Sleep and Rest-Activity Rhythms in Recovering Patients with Severe Concurrent Mental and Substance Use Disorder: A Pilot Study.

Objective: Mental health and substance use disorders are commonly associated with disrupted sleep and circadian rest-activity rhythms. How these disorders in combination relate to sleep and circadian organization is not well studied. We provide here the first quantitative assessment of sleep and rest-activity rhythms in inpatients with complex concurrent disorders, taking into account categories of substance use (stimulant vs. stimulant and opioid use) and psychiatric diagnosis (psychotic disorder and mood disorder). We also explore how sleep and rest-activity rhythms relate to psychiatric functioning. Methods: A total of 44 participants (10 female) between the age of 20-60 years (median = 29 years) wore wrist accelerometers over 5-70 days and completed standardized questionnaires assessing chronotype and psychiatric functioning (fatigue, psychiatric symptom severity, and impulsiveness). To examine potential influences from treatment, we computed (1) length of stay; (2) days of abstinence from stimulants and opioids as a measure of withdrawal; and (3) a sedative load based on prescribed medications. Results: Participants exhibited a sustained excessive sleep duration, frequent nighttime awakenings, and advanced rest-activity phase related to sedative load. Sleep disruptions were elevated in participants with a history of opioid use. Patients with a psychotic disorder showed the longest sleep and most fragmented and irregular rest-activity patterns. Non-parametric circadian rhythm analysis revealed a high rhythm amplitude by comparison with population norms, and this was associated with greater psychiatric symptom severity. Psychiatric symptom severity was also associated with greater fatigue and later MCTQ chronotype. Conclusions: This pilot study provides initial information on the prevalence and severity of sleep and circadian rhythm disturbances in individuals with severe concurrent disorders. The results underline the need for further studies to start to understand the role of sleep in the disease and recovery process in this understudied population.

Demographic and temporal trends in mental health and substance use services provided by primary care physicians in British Columbia, Canada.

BACKGROUND: As the demand for mental health and substance use (MHSU) services increases, there will be an even greater need for health human resources to deliver this care. This study investigates how family physicians' (FP) contact volume, and more specifically, MHSU contact volume, is shaped by demographic trends among FPs in British Columbia, Canada. METHODS: We used annual physician-level administrative billing data and demographic information on FPs in British Columbia between 1996 and 2017. This study analyzes trends in primary care service provision among graduating cohorts of FPs, FPs of different ages (as measured by years since graduation), and FPs practicing during different time periods. Additionally, analyses are stratified by FP sex to account for potential differences in labour supply patterns between male and female FPs. RESULTS: Our results show that while FPs' overall contacts with patients decreased between 1996 and 2017, their annual number of MHSU contacts increased, which was largely driven by an increase in substance use visits. Demographically, the proportion of female FPs in the labour force rose over time. Observed trends were similar, though not identical in male and female FPs, as males tended to have higher overall contact volume (both total contacts and MHSU), but also steeper declines in contact volume in later careers. The number of contacts (both total and MHSU) changed across career stage - rising steadily from start to mid-career, peaking at 20-30 years in practice, and decreasing steadily thereafter. This was evident for all cohorts and consistent over the 21-year study period but flattened in amplitude over time. Our findings also point to potential cohort effects on labour supply. The inverse U-shaped career trend extended to MHSU contacts, but its peak seems to have shifted to a later career stage (peaking at 30-40 years of practice) over time. CONCLUSIONS: Our study shows changing dynamics in MHSU service delivery among FPs over time, across the life span and between FP sexes that are likely to influence access to care beyond simply the number of FPs. Given the healthcare needs of the population, these findings point to potential future changes in provision of MHSU services.

Light and the human circadian clock.

The circadian clock can only reliably fulfil its function if it is stably entrained. Most clocks use the light-dark cycle as environmental signal (zeitgeber) for this active synchronisation. How we think about clock function and entrainment has been strongly influenced by the early concepts of the field's pioneers, and the astonishing finding that circadian rhythms continue a self-sustained oscillation in constant conditions has become central to our understanding of entrainment.Here, we argue that we have to rethink these initial circadian dogmas to fully understand the circadian programme and how it entrains. Light is also the prominent zeitgeber for the human clock, as has been shown experimentally in the laboratory and in large-scale epidemiological studies in real life, and we hypothesise that social zeitgebers act through light entrainment via behavioural feedback loops (zeitnehmer). We show that human entrainment can be investigated in detail outside of the laboratory, by using the many 'experimental' conditions provided by the real world, such as daylight savings time, the 'forced synchrony' imposed by the introduction of time zones, or the fact that humans increasingly create their own light environment. The conditions of human entrainment have changed drastically over the past 100 years and have led to an increasing discrepancy between biological and social time (social jetlag). The increasing evidence that social jetlag has detrimental consequences for health suggests that shift-work is only an extreme form of circadian misalignment, and that the majority of the population in the industrialised world suffers from a similarly 'forced synchrony'.

