Psychometric Evaluation of the Insomnia Severity Index in U.S. College Students.

Psychometric properties of the Insomnia Severity Index (ISI) were analyzed in U.S. college samples. ISI items and total score with sleep and psychosocial questionnaires were examined in Experiment I. ISI diagnostic accuracy in a clinical sample with and without insomnia was assessed in Experiment II. ISI test-retest validity, confirmatory factor analysis (CFA), and item response theory via graded response model (GRM) were assessed in Experiment III. Results indicated analogous ISI and sleep diary items showed moderate correlations (r1 = .40; r2 = .45). The ISI total had weak to strong correlations with other indicators of sleep-related disturbance (rs = .25-.62). The ISI had weak to moderate correlations with psychosocial measures commonly associated with insomnia (rs = .10-.57). The diagnostic accuracy of the ISI was very high (area under the curve [AUC] = .999). Sensitivity and specificity were maximized at a cutoff score ≥ 8. The ISI demonstrated good test-retest reliability (ICC = .87). CFA revealed a three-factor model for two study samples and GRM indicated better ability of the ISI to assess moderate (Sample III) and moderate to high (Sample I) levels of insomnia severity. The ISI demonstrated good psychometric properties and appears generally valid for screening insomnia disorder and assessing insomnia severity in college students. Overlap with psychological symptoms suggests caution while interpreting these constructs independently.

Patient perceptions of digital and therapist-led CBT for insomnia: A qualitative study.

OBJECTIVES: Technology has the potential to increase access to evidence-based insomnia treatment. Patient preferences/perceptions of automated digital cognitive behavior therapy for insomnia (CBTI) and telehealth-delivered CBTI remain largely unexplored among middle-aged and older adults. Using a qualitative approach, the current study describes patients' reasons for participating in the clinical trial, preferences for digital CBTI (dCBTI) versus therapist-led CBTI, patient attitudes toward dCBTI, and patient attitudes toward telehealth-delivered therapist-led CBTI. METHOD: Middle-aged and older adults (N = 80) completed a semi-structured interview before CBTI exposure. Qualitative responses were coded, and themes were inductively extracted. RESULTS: Most (62.5%) of the participants expressed a preference for therapist-led CBTI to dCBTI. Convenience was the most commonly reported advantage of dCBTI (n = 55) and telehealth-delivered CBTI (n = 65). Decreasing transit time and pandemic-related health concerns were identified as advantages to dCBTI and telehealth-delivered CBTI. Lack of human connection and limited personalization were perceived as disadvantages of dCBTI. Only three participants reported technological barriers to dCBTI and telehealth-delivered CBTI. CONCLUSION: Findings suggest that, despite an overall preference for therapist-led treatment, most middle-aged and older adults are open to dCBTI. As both dCBTI and telehealth-delivered CBTI are perceived as convenient, these modalities offer the potential to increase access to insomnia care.

Effects of a Triage Checklist to Optimize Insomnia Treatment Outcomes and Reduce Hypnotic Use: The RESTING Study.

STUDY OBJECTIVES: Evaluate a triaged stepped-care strategy among adults 50 and older with insomnia disorder. METHODS: Participants (N=245) were classified at baseline by a Triage-Checklist. Those projected to do better if they start treatment with therapist versus digitally delivered CBT-I (tCBT-I versus dCBT-I) constituted the YES stratum (n=137); the rest constituted the NO stratum (n=108). Participants were randomized within stratum to a strategy that utilized only dCBT-I (ONLN) or to a strategy that prospectively allocated the first step of care to dCBT-I or tCBT-I based on the Triage-Checklist and switched dCBT-I non-responders at 2-months to tCBT-I (STEP). Co-primary outcomes were the insomnia severity index (ISI) and the average nightly amount of prescription hypnotic medications used (MEDS), assessed at 2,4,6,9, and 12 months post-randomization. RESULTS: Mixed effects models revealed that, compared to ONLN, participants in STEP had greater reductions in ISI (p=0.001; η2=0.01) and MEDS (p=0.019, η2=0.01). Within the YES stratum, compared to ONLN, those in STEP had greater reductions in ISI (p=0.0001, η2=0.023) and MEDS (p=0.018, η2=0.01). Within the ONLN arm, compared to the YES stratum, those in the NO stratum had greater reductions in ISI (p=0.015, η2=0.01) but not in MEDS. Results did not change with treatment-dose covariate adjustment. CONCLUSIONS: Triaged-stepped care can help guide allocation of limited CBT-I treatment resources to promote effective and safe treatment of chronic insomnia among middle age and older adults. Further refinement of the Triage-Checklist and optimization of the timing and switching criteria may improve the balance between effectiveness and use of resources.

Alcohol Use Predicts Longer But More Fragmented Sleep: A Daily Diary Study of Alcohol, Sleep, and PTSD in Nurses.

