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).

Pre-sleep cognitive activity in adults: A systematic review.

This systematic review focuses on three themes: 1) the nature of pre-sleep cognitive activity in good sleepers and individuals with insomnia, 2) the links between measures of pre-sleep cognitive activity and sleep onset latency (SOL) or insomnia, and 3) the effect of manipulating pre-sleep cognitive activity on SOL or insomnia. Regarding the first theme, mentation reports have been collected in a sleep laboratory, with an ambulatory monitoring device, or using a voice-activated tape-recorder. Normal transition to sleep is characterized by sensorial imagery, deactivation of higher cognitive processes, and hallucinations. Moreover, pre-sleep thoughts in individuals with insomnia frequently relate to planning or problem-solving, and are more unpleasant than in good sleepers. Regarding the second theme, twelve questionnaires and three interviews were identified. Insomnia is associated with more thoughts interfering with sleep, counterfactual processing, worries, maladaptive thought control strategies, covert monitoring, and cognitive arousal. Regarding the third theme, several strategies have been tested: mental imagery, hypnosis, paradoxical intention, articulatory suppression, ordinary suppression, and distraction. Their effect is either beneficial, negligible, or detrimental. Future research should focus on the mechanisms through which some forms of cognitive activity affect sleep onset latency.

Disassembling insomnia symptoms and their associations with depressive symptoms in a community sample: the differential role of sleep symptoms, daytime symptoms, and perception symptoms of insomnia.

OBJECTIVE: Insomnia and depression are closely related. However, few studies have investigated whether certain insomnia symptoms differentially relate to certain depressive symptoms. The present study aimed to examine relationship between specific types of insomnia symptoms (sleep symptoms, daytime symptoms, and perception symptoms) and specific symptoms of depression. DESIGN: Cross-sectional, observational study data from the Sleep, Health, Activity, Diet and Environment and Social Factors (SHADES) Survey. SETTING: Community-level population. PARTICIPANTS: A total of 1003 community-based adults aged 22-60 from the Philadelphia area. MEASUREMENTS: Insomnia symptoms were represented by scores of sleep symptoms, daytime symptoms and perception symptoms, derived from the Insomnia Severity Index (ISI). Depression symptoms were assessed with the items of the Patient Health Questionnaire 9 (PHQ-9). RESULTS: A Confirmatory Factor Analysis (CFA) supported the three-factor model based on ISI data. Binary logistic regressions examined independent associations between the three insomnia symptom types and individual depression symptoms. Sleep symptoms were more strongly associated with physiological aspects of depressive symptoms (appetite symptoms, psychomotor symptoms, and suicidal ideation). The daytime symptoms, on the other hand, were significantly associated with almost all depressive symptoms, except for appetite. Moreover, daytime symptoms were exclusively related to cognitive symptoms of depression (eg, trouble concentrating). The perception symptoms were independently associated with mood symptoms, tiredness, appetite, and judgment of oneself as a failure, but not with psychomotor, cognitive and suicidal ideation symptoms. CONCLUSION: Daytime symptoms and perception symptoms of insomnia were more strongly associated with a full range of depressive symptoms than sleep symptoms. The sleep symptoms were mainly associated with more physiological symptoms of depression, implicating more biological mechanisms. Further research is needed regarding how these types of insomnia symptoms differentially related to multiple health consequences.

Information processing during NREM sleep and sleep quality in insomnia.

Insomnia sufferers (INS) are cortically hyperaroused during sleep, which seems to translate into altered information processing during nighttime. While information processing, as measured by event-related potentials (ERPs), during wake appears to be associated with sleep quality of the preceding night, the existence of such an association during nighttime has never been investigated. This study aims to investigate nighttime information processing among good sleepers (GS) and INS while considering concomitant sleep quality. Following a multistep clinical evaluation, INS and GS participants underwent 4 consecutive nights of PSG recordings in the sleep laboratory. Thirty nine GS (mean age 34.56±9.02) and twenty nine INS (mean age 43.03±9.12) were included in the study. ERPs (N1, P2, N350) were recorded all night on Night 4 (oddball paradigm) during NREM sleep. Regardless of sleep quality, INS presented a larger N350 amplitude during SWS (p=0.042) while GS showed a larger N350 amplitude during late-night stage 2 sleep (p=0.004). Regardless of diagnosis, those who slept objectively well showed a smaller N350 amplitude (p=0.020) while those who slept subjectively well showed a smaller P2 (p<0.001) and N350 amplitude (p=0.006). Also, those who reported an objectively bad night as good showed smaller P2 (p< 0.001) and N350 (p=0.010) amplitudes. Information processing seems to be associated with concomitant subjective and objective sleep quality for both GS and INS. However, INS show an alteration in information processing during sleep, especially for inhibition processes, regardless of their sleep quality.