Machiavellian strategist or cultural learner? Mentalizing and learning over development in a resource-sharing game.

Theorists have sought to identify the key selection pressures that drove the evolution of our species' cognitive abilities, life histories and cooperative inclinations. Focusing on two leading theories, each capable of accounting for many of the rapid changes in our lineage, we present a simple experiment designed to assess the explanatory power of both the Machiavellian Intelligence and the Cultural Brain/Intelligence Hypotheses. Children (aged 3-7 years) observed a novel social interaction that provided them with behavioural information that could either be used to outmanoeuvre a partner in subsequent interactions or for cultural learning. The results show that, even after four rounds of repeated interaction and sometimes lower pay-offs, children continued to rely on copying the observed behaviour instead of harnessing the available social information to strategically extract pay-offs (stickers) from their partners. Analyses further reveal that superior mentalizing abilities are associated with more targeted cultural learning - the selective copying of fewer irrelevant actions - while superior generalized cognitive abilities are associated with greater imitation of irrelevant actions. Neither mentalizing capacities nor more general measures of cognition explain children's ability to strategically use social information to maximize pay-offs. These results provide developmental evidence favouring the Cultural Brain/Intelligence Hypothesis over the Machiavellian Intelligence Hypothesis.

Impact of COVID-19 social-distancing on sleep timing and duration during a university semester.

Social-distancing directives to contain community transmission of the COVID-19 virus can be expected to affect sleep timing, duration or quality. Remote work or school may increase time available for sleep, with benefits for immune function and mental health, particularly in those individuals who obtain less sleep than age-adjusted recommendations. Young adults are thought to regularly carry significant sleep debt related in part to misalignment between endogenous circadian clock time and social time. We examined the impact of social-distancing measures on sleep in young adults by comparing sleep self-studies submitted by students enrolled in a university course during the 2020 summer session (entirely remote instruction, N = 80) with self-studies submitted by students enrolled in the same course during previous summer semesters (on-campus instruction, N = 452; cross-sectional study design). Self-studies included 2-8 week sleep diaries, two chronotype questionnaires, written reports, and sleep tracker (Fitbit) data from a subsample. Students in the 2020 remote instruction semester slept later, less efficiently, less at night and more in the day, but did not sleep more overall despite online, asynchronous classes and ~44% fewer work days compared to students in previous summers. Subjectively, the net impact on sleep was judged as positive or negative in equal numbers of students, with students identifying as evening types significantly more likely to report a positive impact, and morning types a negative impact. Several features of the data suggest that the average amount of sleep reported by students in this summer course, historically and during the 2020 remote school semester, represents a homeostatic balance, rather than a chronic deficit. Regardless of the interpretation, the results provide additional evidence that social-distancing measures affect sleep in heterogeneous ways.

The human circadian clock's seasonal adjustment is disrupted by daylight saving time.

A quarter of the world's population is subjected to a 1 hr time change twice a year (daylight saving time, DST). This reflects a change in social clocks, not environmental ones (e.g., dawn). The impact of DST is poorly understood. Circadian clocks use daylight to synchronize (entrain) to the organism's environment. Entrainment is so exact that humans adjust to the east-west progression of dawn within a given time zone. In a large survey (n = 55,000), we show that the timing of sleep on free days follows the seasonal progression of dawn under standard time, but not under DST. In a second study, we analyzed the timing of sleep and activity for 8 weeks around each DST transition in 50 subjects who were chronotyped (analyzed for their individual phase of entrainment). Both parameters readily adjust to the release from DST in autumn but the timing of activity does not adjust to the DST imposition in spring, especially in late chronotypes. Our data indicate that the human circadian system does not adjust to DST and that its seasonal adaptation to the changing photoperiods is disrupted by the introduction of summer time. This disruption may extend to other aspects of seasonal biology in humans.

