Effects of cognitive behavioural therapy and bright light therapy for insomnia in youths with eveningness: study protocol for a randomised controlled trial.

BACKGROUND: Insomnia and eveningness are common and often comorbid conditions in youths. While cognitive behavioural therapy for insomnia (CBT-I) has been suggested as a promising intervention, it remains unclear whether it is sufficient to also address circadian issues in youths. In addition, despite that light has been shown to be effective in phase-shifting one's circadian rhythm, there has been limited data on the effects of bright light therapy and its combination with CBT-I on sleep and circadian outcomes in youths. The current protocol outlines a randomised controlled trial that examines the efficacy of CBT-I and CBT-I plus bright light therapy (BLT) in reducing insomnia severity, improving mood symptoms and daytime functioning (e.g. sleepiness, fatigue, cognitive function), and improving subjective and objective sleep and circadian measures compared to a waitlist control group. METHODS: We will carry out a randomised controlled trial (RCT) with 150 youths aged 12-24 who meet the criteria of insomnia and eveningness. Participants will be randomised into one of three groups: CBT-I with bright light therapy, CBT-I with placebo light, and waitlist control. Six sessions of CBT-I will be delivered in a group format, while participants will be currently asked to use a portable light device for 30 min daily immediately after awakening throughout the intervention period for bright light therapy. The CBT-I with light therapy group will receive bright constant green light (506 lx) while the CBT-I with placebo light group will receive the modified light device with the LEDs emitting less than 10 lx. All participants will be assessed at baseline and post-treatment, while the two active treatment groups will be additionally followed up at 1 month and 6 months post-intervention. The primary outcome will be insomnia severity, as measured by the Insomnia Severity Index. Secondary outcomes include self-reported mood, circadian, daytime functioning, and quality of life measures, as well as sleep parameters derived from actigraphy and sleep diary and neurocognitive assessments. Objective measures of the circadian phase using dim-light melatonin onset assessment and sleep parameters using polysomnography will also be included as the secondary outcomes. DISCUSSION: This study will be the first RCT to directly compare the effects of CBT-I and BLT in youths with insomnia and eveningness. Findings from the study will provide evidence to inform the clinical management of insomnia problems and eveningness in youths. TRIAL REGISTRATION: ClinicalTrials.gov NCT04256915. Registered on 5 February 2020.

Exploring the Role of First-Person Singular Pronouns in Detecting Suicidal Ideation: A Machine Learning Analysis of Clinical Transcripts.

Linguistic features, particularly the use of first-person singular pronouns (FPSPs), have been identified as potential indicators of suicidal ideation. Machine learning (ML) and natural language processing (NLP) have shown potential in suicide detection, but their clinical applicability remains underexplored. This study aimed to identify linguistic features associated with suicidal ideation and develop ML models for detection. NLP techniques were applied to clinical interview transcripts (n = 319) to extract relevant features, including four cases of FPSP (subjective, objective, dative, and possessive cases) and first-person plural pronouns (FPPPs). Logistic regression analyses were conducted for each linguistic feature, controlling for age, gender, and depression. Gradient boosting, support vector machine, random forest, decision tree, and logistic regression were trained and evaluated. Results indicated that all four cases of FPSPs were associated with depression (p < 0.05) but only the use of objective FPSPs was significantly associated with suicidal ideation (p = 0.02). Logistic regression and support vector machine models successfully detected suicidal ideation, achieving an area under the curve (AUC) of 0.57 (p < 0.05). In conclusion, FPSPs identified during clinical interviews might be a promising indicator of suicidal ideation in Chinese patients. ML algorithms might have the potential to aid clinicians in improving the detection of suicidal ideation in clinical settings.

Secular trends in sleep and circadian problems among adolescents in Hong Kong: From 2011-2012 to 2017-2019.

