Psychiatric comorbidities and prescribing tendencies of sleep medications and related medications in young people with insomnia: a United States commercial claims-based analysis.

STUDY OBJECTIVES: To characterize children and youth newly diagnosed with insomnia and to describe their use of sleep and other related prescription medications. METHODS: Within a commercial claims database (January 1, 2016-December 31, 2021), we identified children and youth (2-24 years) with a newly recorded insomnia diagnosis (G47.0x; F51.0x) and examined psychiatric diagnoses in the prior 6 months. We evaluated sleep and related prescription medications dispensed in the week after new insomnia diagnoses (i.e. trazodone, other antidepressants, hydroxyzine, alpha-agonists, benzodiazepines, non-benzodiazepine hypnotics "z-drugs," antipsychotics, and others). Analyses were stratified by age and psychiatric comorbidities. RESULTS: Among 68 698 children and 108 118 older youth (18-24 years) with a new insomnia diagnosis, three-quarters had a diagnosed comorbid psychiatric condition; anxiety disorders, depression, and ADHD were the most common. Among those without comorbid psychiatric diagnoses, 20.2% of children and 37.4% of older youth had a sleep or related medication dispensed in the following week. In children without a comorbid psychiatric diagnosis, alpha-agonists, hydroxyzine, and trazodone were the most common medications; in older youth, trazodone was the most common medication followed by hydroxyzine, z-drugs, and SSRIs. Sleep and related prescription medications were more commonly dispensed to those with psychiatric comorbidities. From 2017 to 2021, there was an increase in hydroxyzine prescriptions following a new insomnia diagnosis and decline in z-drug and benzodiazepine prescriptions. CONCLUSIONS: Our findings from a nationwide sample of young people with insomnia highlight the high prevalence of psychiatric comorbidities and variety of sleep and related medications they receive. Characterizing prescribing tendencies informs guideline development and future research.

Sleep Physiology and Neurocognition Among Adolescents With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Few studies have characterized the nature of sleep problems among adolescents with attention-deficit/hyperactivity disorder (ADHD) using polysomnography (PSG). Additionally, although adolescents with ADHD and adolescents with sleep disturbances display similar neurocognitive deficits, the role of sleep in contributing to neurocognitive impairment in adolescent ADHD is unknown. This study investigated differences in PSG-measured sleep among adolescents with ADHD compared with non-psychiatric controls and associations with neurocognition. METHOD: Medication-free adolescents aged 13 to 17 (N = 62, n = 31 with ADHD; mean age = 15.3 years; 50% female) completed a diagnostic evaluation, 3 nights of ambulatory PSG, the Cambridge Neuropsychological Test Automated Battery, and subjective reports of sleep and executive functioning. Linear regressions covarying for age, sex, and pubertal status examined group differences in sleep indices, and partial Pearson correlations assessed relations between sleep and neurocognition. RESULTS: Although adolescents with ADHD did not exhibit differences in PSG-measured sleep duration, awakenings, or latency (ps > .05) compared with non-psychiatric controls, they displayed lower slow wave sleep percentage (ß = -.40) and non-rapid eye movement (NREM) electroencephalogram (EEG) delta power (ß = -.29). They also exhibited greater stage 2 percentage (ß = .41), NREM EEG sigma power (ß = .41), and elevated self-reported sleep disturbances (ps < .05). Lower NREM EEG delta power, increased high-frequency power, and slower decline in NREM EEG delta power overnight were associated with poorer neurocognition among adolescents with ADHD. CONCLUSIONS: Adolescents with ADHD reported more sleep disturbances than non-psychiatric controls and exhibited differences in sleep stage distribution and NREM sleep EEG frequency. Sleep-EEG spectral indices were associated with impaired neurocognition, suggesting that physiological sleep processes may underlie neurocognitive deficits in ADHD. Future studies may clarify whether sleep plays a causal role in neurocognitive impairments in adolescent ADHD and whether interventions normalizing sleep improve neurocognition. CLINICAL TRIAL REGISTRATION INFORMATION: Sleep Dysfunction and Neurocognitive Outcomes in Adolescent ADHD; https://clinicaltrials.gov/; NCT02897362. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list.