Light in the Senior Home: Effects of Dynamic and Individual Light Exposure on Sleep, Cognition, and Well-Being.

Disrupted sleep is common among nursing home patients and is associated with cognitive decline and reduced well-being. Sleep disruptions may in part be a result of insufficient daytime light exposure. This pilot study examined the effects of dynamic "circadian" lighting and individual light exposure on sleep, cognitive performance, and well-being in a sample of 14 senior home residents. The study was conducted as a within-subject study design over five weeks of circadian lighting and five weeks of conventional lighting, in a counterbalanced order. Participants wore wrist accelerometers to track rest-activity and light profiles and completed cognitive batteries (National Institute of Health (NIH) toolbox) and questionnaires (depression, fatigue, sleep quality, lighting appraisal) in each condition. We found no significant differences in outcome variables between the two lighting conditions. Individual differences in overall (indoors and outdoors) light exposure levels varied greatly between participants but did not differ between lighting conditions, except at night (22:00-6:00), with maximum light exposure being greater in the conventional lighting condition. Pooled data from both conditions showed that participants with higher overall morning light exposure (6:00-12:00) had less fragmented and more stable rest-activity rhythms with higher relative amplitude. Rest-activity rhythm fragmentation and long sleep duration both uniquely predicted lower cognitive performance.

Epidemiology of the human circadian clock.

Humans show large inter-individual differences in organising their behaviour within the 24-h day-this is most obvious in their preferred timing of sleep and wakefulness. Sleep and wake times show a near-Gaussian distribution in a given population, with extreme early types waking up when extreme late types fall asleep. This distribution is predominantly based on differences in an individuals' circadian clock. The relationship between the circadian system and different "chronotypes" is formally and genetically well established in experimental studies in organisms ranging from unicells to mammals. To investigate the epidemiology of the human circadian clock, we developed a simple questionnaire (Munich ChronoType Questionnaire, MCTQ) to assess chronotype. So far, more than 55,000 people have completed the MCTQ, which has been validated with respect to the Horne-Østberg morningness-eveningness questionnaire (MEQ), objective measures of activity and rest (sleep-logs and actimetry), and physiological parameters. As a result of this large survey, we established an algorithm which optimises chronotype assessment by incorporating the information on timing of sleep and wakefulness for both work and free days. The timing and duration of sleep are generally independent. However, when the two are analysed separately for work and free days, sleep duration strongly depends on chronotype. In addition, chronotype is both age- and sex-dependent.

The Munich ChronoType Questionnaire for Shift-Workers (MCTQShift).

Sleep is systematically modulated by chronotype in day-workers. Therefore, investigations into how shift-work affects sleep, health, and cognition may provide more reliable insights if they consider individual circadian time (chronotype). The Munich ChronoType Questionnaire (MCTQ) is a useful tool for determining chronotype. It assesses chronotype based on sleep behavior, specifically on the local time of mid-sleep on free days corrected for sleep debt accumulated over the workweek (MSFsc). Because the original MCTQ addresses people working standard hours, we developed an extended version that accommodates shift-work (MCTQ(Shift)). We first present the validation of this new version with daily sleep logs (n = 52) and actimetry (n = 27). Next, we evaluated 371 MCTQ(Shift) entries of shift-workers (rotating through 8-h shifts starting at 0600 h, 1400 h, and 2200 h). Our results support experimental findings showing that sleep is difficult to initiate and to maintain under the constraints of shift-work. Sleep times are remarkably stable on free days (on average between midnight and 0900 h), so that chronotype of shift-workers can be assessed by means of MSF-similar to that of day-workers. Sleep times on free-days are, however, slightly influenced by the preceding shift (displacements <1 h), which are smallest after evening shifts. We therefore chose this shift-specific mid-sleep time (MSF(E)) to assess chronotype in shift-workers. The distribution of MSF(E) in our sample is identical to that of MSF in day-workers. We propose conversion algorithms for chronotyping shift-workers whose schedules do not include free days after evening shifts.

Chronotype modulates sleep duration, sleep quality, and social jet lag in shift-workers.