OBJECTIVE: The study aimed to investigate secular trends in sleep and circadian problems in Hong Kong Chinese adolescents. METHODS: This study analyzed cross-sectional data from two large-scale school-based sleep surveys conducted in 2011-2012 and 2017-2019. Sleep and circadian problems, including sleep-wake pattern, insomnia, chronotype, social jetlag, daytime sleepiness, and other sleep-related factors, were compared between two survey years. RESULTS: A total of 8082 adolescents (5639 students in 2011-2012 [Mean age: 14.4 years, 50.9% boys] and 2443 students in 2017-2019 [Mean age: 14.7 years, 54.0% boys]) were included in this 7-year study. The average time in bed of Hong Kong adolescents decreased from 8.38 hours to 8.08 hours from 2011-2012 to 2017-2019. There was a 0.28-hour delay in weekday bedtime, 0.54-hour advance in weekend wake-up time, and a 0.36-hour decline in average time in bed, resulting in increased trends of sleep loss (Time in bed <8h: OR = 2.06, 95%CI: 1.44-2.93, p < 0.01; Time in bed <7h: OR = 2.73, 95%CI: 1.92-3.89, p < 0.01), daytime sleepiness (OR = 1.70, 95%CI: 1.34-2.16, p < 0.01), and evening chronotype (OR = 1.26, 95%CI: 1.08-1.48, p < 0.01). The increased trend in insomnia disorder, however, was insignificant when covariates were adjusted. CONCLUSION: A secular trend of reduced time in bed, delay in weekday bedtime, advance in weekend wake-up time, increase in evening chronotype and daytime sleepiness from 2011-2012 to 2017-2019 were observed. There is a timely need for systematic intervention to promote sleep health in adolescents.

Patterns and factors associated with the prescription of psychotropic medications after diagnosis of cancer in Chinese patients: A population-based cohort study.

PURPOSE: Patients with cancer may be prescribed psychotropic medications to address their psychiatric symptoms and disorders. This study examined the patterns and factors associated with the prescription of psychotropics after cancer diagnosis using a population-based database in Hong Kong. METHODS: Patients who were diagnosed with malignant cancer and had no documented psychiatric diagnosis or psychotropic medications prior to cancer diagnosis, were included. Multivariable log-binomial models were used to explore the associations between predictive factors and psychotropic medications use. RESULTS: Among 9337 patients, 1868 patients (20.0%) were newly prescribed with psychotropic medications after cancer diagnoses, most commonly hypnotics (50.3%) and antidepressants (32.8%). About one-third (31.4%) were prescribed chronic psychotropics (≥90 days). Approximately 48.3% of patients who were prescribed psychotropic medications received their prescriptions within 1 year after diagnosed with cancer. Only 18.6% of those prescribed psychotropic medications had a registered psychiatric diagnosis. Patients with multiple comorbidities (adjusted risk ratio[aRR] = 2.74; CI = 2.46-3.05) and diagnosed with oral (aRR = 1.89; CI = 1.52-2.35) or respiratory cancers (aRR = 1.62; CI = 1.36-1.93) were more likely to be prescribed psychotropics. CONCLUSIONS: The use of psychotropic medication is common (20%) among patients with cancer. Our findings highlight the importance of identification and documentation of psychiatric needs among patients with cancer.

Subtyping at-risk adolescents for predicting response toward insomnia prevention program.

BACKGROUND: Previous study has shown that a brief cognitive-behavioral prevention insomnia program could reduce 71% risk of developing insomnia among at-risk adolescents. This study aimed to evaluate the differential response to insomnia prevention in subgroups of at-risk adolescents. METHODS: Adolescents with a family history of insomnia and subthreshold insomnia symptoms were randomly assigned to a 4-week insomnia prevention program or nonactive control group. Assessments were conducted at baseline, 1 week, and 6- and 12-month after the intervention. Baseline sleep, daytime, and mood profiles were used to determine different subgroups by using latent class analysis (LCA). Analyses were conducted based on the intention-to-treat approach. RESULTS: LCA identified three subgroups: (a) insomnia symptoms only, (b) insomnia symptoms with daytime sleepiness and mild anxiety, and (c) insomnia symptoms with daytime sleepiness, mild anxiety, and depression. The incidence rate of insomnia disorder over the 12-month follow-up was significantly reduced for adolescents receiving intervention in subgroup 3 compared with the controls (hazard ratio [HR] = 0.37; 95% confidence interval [CI]: 0.13-0.99; p = .049) and marginally for subgroup 2 (HR = 0.14; 95% CI: 0.02-1.08; p = .059). In addition, adolescents who received intervention in subgroups 2 and 3 had a reduced risk of excessive daytime sleepiness (subgroup 2: adjusted OR [AdjOR] = 0.45, 95% CI: 0.23-0.87; subgroup 3: AdjOR = 0.32, 95% CI: 0.13-0.76) and possible anxiety (subgroup 2: AdjOR = 0.47, 95% CI: 0.27-0.82; subgroup 3: AdjOR = 0.33, 95% CI: 0.14-0.78) compared with the controls over the 12-month follow-up. CONCLUSIONS: Adolescents at risk for insomnia can be classified into different subgroups according to their psychological profiles, which were associated with differential responses to the insomnia prevention program. These findings indicate the need for further phenotyping and subgrouping at-risk adolescents to develop personalized insomnia prevention.