Prenatal exposure to methylmercury and PCBs affects distinct stages of information processing: an event-related potential study with Inuit children.

Methylmercury (MeHg) and polychlorinated biphenyls (PCBs) are seafood contaminants known for their adverse effects on neurodevelopment. This study examines the relation of developmental exposure to these contaminants to information processing assessed with event-related potentials (ERPs) in school-aged Inuit children from Nunavik (Arctic Québec). In a prospective longitudinal study on child development, exposure to contaminants was measured at birth and 11 years of age. An auditory oddball protocol was administered at 11 years to measure ERP components N1 and P3b. Multiple regression analyses were performed to examine the associations of levels of the contaminants to auditory oddball performance (mean reaction time, omission errors and false alarms) and ERP parameters (latency and amplitude) after control for potential confounding variables. A total of 118 children provided useable ERP data. Prenatal MeHg exposure was associated with slower reaction times and fewer false alarms during the oddball task. Analyses of the ERP parameters revealed that prenatal MeHg exposure was related to greater amplitude and delayed latency of the N1 wave in the target condition but not to the P3b component. MeHg effects on the N1 were stronger after control for seafood nutrients. Prenatal PCB exposure was not related to any endpoint for sample as a whole but was associated with a decrease in P3b amplitude in the subgroup of children who had been breast-fed for less than 3 months. Body burdens of MeHg and PCBs at 11 years were not related to any of the behavioural or ERP measures. These data suggest that prenatal MeHg exposure alters attentional mechanisms modulating early processing of sensory information. By contrast, prenatal PCB exposure appears to affect information processing at later stages, when the information is being consciously evaluated. These effects seem to be mitigated in children who are breast-fed for a more extended period.

The relation of lead neurotoxicity to the event-related potential P3b component in Inuit children from arctic Québec.

The event-related potential (ERP) P3b, a cognitive electrophysiological measure that has been linked to working memory processing in many experimental paradigms, was measured in Inuit children from Nunavik (Arctic Québec, Canada) to assess lead (Pb) neurotoxicity. Visual and auditory oddball paradigms were administered at 5 (N=27) and 11 (N=110) years of age, respectively, to elicit this ERP component. Pearson correlations and multiple regression analyses were performed to examine the associations between Pb levels and P3b parameters (peak latency and amplitude). Greater prenatal Pb exposure was related to a decrease in P3b amplitude at 5 years of age, and early childhood Pb exposure was associated with delayed P3b latency at 5 years. No significant association was observed at 11 years. These results, in line with those from previous neurobehavioral studies, suggest that Pb exposure affects cognitive processing in children even though the Pb levels measured in a large majority of our sample were below the threshold value for public health intervention used by federal agencies. This study strengthens the arguments for reducing sources of Pb exposure in Nunavik and for lowering the blood Pb concentrations considered "acceptable" in governmental policies.

Is quality of sleep related to the N1 and P2 ERPs in chronic psychophysiological insomnia sufferers?

INTRODUCTION: Our recent ERPs study suggested inhibition deficits in addition to cortical arousal in insomnia sufferers (INS) relative to good sleepers (GS). The aim of the present study was to investigate the relation between objective sleep parameters and the amplitudes and latencies of ERPs components N1 and P2 in a multi-assessment protocol. METHODS: Participants, 15 INS and 16 GS, underwent four consecutive nights of polysomnography recordings (N1 to N4). ERPs in the evening and upon awakening were recorded on N3 and N4, with the addition of sleep-onset recordings on N4. Auditory stimuli consisted of 'standard' and 'deviant' tones. Objective sleep measures were computed on each night [sleep efficiency (SE), wake after sleep onset (WASO), total sleep time (TST) and sleep-onset latency (SOL)]. The amplitude and latency of N1 and P2 components were assessed for each recorded session on each night and related to measures of sleep of the same nights (N3 and N4). RESULTS: Pearson's correlations between the amplitude and latency of N1 and P2 and objective sleep measures revealed that arousal levels in the evening, before going to bed seem to have an impact on subsequent sleep quality. Furthermore, the sleep quality of the previous night also appeared to have an impact on morning (daily) arousal levels. CONCLUSION: These results suggest that hyperactivation and inhibition deficits present in insomnia sufferers are directly associated with a poorer sleep quality. This highlights once again that when information processing and/or performance is assessed, the sleep quality of the night preceding the evaluation shall be documented.