Behavioral Treatment of Insomnia and Sleep Disturbances in School-Aged Children and Adolescents.

Insomnia and related sleep disturbances are prevalent among youth and are associated with adverse consequences, including poorer psychiatric functioning. Behavioral sleep interventions, ranging from brief educational interventions to behavioral therapies (cognitive behavior therapy-insomnia), are associated with positive outcomes for pediatric sleep health. In addition, sleep interventions may improve psychiatric health for children and adolescents with neurodevelopmental and internalizing disorders. Additional research is necessary to clarify the efficacy of these interventions over the long-term and across demographic groups; however, evidence suggests incorporating behavioral sleep strategies may prove beneficial to pediatric patients with sleep disturbances and related psychiatric complaints.

The relationship between stress responding in family context and stress sensitivity with sleep dysfunction in individuals at clinical high-risk for psychosis.

Stress and sleep have been implicated in the etiology of psychosis, and literature suggests they are closely related. Two distinct domains of stress associated with sleep dysfunction in the general population are responsivity to environmental stressors and stress sensitivity. However, to date, no research has examined relationships between these stress domains and sleep dysfunction in individuals at clinical high-risk (CHR) for psychosis. A total of 57 CHR (mean age = 18.89, SD = 1.82) and 61 healthy control (HC; mean age = 18.34, SD = 2.41) adolescents and young adults completed a measure of emerging stress intolerance. A subset of participants (CHR = 50, HC = 49) completed a measure indexing responsivity to family stressors - an integral context for this developmental stage overlapping with the psychosis-risk period. Sleep efficiency, continuity, and duration were objectively assessed by actigraphy (CHR = 38, HC = 36). Partial correlations with age and sex as covariates were conducted in both groups separately to examine relationships between stress and sleep. Results indicated that automatic maladaptive responsivity to family stressors was associated with disrupted sleep in the CHR but not HC group. Specifically, greater involuntary engagement was associated with poorer sleep efficiency (r = -.42) but not sleep continuity (r = 0.31) and duration (r = .-19). Interestingly, both adaptative and maladaptive voluntary responses to stressors (engagement and disengagement coping) were not associated with sleep. Finally, impaired stress tolerance was associated with sleep efficiency (r = -0.47), continuity (r = 0.37), and duration (r = -0.43). Taken together, findings provided important groundwork for understanding the role of the relationship between involuntary maladaptive responsivity to family stressors and stress sensitivity with sleep in psychosis etiology.

Overnight Delta Dynamics Associated with Daytime Psychomotor Performance in Adults with Insomnia and Healthy Controls.

PURPOSE: Sleep is vital to cognition, yet underlying mechanisms remain unclear. Although sleep duration and continuity are two well-established contributors, additional factors-including homeostatic sleep drive processes-may also underlie cognition-related sleep restoration. This study investigates the relative contributions of sleep EEG factors to psychomotor functioning in adults with insomnia and healthy controls (HC) to identify the most significant sleep factors supporting psychomotor functioning. MATERIALS AND METHODS: Adults with insomnia (n = 37) and HC (n = 39) completed 3 nights of polysomnography and a complex psychomotor task (switching attention task; SAT). Univariate correlations identified the most significant predictors (traditional PSG, spectral EEG, initial delta peak, and overnight delta decline) of SAT performance, which were then entered into multivariable linear regressions examining whether predictors remained significant after accounting for shortened/fragmented sleep and whether relationships differed across groups. RESULTS: In addition to greater wake after sleep onset (WASO; r = 0.33), a slower overnight delta decline (r = 0.50) and a lower initial delta peak (r = -0.38) were the most significant predictors of poorer SAT performance. Both overnight delta decline (F(7, 68) = 12.52, p < 0.001) and initial delta peak (F(7, 68) = 7.85, p = 0.007) remained significant predictors after controlling for demographics, total sleep time, and WASO. Relationships were analogous across subject groups. CONCLUSION: Findings suggest that, in addition to sleep duration and continuity, processes related to recovery from and dissipation of homeostatic sleep drive may support psychomotor performance and broadly support daytime functioning in individuals with and without insomnia. Future research may examine overnight delta dynamics as transdiagnostic processes supporting cognition-related sleep restoration across a range of clinical populations.