The impacts of intra-individual daily sleep variability on daytime functioning and sleep architecture in healthy young adults: An experimental study.

Sleep variability is commonly seen in the young populations. This study aimed to examine the impacts of experimentally induced sleep variability on sleepiness, mood, cognitive performance and sleep architectures among young adults. Thirty-six healthy individuals (aged 18-22 years) were randomly assigned to either variable sleep schedule (n = 20) or control (n = 16) groups. The protocol involved 1 week of regular sleep (time in bed = 7.5 hr) in the home setting, followed by one adaptation night (time in bed = 7.5 hr), one baseline night (time in bed = 7.5 hr), and 6 nights of sleep manipulation in the laboratory monitored by polysomnography (three cycles of variable sleep schedule by changing daily time in bed alternating between 6 hr and 9 hr for variable sleep schedule group versus fixed sleep schedule with daily time in bed for 7.5 hr for control group). Sleepiness, mood, sustained attention, processing speed, response inhibition and working memory were measured every morning and evening. The variable sleep schedule group reported a higher level of sleepiness, especially in the mornings, and increased negative mood in the evenings. There were no significant differences in positive mood, cognitive performance and sleep macro- and micro-structures. Our results showed the negative effects of sleep variability on daytime functioning especially sleepiness and negative mood, suggesting the need to address variable sleep schedules through sleep intervention.

Association between matched chronotype and poor mental health among shift workers: a systematic review and meta-analysis.

BACKGROUND: Nearly 0.7 billion workers are involved in the shift work system, leading to concerns about its potential impacts on the large-scale population mental health. This study aimed to synthesise evidence of the associations between matched chronotype and the risk of poor mental health among shift workers. METHODS: Six computerised databases were searched from inception to September 2022. Observational studies were selected if they reported any association between common mental health parameters and chronotype scores/types of shift workers. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was followed. We extracted adjusted risk estimates to calculate pooled effect sizes and explore sources of heterogeneity. The study was registered in PROSPERO: CRD42022357437. RESULTS: Fourteen studies including 49 909 workers were identified. Ever shift workers had a higher risk of poor mental health than the day workers (pooled OR 1.15, 95% CI 1.03 to 1.28; I2=14%, p=0.29), with the evening chronotype ever shift workers having a 1.47 times higher risk than those who worked during the day (pooled OR 1.47, 95% CI 1.13 to 1.91; I2=42%, p=0.16). Sensitivity analysis excluding studies with the highest risk of bias of each group demonstrated consistent findings. CONCLUSIONS: Evening chronotype ever shift workers have poorer mental health than shift workers with other chronotypes. Chronotype remains unrecognised in the contemporary rostering system, making it a hidden contributor to occupational mental health. Work-related physical and mental stresses may be prevented/mitigated with further investigation on optimising shift work schedule combined with individual chronotype preference.

Sleep and academic performance among students in Hong Kong: Curvilinear relationship suggesting an optimal amount of sleep.