This study explores chronotype-dependent tolerance to the demands of working morning, evening, and night shifts in terms of social jet lag, sleep duration, and sleep disturbance. A total of 238 shift-workers were chronotyped with the Munich ChronoType Questionnaire for shift-workers (MCTQ(Shift)), which collects information about shift-dependent sleep duration and sleep timing. Additionally, 94 shift-workers also completed those items of the Sleep Questionnaire from the Standard Shift-Work Index (SSI) that assess sleep disturbances. Although all participants worked morning, evening, and night shifts, subsamples differed in rotation direction and speed. Sleep duration, social jet lag, and sleep disturbance were all significantly modulated by the interaction of chronotype and shift (mixed-model ANOVAs). Earlier chronotypes showed shortened sleep duration during night shifts, high social jet lag, as well as higher levels of sleep disturbance. A similar pattern was observed for later chronotypes during early shifts. Age itself only influenced sleep duration and quality per se, without showing interactions with shifts. We found that workers slept longer in fast, rotating shift schedules. Since chronotype changes with age, investigations on sleep behavior and circadian misalignment in shift-workers have to consider chronotype to fully understand interindividual and intraindividual variability, especially in view of the current demographic changes. Given the impact of sleep on health, our results stress the importance of chronotype both in understanding the effects of shift-work on sleep and in devising solutions to reduce shift-work-related health problems.

The influence of internal time, time awake, and sleep duration on cognitive performance in shiftworkers.

To date, studies investigating the consequences of shiftwork have predominantly focused on external (local) time. Here, we report the daily variation in cognitive performance in rotating shiftworkers under real-life conditions using the psychomotor vigilance test (PVT) and show that this function depends both on external and internal (biological) time. In addition to this high sensitivity of PVT performance to time-of-day, it has also been extensively applied in sleep deprivation protocols. We, therefore, also investigated the impact of shift-specific sleep duration and time awake on performance. In two separate field studies, 44 young workers (17 females, 27 males; age range 20-36 yrs) performed a PVT test every 2 h during each shift. We assessed chronotype by the MCTQ(Shift) (Munich ChronoType Questionnaire for shiftworkers). Daily sleep logs over the 4-wk study period allowed for the extraction of shift-specific sleep duration and time awake in a given shift, as well as average sleep duration ("sleep need"). Median reaction times (RTs) significantly varied across shifts, depending on both Local Time and Internal Time. Variability of reaction times around the 24 h mean (≈ ±5%) was best explained by a regression model comprising both factors, Local Time and Internal Time (p < .001). Short (15th percentile; RT(15%)) and long (85th percentile; RT(85%)) reaction times were differentially affected by Internal Time and Local Time. During night shifts, only median RT and RT(85%) were impaired by the duration of time workers had been awake (p < .01, consistent with the highest sleep pressure), but not RT(15%). Proportion of sleep before a test day (relative to sleep need) significantly affected median RT and RT(85%) during morning shifts (p < .01). RT(15%) was worst in the beginning of the morning shift, but improved to levels above average with increasing time awake (p < .05), whereas RT(85%) became worse (p < .05). Hierarchical mixed models confirmed the importance of chronotype and sleep duration on cognitive performance in shiftworkers, whereas the effect of time awake requires further research. Our finding that both Local Time and Internal Time, in conjunction with shift-specific sleep behavior, strongly influence performance extends predictions derived from laboratory studies.

Blue-enriched office light competes with natural light as a zeitgeber.

OBJECTIVES: Circadian regulation of human physiology and behavior (eg, body temperature or sleep-timing), depends on the "zeitgeber" light that synchronizes them to the 24-hour day. This study investigated the effect of changing light temperature at the workplace from 4000 Kelvin (K) to 8000 K on sleep-wake and activity-rest behavior. METHODS: An experimental group (N=27) that experienced the light change was compared with a non-intervention group (N=27) that remained in the 4000 K environment throughout the 5-week study period (14 January to 17 February). Sleep logs and actimetry continuously assessed sleep-wake behavior and activity patterns. RESULTS: Over the study period, the timing of sleep and activity on free days steadily advanced parallel to the seasonal progression of sunrise in the non-intervention group. In contrast, the temporal pattern of sleep and activity in the experimental group remained associated with the constant onset of work. CONCLUSION: The results suggest that artificial blue-enriched light competes with natural light as a zeitgeber. While subjects working under the warmer light (4000 K) appear to entrain (or synchronize) to natural dawn, the subjects who were exposed to blue-enriched (8000 K) light appear to entrain to office hours. The results confirm that light is the dominant zeitgeber for the human clock and that its efficacy depends on spectral composition. The results also indicate that blue-enriched artificial light is a potent zeitgeber that has to be used with diligence.