Regularity and Timing of Sleep Patterns and Behavioral Health Among Adolescents.

OBJECTIVE: Sleep is vital to supporting adolescent behavioral health and functioning; however, sleep disturbances remain under-recognized and undertreated in many health care settings. One barrier is the complexity of sleep, which makes it difficult for providers to determine which aspects-beyond sleep duration-may be most important to assess and treat to support adolescent health. This study examined associations between 2 sleep indices (regularity and timing) and adolescent behavioral health and functioning over and above the impact of shortened/fragmented sleep. METHOD: Eighty-nine adolescents recruited from the community (mean age = 14.04, 45% female participants) completed 7 days/nights of actigraphy and, along with a parent/guardian, reported on behavioral health (internalizing and externalizing symptoms) and psychosocial functioning. Stepwise linear regressions examined associations between sleep timing and regularity and behavioral/functional outcomes after accounting for shortened/fragmented sleep. RESULTS: Delayed sleep timing was associated with greater self-reported internalizing (F[6,82] = 11.57, p = 0.001) and externalizing (F[6,82] = 11.12, p = 0.001) symptoms after accounting for shortened/fragmented sleep. Irregular sleep was associated with greater self-reported and parent-reported externalizing symptoms (self: F[7,81] = 6.55, p = 0.01; parent: F[7,80] = 6.20, p = 0.01) and lower psychosocial functioning (self: F[7,81] = 6.03, p = 0.02; parent: F[7,78] = 3.99, p < 0.05) after accounting for both shortened/fragmented sleep and delayed sleep timing. CONCLUSION: Sleep regularity and timing may be critical for understanding the risk of poor behavioral health and functional deficits among adolescents and as prevention and intervention targets. Future work should focus on developing and evaluating convenient, low-cost, and effective methods for addressing delayed and/or irregular adolescent sleep patterns in real-world health care settings.

Impact of daily caffeine intake and timing on electroencephalogram-measured sleep in adolescents.

STUDY OBJECTIVES: Caffeine use is ubiquitous among adolescents and may be harmful to sleep, with downstream implications for health and development. Research has been limited by self-reported and/or aggregated measures of sleep and caffeine collected at a single time point. This study examines bidirectional associations between daily caffeine consumption and electroencephalogram-measured sleep among adolescents and explores whether these relationships depend on timing of caffeine use. METHODS: Ninety-eight adolescents aged 11-17 (mean =14.38, standard deviation = 1.77; 50% female) participated in 7 consecutive nights of at-home sleep electroencephalography and completed a daily diary querying morning, afternoon, and evening caffeine use. Linear mixed-effects regressions examined relationships between caffeine consumption and total sleep time, sleep-onset latency, sleep efficiency, wake after sleep onset, and time spent in sleep stages. Impact of sleep indices on next-day caffeine use was also examined. RESULTS: Increased total caffeine consumption was associated was increased sleep-onset latency (ß = .13; 95% CI = .06, .21; P < .001) and reduced total sleep time (ß = -.17; 95% confidence interval [CI] = -.31, -.02; P = .02), sleep efficiency (ß = -1.59; 95% CI = -2.51, -.67; P < .001), and rapid eye movement sleep (ß = -.12; 95% CI = -.19, -.05; P < .001). Findings were driven by afternoon and evening caffeine consumption. Reduced sleep efficiency was associated with increased afternoon caffeine intake the following day (ß = -.006; 95% CI = -.012, -.001; P = .01). CONCLUSIONS: Caffeine consumption, especially afternoon and evening use, impacts several aspects of adolescent sleep health. In contrast, most sleep indicators did not affect next-day caffeine use, suggesting multiple drivers of adolescent caffeine consumption. Federal mandates requiring caffeine content labeling and behavioral interventions focused on reducing caffeine intake may support adolescent sleep health. CITATION: Lunsford-Avery JR, Kollins SH, Kansagra S, Wang KW, Engelhard MM. Impact of daily caffeine intake and timing on electroencephalogram-measured sleep in adolescents. J Clin Sleep Med. 2022;18(3):877-884.