OBJECTIVES: This study aimed to elucidate the association between sleep and academic performance using standardized academic assessment in a large and representative sample of school children and adolescents in Hong Kong. METHODS: This school-based cross-sectional study was conducted in 2016. Students completed territory-wide standardized tests in Chinese, English, and Mathematics and a set of questionnaires covering sleep, academic anxiety and motivation. Parents provided additional information on socioeconomic status and children's study behaviors. Weekday proxy sleep duration was reflected by time-in-bed, the difference between bedtime and wakeup time. RESULTS: The study included 4262 Grade 3 (G.3) (mean age [SD], 9.2 [0.6] years; girls: 49.7%) and 3297 G.9 students (mean age [SD], 15.3 [0.74]; girls: 57.5%) from 77 schools. Apart from showing a general insufficiency of students' sleep in this metropolitan city, there was a significant quadratic relationship (G.3: ß = -0.05, p < .001; G.9: ß = -0.03, p < .01), indicating that students with an optimal level of sleep (9.5 h and 8.5 h in G.3 and G.9, respectively) tend to have better academic performance. The significant association remained after controlling for socioeconomic and study-related variables in that sleeping too little or too much was associated with poor academic performance. CONCLUSIONS: This is the first study to explore the curvilinear association between sleep duration and academic performance by using standardized test and simultaneously examining learning-related controls with a large representative sample in Hong Kong. The findings suggested that there is an inverted U-shaped relationship between sleep duration and academic performance in both school-aged children and adolescents. It is recommended that systematic sleep education and intervention is necessary to encourage the development of optimal sleep pattern, which might have beneficial effect on academic performance for students at both primary and secondary level.

Clinical and neuroimaging markers of neurodegeneration in first-degree relatives of patients with REM sleep behavior disorder with and without isolated rapid eye movement sleep without atonia: A case-control clinical and dopamine PET study.

OBJECTIVES: The current study aimed to examine the neurodegenerative implication of isolated REM sleep without atonia (RSWA) among first-degree relatives of patients with REM sleep behaviour disorder (RBD). METHODS: This cross-sectional case-control study recruited three groups of subjects: First-degree relatives of RBD patients with isolated RSWA (n = 17), first-degree relatives of RBD patients without isolated RSWA (n = 18), and normal controls who did not have any RWSA and family history of RBD (n = 15). Prodromal Parkinson's Disease likelihood ratio by the updated MDS Research Criteria and striatal dopaminergic transmission function of the subjects as assessed by triple-tracer (18F-DOPA, 11C-Raclopride, and 18F-FDG) PET/CT scan were used as proxy markers of neurodegeneration. RESULTS: In contrary to our hypothesis, the three groups did not differ in their pre- or post-striatal dopaminergic transmission function, and their Prodromal Parkinson's Disease likelihood ratio. However, they differed significantly in their frequency of a having first-degree relatives with Parkinson's disease or dementia of Lewy body (first-degree relativess with RSWA vs first degree relatives without RSWA vs normal controls = 58.8% vs 22.2% vs 0%, p = 0.001). CONCLUSION: FDRs of RBD patients with isolated RSWA did not have increased neurodegenerative markers compared to FDRs of RBD patients without isolated RSWA and normal control, despite an paradoxical increase in frequency of Parkinson's disease or dementia of Lewy body among their family compared to FDRs of RBD patients without isolated RSWA. Further longitudinal follow-up study will be needed to ascertain their long-term prognosis.

Isolated dream-enactment behaviours as a prodromal hallmark of rapid eye movement sleep behaviour disorder.