Alterations of visual evoked potentials in preschool Inuit children exposed to methylmercury and polychlorinated biphenyls from a marine diet.

The aim of the present study was to assess the impact of chronic exposure to polychlorinated biphenyls (PCBs) and methylmercury on visual brain processing in Inuit children from Nunavik (Northern Québec, Canada). Concentrations of total mercury in blood and PCB 153 in plasma had been measured at birth and they were again measured at the time of testing in 102 preschool aged children. Relationships between contaminants and pattern-reversal visual evoked potentials (VEPs) were assessed by multivariate regression analyses, taking into account several potential confounding variables. The possible protective effects of selenium and omega-3 polyunsaturated fatty acids against methylmercury and PCB toxicity were also investigated. Results indicate that exposure to methylmercury and PCBs resulting from fish and sea mammal consumption were associated with alterations of VEP responses, especially for the latency of the N75 and of the P100 components. In contrast, the concomitant intake of omega-3 polyunsaturated fatty acids was associated with a shorter latency of the P100. However, no significant interactions between nutrients and contaminants were found, contradicting the notion that these nutrients could afford protection against environmental neurotoxicants. Interestingly, significant associations were found with concentrations of neurotoxicants in blood samples collected at the time of testing, i.e. at the preschool age. Our findings suggest that VEP can be used as a valuable tool to assess the developmental neurotoxicity of environmental contaminants in fish-eating populations.

Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial.

CONTEXT: Insomnia is a prevalent health complaint associated with daytime impairments, reduced quality of life, and increased health-care costs. Although it is often self-treated with herbal and dietary supplements or with over-the-counter sleep aids, there is still little evidence on the efficacy and safety of those products. OBJECTIVE: To evaluate the efficacy and safety of a valerian-hops combination and diphenhydramine for the treatment of mild insomnia. DESIGN AND SETTING: Multicenter, randomized, placebo-controlled, parallel-group study conducted in 9 sleep disorders centers throughout the United States. PATIENTS: A total of 184 adults (110 women, 74 men; mean age of 44.3 years) with mild insomnia. INTERVENTIONS: (1) Two nightly tablets of standardized extracts of a valerian (187-mg native extracts; 5-8:1, methanol 45% m/m) and hops (41.9-mg native extracts; 7-10:1, methanol 45% m/m) combination for 28 days (n = 59), (2) placebo for 28 days (n = 65), or (3) 2 tablets of diphenhydramine (25 mg) for 14 days followed by placebo for 14 days (n = 60). OUTCOME MEASURES: Sleep parameters measured by daily diaries and polysomnography, clinical outcome ratings from patients and physicians, and quality of life measures. RESULTS: Modest improvements of subjective sleep parameters were obtained with both the valerian-hops combination and diphenhydramine, but few group comparisons with placebo reached statistical significance. Valerian produced slightly greater, though nonsignificant, reductions of sleep latency relative to placebo and diphenhydramine at the end of 14 days of treatment and greater reductions than placebo at the end of 28 days of treatment. Diphenhydramine produced significantly greater increases in sleep efficiency and a trend for increased total sleep time relative to placebo during the first 14 days of treatment. There was no significant group difference on any of the sleep continuity variables measured by polysomnography. In addition, there was no alteration of sleep stages 3-4 and rapid eye movement sleep with any of the treatments. Patients in the valerian and diphenhydramine groups rated their insomnia severity lower relative to placebo at the end of 14 days of treatment. Quality of life (Physical component) was significantly more improved in the valerian-hops group relative to the placebo group at the end of 28 days. There were no significant residual effects and no serious adverse events with either valerian or diphenhydramine and no rebound insomnia following their discontinuation. CONCLUSIONS: The findings show a modest hypnotic effect for a valerian-hops combination and diphenhydramine relative to placebo. Sleep improvements with a valerian-hops combination are associated with improved quality of life. Both treatments appear safe and did not produce rebound insomnia upon discontinuation during this study. Overall, these findings indicate that a valerian-hops combination and diphenhydramine might be useful adjuncts in the treatment of mild insomnia.