Eveningness chronotype preference among individuals at clinical high risk for psychosis.

BACKGROUND: Circadian rhythm disturbances are frequently implicated in psychosis. Indeed, research has suggested several avenues by which circadian rhythms may play a mechanistic role as well as contribute to clinical outcomes. Despite its potential role as a risk factor, little is known about circadian rhythm disruption among individuals at clinical high risk (CHR) for psychosis, clinical correlates, or specificity to the psychosis risk syndrome. METHODS: Eighty-four CHR, 74 individuals with depressive disorders (DD), and 101 non-psychiatric controls (NPC) participated in structured clinical interviews and provided self-reports of chronotype preference. Clinical (positive, negative, anxious, and depressive symptoms) and social functioning outcomes were self-reported and/or clinician-rated. Analyses of covariance controlling for demographics examined group differences in chronotype preference, and partial Pearson correlations evaluated associations with clinical/functional outcomes. RESULTS: Group differences were observed (F(11, 246) = 8.05, p < .001) with CHR and DD individuals indicating greater eveningness preference compared to NPC. A follow-up sensitivity analysis examining CHR participants with (n = 25) and without (n = 59) depressive disorders indicated no difference in chronotype preference (F(10,72) = 0.00, p = .99). Greater eveningness preference was related to greater negative symptoms (i.e., avolition; r = -0.25) and anxiety (r = -0.34) among CHR individuals. CONCLUSIONS: CHR and DD display greater preference for eveningness chronotype compared to NPC indicating the disruption is associated with a range of mental health concerns, and not specific to the psychosis-risk syndrome. However, comorbidity with DD did not appear to be driving the finding in the CHR group. Further research may examine shared versus non-shared underlying mechanisms contributing to chronotype preference across psychiatric presentations.

Optimizing computation of overnight decline in delta power: Evidence for slower rate of decline in delta power in insomnia patients.

OBJECTIVE: To determine the best of commonly used methods for computing the rate of decline in non-rapid eye movement (NREM) sleep EEG delta power overnight (Delta Decline) in terms of vulnerability to missing data and to evaluate whether this rate is slower in insomnia patients than healthy controls (HC). METHODS: Fifty-one insomnia patients and 53 HC underwent 6 nights of polysomnography. Four methods for estimating Delta Decline were compared (exponential and linear best-fit functions using NREM (1) episode mean, (2) peak, and (3) total delta power and (4) delta power for all available NREM epochs). The best method was applied to compare groups on linear and exponential rates of Delta Decline. RESULTS: Best-fit models using all available NREM epochs were significantly less vulnerable to deviation due to missing data than other methods. Insomnia patients displayed significantly slower linear and exponential Delta Decline than HC. CONCLUSIONS: Computing Delta Decline using all available NREM epochs was the best of the methods studied for minimizing the effects of missing data. Insomnia patients display slower Delta Decline, which is not explained by differences in total sleep time or wake after sleep onset. SIGNIFICANCE: This study supports using all available NREM epochs in Delta Decline computation and suggests a slower rate in insomnia.

Behavioral Treatment of Insomnia and Sleep Disturbances in School-Aged Children and Adolescents.

Insomnia and related sleep disturbances are prevalent among youth and are associated with adverse consequences, including poorer psychiatric functioning. Behavioral sleep interventions, ranging from brief educational interventions to behavioral therapies (cognitive behavior therapy-insomnia), are associated with positive outcomes for pediatric sleep health. In addition, sleep interventions may improve psychiatric health for children and adolescents with neurodevelopmental and internalizing disorders. Additional research is necessary to clarify the efficacy of these interventions over the long-term and across demographic groups; however, evidence suggests incorporating behavioral sleep strategies may prove beneficial to pediatric patients with sleep disturbances and related psychiatric complaints.

Sluggish Cognitive Tempo in Adults Referred for an ADHD Evaluation: A Psychometric Analysis of Self- and Collateral Report.