Recurrent dream-enactment behaviours (DEB) and rapid eye movement (REM) sleep without atonia (RSWA) are two diagnostic hallmarks of REM sleep behaviour disorder (RBD), a specific prodrome of α-synucleinopathy. Whilst isolated RSWA (without DEB) was suggested as a prodrome of RBD, the implication of 'isolated' recurrent DEB remains under-investigated. In this cross-sectional study, we sought to investigate neurodegenerative markers amongst the first-degree relatives (FDRs, aged >40 years) of patients with RBD who underwent clinical assessment for DEB, neurodegenerative markers, and video-polysomnography assessment. Isolated recurrent DEB was defined as: (i) three or more episodes of DEB, (ii) had a DEB episode in the past 1 year, and (iii) subthreshold RSWA. We identified 29 FDRs (mean [SD] age 53.4 [8.3] years, 55.2% male) with isolated recurrent DEB and 98 age and sex-matched FDRs as controls. Isolated DEB was associated with nightmare (27.6% versus 11.2%, p = 0.02), and the DEB group had a higher rate of current smoking (27.6% versus 3.1%, p = 0.006), type 2 diabetes mellitus (24.1% versus 10.2%, p = 0.003), anxiety disorder (24.1% versus 11.2%, p = 0.02), and constipation (hard lump of stool, 31.0% versus 7.1%, p < 0.001) than the control group. The present findings revealed that family relatives of patients with RBD with isolated recurrent DEB have increased risk of RBD and neurodegenerative features, which adds to the emerging data that isolated DEB is a prodromal feature of RBD and α-synucleinopathy neurodegeneration.

The impact of sleep-corrected social jetlag on mental health, behavioral problems, and daytime sleepiness in adolescents.

STUDY OBJECTIVES: This study aimed to examine the effect of sleep-corrected social jetlag (SJLsc) on mental health, behavioral problems, and daytime sleepiness in adolescents. METHODS: This was a cross-sectional study which included 4787 adolescents (Mean age: 14.83±1.6y, 56.0% girls) recruited from 15 secondary schools in Hong Kong. SJLsc was defined as the absolute difference between sleep-corrected midsleep on weekdays and weekends, at which the sleep debt has been considered. It was classified into three groups: low-level ("LSJLsc", <1h), mid-level ("MSJLsc", ≥1h and <2h), and high-level of SJLsc ("HSJLsc", ≥2h). Adolescents' mental health, behavioral problems and daytime sleepiness were measured by the General Health Questionnaire (GHQ-12), the Strengths and Difficulties Questionnaire (SDQ) and the Pediatric Daytime Sleepiness Scale (PDSS). Logistic regression analysis and restricted cubic spline regression (RCS) analysis were applied with consideration of confounders including age, gender, puberty and sleep problems. RESULTS: Nearly half (46.9%) of adolescents had SJLsc for at least 1 h. Greater SJLsc was associated with more behavioral difficulties (MSJLsc: OR: 1.20, p = 0.03; HSJLsc: OR: 1.34, p = 0.02) when controlling for age, sex, puberty, chronotype, insomnia, and time in bed. There was a dose-response relationship in which higher SJLsc had an increased risk of conduct problems and hyperactivity, while only high-level SJLsc was associated with a peer relationship problem. In RCS analysis, SJLsc was associated with a higher likelihood of behavioral difficulties (p = 0.03) but not poor mental health or daytime sleepiness. CONCLUSIONS: Sleep-corrected social jetlag was a unique risk factor for behavioral problems in adolescents. Our findings highlighted the need for interventions to promote healthy sleep-wake patterns in school adolescents.

Dim light melatonin patterns in unaffected offspring of parents with bipolar disorder: A case-control high-risk study.

BACKGROUND: Circadian dysregulation has long been thought to be a key component in the pathophysiology of bipolar disorder (BD). However, it remains unclear whether this dysregulation constitutes a risk factor, manifestation, or consequence of BD. This study aimed to compare dim light melatonin secretion patterns between unaffected offspring of parents with BD (OBD) and offspring of control parents (OCP). METHODS: This case-control study included unaffected OBD (mean age 14.0 years; male 50.0 %) and age- and sex-matched OCP (mean age 13.0 years; male: 43.5 %). Seventeen saliva samples were collected in dim light conditions. Dim light melatonin onset (DLMO), phase angles, and area under the curve (AUC) were calculated. RESULTS: 185 saliva samples from 12 OBD (n = 12) and 741 from OCP (n = 46) were collected. Unaffected OBD had a significant lower nocturnal melatonin level (14.8 ± 4.6 vs. 20.3 ± 11.7 pg/mL) and a smaller melatonin AUC within two hours after DLMO (35.5 ± 11.3 vs. 44.6 ± 18.1 pg/mL) but a significant larger phase angle between DLMO and sleep onset (2.2 ± 1.0 vs. 1.4 ± 1.2 h) than OCP. There was no significant between-group difference in DLMO. The graphic illustrations showed a considerably flattened melatonin secretion in unaffected OBD. LIMITATIONS: The main limitations include lack of 24-h dim melatonin secretion measurement, large age range of participants, and small sample size. CONCLUSIONS: These findings suggest that unaffected OBD already presented with circadian rhythm dysregulations. Future investigations are needed to clarify the role of abnormal melatonin secretion in the onset of BD.

