Behavioral Insomnia Therapy (CBT-I) is the gold standard insomnia treatment and the Insomnia Severity Index (ISI) is a frequently used treatment outcome measure. The ISI has strong psychometric properties and is purported to measure perceived insomnia symptom severity. However, little is known about the factors that drive insomnia severity perception and the psychometric properties of the ISI post-CBT-I. METHODS: Participants were treatment-seeking adults meeting DSM-5 Insomnia Disorder criteria (n = 203, ages 18-77, M = 45.95 years). Participants completed sleep and mood questionnaires, including the ISI, pre- and post-CBT-I. They completed daily Consensus Sleep Diaries each morning throughout two pre-treatment weeks, eight weeks of treatment and two weeks post-treatment. A hierarchical regression analysis examined what predicted post-CBT-I ISI scores and Cronbach's alpha was computed to examine post-treatment reliability of the ISI. RESULTS: The regression analysis revealed that lower post-treatment ISI scores were associated with lower pre-treatment ISI, and greater decreases in fatigue and generalized anxiety symptoms. The model did not significantly improve when pre-treatment sleep effort or changes in sleep diary indices were added. The post-treatment ISI Cronbach's alpha was .88. CONCLUSIONS: Although the ISI has been shown to have sound psychometric properties, clinicians should consider that post CBT-I ISI scores are not related to their sleep improvements. Instead, they seem to be related to whether patients perceive themselves as poor sleepers pre-treatment and whether they felt less tired and anxious after CBT-I. Researchers should consider the impact of factors other than sleep when using the ISI at post-treatment. Patients are telling us that CBT-I should focus on addressing symptoms of fatigue and general anxiety; perhaps CBT-I could be improved further to address these concerns more effectively. SUMMARY: This investigation shows that when individuals are rating their symptom severity after CBT-I, they are also integrating how they felt before treatment and whether they experienced a change in their fatigue or anxiety.

Economic burden of insomnia symptoms in Canada.

OBJECTIVE: To estimate health care and productivity costs associated with insomnia symptoms in Canadian adults. METHODS: Three pieces of information were needed to calculate estimates based on a prevalence-based approach: (1) the pooled relative risk estimates of health outcomes consistently associated with insomnia symptoms obtained from recent meta-analyses of prospective cohort studies; (2) the direct (health care) and indirect (lost productivity due to premature mortality) costs of these health outcomes using the Economic Burden of Illness in Canada information; and (3) the prevalence of insomnia symptoms in Canadian men (18.1%) and women (29.5%) obtained from a nationally-representative survey. RESULTS: The direct, indirect, and total costs of insomnia symptoms in Canada in 2021 were $1.9 billion, $12.6 million, and $1.9 billion, respectively. This value represents 1.9% of the overall burden of illness costs for 2021 in Canada. The 2 most expensive chronic diseases attributable to insomnia symptoms were type 2 diabetes ($754 million) and depression ($706 million). The main contributor to the costs for type 2 diabetes and depression was prescription drugs. A 5% decrease in insomnia symptoms (from 23.8% to 18.8%) would result in an estimated $353 million in avoided costs while a 5% increase in insomnia symptoms (from 23.8% to 28.8%) would result in an estimated $333 million in additional expenditures yearly. CONCLUSIONS: Insomnia symptoms greatly contribute to the economic burden of illness in Canada. Reducing the prevalence of insomnia symptoms would reduce its societal burden.

Can we modify maladaptive attributions for fatigue?

Research has shown that those with insomnia focus primarily on their sleep as a cause of daytime fatigue rather than the multitude of other possible causes of fatigue. This can create sleep-related anxiety and further perpetuate the sleep disturbance. In order to lessen the increased focus on sleep, the present study investigated whether people could learn to consider other attributions for fatigue via an information-based manipulation. Undergraduate students (N = 88) were randomized to two information groups: They either received information about common factors that could explain daytime fatigue (the fatigue information condition) or received generic sleep-related information (the control condition). Each group was tested pre- and post-intervention. Fatigue information participants were significantly more likely to consider non-sleep-related attributions for fatigue at post-intervention, relative to control participants. These results demonstrate that attributions for fatigue may be amenable to change via an information-based intervention; thus, this research explores a preliminary step toward investigating refinements to insomnia treatments.

The role of beliefs about sleep in nightly perceptions of sleep quality across a depression continuum.

BACKGROUND: Poor sleep quality is common in depression, but complaints of poor sleep quality are not necessarily tied to objective sleep, and the construct of sleep quality remains poorly understood. Previous work suggests that beliefs about sleep may influence sleep quality appraisals, as might sleep variability from night to night. OBJECTIVE: We tested whether beliefs about sleep predict daily sleep quality ratings above and beyond nightly variability of actigraphy and diary-assessed sleep over the course of multiple nights. METHODS: Eighty-eight participants aged 18-65 years across a depressive continuum completed sleep diaries and reported their sleep quality and mood each morning; actigraphy was also completed for 67 of those participants. Multilevel models were used to test previous night's total sleep time and sleep efficiency as predictors of self-reported sleep quality (VAS-SQ) and mood (VAS-M), and whether unhelpful beliefs about sleep predicted VAS-SQ and VAS-M above and beyond the sleep variables. RESULTS: Individuals across a depression continuum with greater unhelpful beliefs about sleep reported worse sleep quality and worse mood upon awakening, even when accounting for nightly variation in actigraphy or diary assessed total sleep time and sleep efficiency. CONCLUSIONS: These results suggest that people are influenced by unhelpful sleep beliefs when making judgements about sleep quality and mood, regardless of how well they slept the previous night. Working with these unhelpful sleep beliefs in cognitive behavioral therapy can thus promote better sleep and mood in people across the depressive continuum.

Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials.

STUDY OBJECTIVES: We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence. RESULTS: Thirty-nine trials (5100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (weighted mean difference of -0.19 cm [95%CI, -0.36 to -0.03 cm]; interaction p = .03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%). CONCLUSION: Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.