Objective: Sluggish cognitive tempo (SCT) symptoms uniquely contribute to psychiatric and functional outcomes in child samples; however, the psychometric properties of SCT measures among adult outpatients are unknown. Method: Adults (n = 124) presenting for an ADHD evaluation provided self- and collateral report of SCT symptoms. Results: The SCT scale had good internal consistency and yielded three factors across raters: Slow/Daydreamy, Sleepy/Sluggish, and Low Initiation/Persistence. SCT scores exhibited convergent validity with ADHD symptoms across raters. Individuals with ADHD received higher SCT ratings than those without ADHD via collateral report, a pattern that was similar when comorbidity was considered. SCT was associated with poorer functioning after accounting for ADHD symptoms with some differential effects based on reporting source. Conclusion: Findings support the internal consistency and validity of a three-factor SCT scale among adult outpatients. Differential results between self- and collateral report demonstrate the importance of multiple reporters of SCT in clinical settings.

Psychotic-Like Experiences Associated with Sleep Disturbance and Brain Volumes in Youth: Findings from the Adolescent Brain Cognitive Development Study.

Background: Sleep disturbance is characteristic of schizophrenia and at-risk populations, suggesting a possible etiological role in psychosis. Biological mechanisms underlying associations between sleep and psychosis vulnerability are unclear, although reduced sleep-regulatory brain structure volumes are a proposed contributor. This study is the first to examine relationships between psychotic-like experiences (PLEs; subclinical symptoms reflecting psychosis vulnerability/risk), sleep, and brain volumes in youth. Methods: Brain volumes of five sleep-related structures were examined in relation to PLEs and difficulties initiating and maintaining sleep (DIMS) in 9260 9-11 year-olds participating in the Adolescent Brain Cognitive Development (ABCD) study. Analytic models examined relationships between DIMS, PLEs, and brain volumes, as well as DIMS as a mediator of brain volume-PLEs relationships. Although sleep regulation structures (i.e., thalamus, basal forebrain, hypothalamus) were of primary interest, other potentially-relevant structures to sleep-related functioning and psychosis (i.e., hippocampus, amygdala) were also examined. Results: PLEs were associated with increased DIMS as well as reduced volume in some, but not all, brain structures, including the thalamus and basal forebrain in children. DIMS was also associated with reduced left thalamus volume in youth. Increased DIMS partially, statistically mediated the relationship between left thalamic volume and PLEs, although the effect was relatively small. Conclusions: Results highlight left thalamic volume as a potential neural mechanism underlying sleep disturbances and PLEs in childhood. Future studies should assess causal relationships between sleep, PLEs, and brain structure across adolescent development, interactions with other psychosis risk factors, and the role of sleep interventions in prevention of psychosis and a range of psychiatric conditions across the lifespan.

Eveningness Diurnal Preference: Putting the "Sluggish" in Sluggish Cognitive Tempo.

OBJECTIVE: Eveningness diurnal preference is common in psychiatric conditions, including attention-deficit/hyperactivity disorder (ADHD) and internalizing disorders. Little is known about how diurnal preference relates to sluggish cognitive tempo (SCT)-a distinct clinical construct associated with functional impairment-in clinical samples. METHOD: Adult outpatients (n = 65; 43 with ADHD, 22 with internalizing/adjustment disorders) self-reported on SCT symptoms (total symptoms; slow/daydreamy, sleepy/sluggish, and low initiation/persistence factors) and diurnal preference. RESULTS: Greater eveningness was associated with overall SCT severity and sleepy/sluggish symptoms in the full sample. Relationships between eveningness and overall SCT severity and slow/daydreamy symptoms were stronger for those with internalizing/adjustment disorders compared to ADHD. The relationship between eveningness and sleepy/sluggish symptoms was uniform across groups. CONCLUSION: Findings suggest a potential role of eveningness preference in adult SCT presentation. Future studies should investigate underlying mechanisms linking these two constructs and the efficacy of circadian interventions in the treatment of SCT among adult outpatients.