Efficacy of Email-delivered Versus Face-to-face Group Cognitive Behavioral Therapy for Insomnia in Youths: A Randomized Controlled Trial.

PURPOSE: The purpose of the study was to compare the efficacy of group-based therapy (GT) and email-delivered self-help (ESH) cognitive behavioral therapy for insomnia (CBT-I) with the wait-list (WL) control group in youths. METHODS: The study involved an assessor-blind, parallel group randomized controlled trial in youths meeting the diagnostic criteria for insomnia disorder. Participants were randomized to one of the three groups (8-week GT, 8-week ESH, or WL). Participants in all three groups were assessed at baseline and after treatment (week 9 for the WL group). The two treatment groups were additionally assessed at one month and six months after the intervention. Treatment effects were examined using linear mixed models. RESULTS: A total of 135 youths (mean age: 20.0 ± 2.5 years, female: 67.4%) were recruited. After treatment, both active treatment groups showed significant improvements in insomnia symptoms (GT vs. WL: Cohen's d = -1.03, ESH vs. WL: d = -.63), less presleep arousal (d = -.52 to -1.47), less sleep-related dysfunctional belief (d = -.88 to -1.78), better sleep hygiene practice (d = -.79 to -.84), and improved daytime functioning (d = -.56 to -.96) compared with the WL group. In addition, GT outperformed ESH in improving maladaptive sleep-related beliefs and mood symptoms at post-treatment and 6-month follow-up. A reduction of suicidality with moderate effect size favoring GT emerged at 6-month follow-up. DISCUSSION: Our findings suggested that both group-based and email-delivered CBT-I were effective in treating youth insomnia, but group-based CBT-I showed superior effects on reducing maladaptive beliefs and mood symptoms.

Validation of the Chinese version of the Munich Chronotype Questionnaire (MCTQHK) in Hong Kong Chinese youths.

Chronotype, referred to as an individual's diurnal preference of timing for rest and activity, can be subjectively measured using the Munich Chronotype Questionnaire (MCTQ). However, the validity of MCTQ has yet to be tested in the youth population. In addition, it remains uncertain if MCTQ is a good measure of chronotype in individuals with insomnia. The current study aimed to validate the Chinese version of MCTQ (MCTQHK) in the youth population and to explore the utility of MCTQHK in individuals with insomnia. The original MCTQ was translated into Chinese language using the translation-back-translation method. Part one of this study included 988 youths who completed a battery of self-report questionnaires online consisting of the MCTQHK and the morningness-eveningness questionnaire (MEQ) for the measures of circadian preference, Insomnia Severity Index (ISI) to assess insomnia symptoms, and Patient Health Questionnaire (PHQ-9) to measure depressive symptoms. Test-retest reliability was examined in 442 participants at one-month follow-up. Of the overall sample, 69 participants were randomly drawn to complete the second part of the study, which included prospective 7-day actigraphy monitoring and a further subset (n = 40) additionally completed a laboratory-based assessment of dim-light melatonin onset (DLMO) as a circadian phase marker. A total of 659 participants with valid responses were finally included in the analyses of the data collected from part one of the study (female = 67.7%; mean age: 20.7 ± 2.02). Results showed that MCTQ parameters, namely the midpoint of sleep on free days (MSF), midpoint of sleep on workdays (MSW), and midpoint of sleep adjusted for sleep debt (MSFsc), were significantly correlated with MEQ score (r = -.514 to -.650, p < .01). Test-retest reliability for MCTQHK was good (intraclass correlation = 0.75 to 0.84). Later MSFsc was significantly associated with greater insomnia and depressive symptoms after controlling for age and sex. All MCTQ parameters showed significant correlations with actigraphy-based midpoint of sleep and circadian rhythm parameters, i.e., acrophase and L5 onset (r = .362 to .619, p < .01), as well as DLMO (r = .393 to .517, p < .05). The associations remained significant after controlling for age. MSFsc derived from MCTQ was significantly correlated with MEQ score in both the healthy sleepers and participants with insomnia (as defined by ISI > 14), r = -.600, p < .001 and r = -.543, p < .001, respectively. The present study demonstrated that MCTQHK is suitable for assessing chronotype with good reliability and validity in Chinese youths and supported the utility of MCTQHK in individuals with insomnia.