Feasibility and Acceptability of Wearable Sleep Electroencephalogram Device Use in Adolescents: Observational Study.

BACKGROUND: Adolescence is an important life stage for the development of healthy behaviors, which have a long-lasting impact on health across the lifespan. Sleep undergoes significant changes during adolescence and is linked to physical and psychiatric health; however, sleep is rarely assessed in routine health care settings. Wearable sleep electroencephalogram (EEG) devices may represent user-friendly methods for assessing sleep among adolescents, but no studies to date have examined the feasibility and acceptability of sleep EEG wearables in this age group. OBJECTIVE: The goal of the research was to investigate the feasibility and acceptability of sleep EEG wearable devices among adolescents aged 11 to 17 years. METHODS: A total of 104 adolescents aged 11 to 17 years participated in 7 days of at-home sleep recording using a self-administered wearable sleep EEG device (Zmachine Insight+, General Sleep Corporation) as well as a wristworn actigraph. Feasibility was assessed as the number of full nights of successful recording completed by adolescents, and acceptability was measured by the wearable acceptability survey for sleep. Feasibility and acceptability were assessed separately for the sleep EEG device and wristworn actigraph. RESULTS: A total of 94.2% (98/104) of adolescents successfully recorded at least 1 night of data using the sleep EEG device (mean number of nights 5.42; SD 1.71; median 6, mode 7). A total of 81.6% (84/103) rated the comfort of the device as falling in the comfortable to mildly uncomfortable range while awake. A total of 40.8% (42/103) reported typical sleep while using the device, while 39.8% (41/103) indicated minimal to mild device-related sleep disturbances. A minority (32/104, 30.8%) indicated changes in their sleep position due to device use, and very few (11/103, 10.7%) expressed dissatisfaction with their experience with the device. A similar pattern was observed for the wristworn actigraph device. CONCLUSIONS: Wearable sleep EEG appears to represent a feasible, acceptable method for sleep assessment among adolescents and may have utility for assessing and treating sleep disturbances at a population level. Future studies with adolescents should evaluate strategies for further improving usability of such devices, assess relationships between sleep EEG-derived metrics and health outcomes, and investigate methods for incorporating data from these devices into emerging digital interventions and applications. TRIAL REGISTRATION: ClinicalTrials.gov NCT03843762; https://clinicaltrials.gov/ct2/show/NCT03843762.

Sluggish cognitive tempo (SCT) in an adult outpatient sample seeking an attention-deficit/hyperactivity disorder assessment: Age of onset and assessment method impact on SCT rates.

BACKGROUND: Sluggish cognitive tempo (SCT) is associated with-but distinct from-attention-deficit/hyperactivity disorder (ADHD). This study examined SCT rates in adult outpatients seeking an ADHD assessment, differences in rates based on ADHD status, impact of assessment method (i.e., reporting source, symptom count, and functional impairment), and age of SCT symptom onset. METHODS: Outpatients (n = 124) completed an SCT measure (n = 120 other-reporters). SCT was based on reporting source (i.e., self-report, other-report, either reporting source ["or" rule], and both reporting sources ["and" rule]), symptom count (i.e., age-based norms at or near the 93rd percentile, and a higher symptom count threshold of five), and functional impairment (i.e., 0, 1, and ≥2 domains). RESULTS: SCT rates varied based on assessment method for the full sample (26%-82%) and among those with (32%-91%) and without (16%-66%) ADHD. Rates decreased with stricter functional impairment and symptom count criteria. SCT was higher in the ADHD group than the non-ADHD group based on other-reporters and the "or" rule, but not the "and" rule. Functional impairment and symptom count criteria did not impact these comparisons. For self-reported SCT rates, ADHD/non-ADHD group comparisons did not differ based on age-based symptom count threshold, but did with a symptom count threshold of five. Self-reported SCT symptom onset was 13.36 years-old and was significantly younger for the ADHD group (11.69 years) than the non-ADHD group (16.36 years). CONCLUSIONS: Elevated SCT symptoms and related impairment are common among adults seeking an ADHD evaluation. These rates and ADHD/non-ADHD group differences vary substantially based on diagnostic methods.