Associations of circadian factors with insomnia symptoms and emotional and behavioral problems among school-age children.

STUDY OBJECTIVES: To examine the associations of circadian characteristics (ie, chronotype and social jetlag) with insomnia symptoms and emotional and behavioral problems among school-age children. METHODS: A total of 620 primary school children (medianage = 10.06, standard deviation = 1.16, 58.7% boys) were recruited and assessed by a set of parent-report questionnaires, including Children's Sleep Habit Questionnaire for measuring sleep-wake patterns and insomnia symptoms (bedtime resistance, sleep onset delay, and night waking), Children's Chronotype Questionnaire for assessing the child's chronotype preference, and Strength and Difficulties Questionnaire for assessing emotional and behavioral problems. Linear regression models were applied to examine the associations of chronotype and social jetlag with insomnia symptoms and mental health outcomes, in which age, sex, family income, and average sleep duration were entered as covariates. RESULTS: Evening chronotype was significantly associated with bedtime resistance and sleep onset delay, while social jetlag was not related to insomnia symptoms. Evening chronotype was also significantly associated with externalizing symptoms after controlling for potential confounders. CONCLUSIONS: Evening chronotype, but not social jetlag, was the risk factor for insomnia symptoms, and evening chronotype was further associated with increased behavioral problems in school-age children. Our findings underscored the roles of circadian factors in relation to sleep and mental health problems in this young population. CITATION: Sun W, Kwok NTT, Chan NY, et al. Associations of circadian factors with insomnia symptoms and emotional and behavioral problems among school-age children. J Clin Sleep Med. 2021;17(10):2107-2114.

Non-pharmacological Approaches for Management of Insomnia.

Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.

A Prevention Program for Insomnia in At-risk Adolescents: A Randomized Controlled Study.

OBJECTIVES: To prevent the future development of insomnia in at-risk adolescents. METHODS: A randomized controlled trial comparing 4 weekly insomnia prevention program with a nonactive control group. Subjects were assessed at baseline, postintervention, and 6 and 12 months after intervention. Assessors were blinded to the randomization. Analyses were conducted on the basis of the intention-to-treat principles. RESULTS: A total of 242 adolescents with family history of insomnia and subthreshold insomnia symptoms were randomly assigned to an intervention group (n = 121; mean age = 14.7 ± 1.8; female: 51.2%) or control group (n = 121; mean age = 15.0 ± 1.7; female: 62.0%). There was a lower incidence rate of insomnia disorder (both acute and chronic) in the intervention group compared with the control group (5.8% vs 20.7%; P = .002; number needed to treat = 6.7; hazard ratio = 0.29; 95% confidence interval: 0.12-0.66; P = .003) over the 12-month follow-up. The intervention group had decreased insomnia symptoms (P = .03) and reduced vulnerability to stress-related insomnia (P = .03) at postintervention and throughout the 12-month follow-up. Decreased daytime sleepiness (P = .04), better sleep hygiene practices (P = .02), and increased total sleep time (P = .05) were observed at postintervention. The intervention group also reported fewer depressive symptoms at 12-month follow-up (P = .02) compared with the control group. CONCLUSIONS: A brief cognitive behavioral program is effective in preventing the onset of insomnia and improving the vulnerability factors and functioning outcomes.

The associations of insomnia symptoms and chronotype with daytime sleepiness, mood symptoms and suicide risk in adolescents.

OBJECTIVES: To investigate the association of insomnia and chronotype preference with daytime impairment and psychopathology in a community sample of adolescents in Hong Kong. METHODS: This was a cross-sectional study that included seven local secondary schools in Hong Kong. A total of 1667 adolescents (mean age: 14.8 ± 1.6 years old; boys: 56.5%) returned a battery of self-report questionnaires including Insomnia Severity Index (ISI) and reduced Horne and Östberg Morningness and Eveningness Questionnaire (rMEQ) for assessing insomnia symptoms and chronotype preference, respectively. A subset of adolescent samples (n = 768) were additionally assessed for suicidal ideation. Potential confounders including age, gender and sleep duration were controlled for in the analyses. RESULTS: The prevalence of insomnia symptoms and eveningness chronotype was 37% and 25.6%, respectively. Regression models indicated that insomnia and eveningness were independently associated with excessive daytime sleepiness (insomnia: adjusted OR [AdjOR] = 3.8; 95% confidence interval [C.I.] = 2.9-5.0; eveningness: AdjOR = 2.6; 95% C.I. = 1.9-3.7), and an increased risk of depression (insomnia: AdjOR = 3.5, 95% C.I. = 2.5-5.0; eveningness: AdjOR = 2.0, 95% C.I. = 1.3-3.2). The odds ratio increased to 8.7 (95% C.I. = 6.1-12.3, p < 0.001) for excessive daytime sleepiness and 4.8 (95% C.I. = 3.2-7.2, p < 0.001) for depression among adolescents with both insomnia and eveningness. Insomnia symptoms, but not eveningness, were associated with anxiety symptoms (AdjOR = 5.8; 95% C.I. = 3.6-9.4) and suicidal ideation (AdjOR = 2.1, 95% C.I. = 1.4-3.2). CONCLUSIONS: The present study provided further evidence that insomnia and eveningness uniquely contributed to poor daytime functioning and mood related outcomes, while the co-existence of these two conditions could confer a greater risk in adolescents. However, insomnia, but not eveningness, was significantly linked to suicidality after controlling for mood symptoms. Our findings highlighted the necessity of timely management of sleep and circadian issues in adolescents.

Rest-Activity Pattern Alterations in Idiopathic REM Sleep Behavior Disorder.

OBJECTIVE: The purpose of this study was to investigate the differences in actigraphy-measured rest-activity patterns (eg, sleep-wake cycle, circadian rest-activity rhythm, and physical activity) across different stages of α-synucleinopathy. METHODS: We compared alterations in 7-day actigraphy-measured rest-activity patterns among patients with clinically diagnosed α-synucleinopathies (n = 44), and their age-, sex-, and body mass index (BMI)-matched patients with idiopathic rapid eye movement (REM) sleep behavior disorder (iRBD, n = 88), and non-rapid eye movement (REM) sleep behavior disorder (RBD) controls (n = 44) in a case-control study (study 1) and between convertors (n = 22) and their age-, sex-, BMI-, iRBD-duration, and follow-up duration-matched non-convertors (n = 66) in a prospective nested case-control study (study 2). RESULTS: In study 1, there were significant increases (all p values were adjusted by false discovery rate < 0.01) in probable napping behaviors (percentage, duration, and episodes), activity fragmentation (estimated by kAR ), and physical inactivity during active periods across controls, and iRBD, to clinically diagnosed α-synucleinopathies. In study 2, higher levels (all p values were adjusted by false discovery rate < 0.05) of baseline objective probable napping, activity fragmentation, and physical inactivity during active periods were associated with the conversion of patients with iRBD into clinically diagnosed α-synucleinopathies at 2 years of follow-up with medium to large effect sizes (Cohen's d: 0.56 to 0.80). These findings were further supported by functional linear modeling analyses. INTERPRETATION: Rest-activity pattern alterations, mainly objective probable napping behaviors, activity fragmentation, and physical inactivity during active period, emerge as early as at the stage of iRBD, which serves as early and robust prodromal markers of the conversion of iRBD into clinically diagnosed α-synucleinopathies. ANN NEUROL 2020;88:817-829.