BACKGROUND: Due to the demanding nature of their profession, nurses are at risk of experiencing irregular sleep patterns, substance use, and fatigue. Evidence supports a reciprocal relationship between alcohol use and sleep disturbances; however, no research has examined such a link in a sample of nurses. One factor that may further impact the dynamic between alcohol and sleep patterns is posttraumatic stress disorder (PTSD) symptoms. We investigated the daily bidirectional associations between alcohol use and several sleep domains (i.e., self-report and actigraphy-determined sleep), and moderation by baseline PTSD symptom severity. METHOD: Over a 14-day period, 392 nurses (92% female; 78% White) completed sleep diaries and actigraphy to assess alcohol use and sleep patterns. Within-person bidirectional associations between alcohol and sleep were examined using multilevel models, with symptoms of PTSD as a cross-level moderator. RESULTS: Daily alcohol use (i.e., ≥ 1 alcoholic beverage; 25.76%) was associated with shorter self-reported sleep onset latency (b = -4.21, p = .003) but longer self-reported wake after sleep onset (b = 2.36, p = .009). Additionally, days with any alcohol use were associated with longer self-reported sleep duration (b = 15.60, p = .006) and actigraphy-determined sleep duration (b = 10.06, p = .037). No sleep variables were associated with next-day alcohol use. Bidirectional associations between alcohol consumption and sleep were similar regardless of baseline PTSD symptoms. CONCLUSION: Our results suggested that on days when nurses drank alcohol, they experienced longer but also more fragmented sleep.

Integration of Sensor-Based and Self-Reported Metrics in a Sleep Diary: A Pilot Exploration.

OBJECTIVES: Discrepancies between sleep diaries and sensor-based sleep parameters are widely recognized. This study examined the effect of showing sensor-based sleep parameters while completing a daily diary. The provision of sensor-based data was expected to reduce variance but not change the mean of self-reported sleep parameters, which would in turn align better with sensor-based data compared to a control diary. METHOD: In a crossover study, 24 volunteers completed week-long periods of control diary (digital sleep diary without sensor-based data feedback) or integrated diary (diary with device feedback), washout, and then the other diary condition. RESULTS: The integrated diary reduced self-reported total sleep time (TST) by <10 minutes and reduced variance in TST. The integrated diary did not impact mean sleep onset latency (SOL) and, unexpectedly, the variance in SOL increased. The integrated diary improved both bias and limits of agreement for SOL and TST. CONCLUSIONS: Integration of wearable, sensor-based device data in a sleep diary has little impact on means, mixed evidence for less variance, and better agreement with sensor-based data than a traditional diary. How the diary impacts reporting and sensor-based sleep measurements should be explored.

Psychometric Evaluation of the Insomnia Severity Index in Nurses.

OBJECTIVES: Examine psychometric properties of the Insomnia Severity Index (ISI) in a sample of nurses. METHOD: In a sample of day shift nurses (N = 289), a confirmatory factor analysis (CFA), convergent and discriminant validity analyses, and a test-retest reliability analysis were performed. RESULTS: CFA showed that a two-factor model provided the best fit. The ISI had moderate to poor convergent validity with sleep diary parameters, and moderate convergent validity with the Sleep Condition Indicator (r = -.66), Pittsburgh Sleep Quality Index (r = .66), and PROMIS Sleep-Related Impairment measure (r = .67). The ISI demonstrated good discriminant validity with the measures Composite Scale of Morningness (r = -.27), Nightmares Disorder Index (r = .25), PTSD Checklist for DSM-5 (sleep items removed; r = .32), and Perceived Stress Scale (r = .43). The ISI had weaker discriminant validity with the PHQ-9 (r = .69) and Generalized Anxiety Disorder Screener (r = .51). The ISI demonstrated a good test-retest reliability (ICCs = .74-.88). CONCLUSIONS: The ISI is a psychometrically strong measure for the assessment of insomnia severity in day shift nurses. Overlap with psychological symptoms, primarily anxiety and depression, suggests caution while interpreting these constructs.

Irregular sleep is linked to poorer mental health: A pooled analysis of eight studies.

OBJECTIVES: Greater sleep disturbances on average are a risk factor for impaired mental health. Recent research has shown that more intraindividual variability (i.e., inconsistency) in sleep (hereafter called "sleep intraindividual variability") may also be uniquely related to mental health, even above the influence of mean sleep patterns averaged across days. The current study examined associations between sleep intraindividual variability and symptoms of anxiety, depression, and insomnia across different facets of sleep intraindividual variability (sleep duration, efficiency, and timing) and sleep measurement types (sleep diary and actigraphy). METHODS: We pooled eight datasets (N = 3053 participants) that assessed repeated measures of sleep diary- and/or actigraphy-determined sleep across multiple days, as well as one-time measures of mental health or sleep disorder symptoms (i.e., anxiety, depression, and insomnia). Multilevel regression analyses were conducted to examine associations between sleep intraindividual variability and mental health or sleep disorder symptoms. RESULTS: Greater diary- and actigraphy-determined sleep duration intraindividual variability was associated with more depression symptoms (diary: b=0.02, p < .001; actigraphy: b=0.03, p = .006) and more insomnia symptoms (diary: b=0.02, p < .001; actigraphy: b=0.02, p < .001). Greater diary-determined sleep efficiency intraindividual variability was associated with fewer anxiety symptoms (b=-0.23, p = .019) and fewer insomnia symptoms (b=-0.15, p < .001). Greater diary- and actigraphy-determined sleep midpoint intraindividual variability was associated with more insomnia symptoms (diary: b=0.41, p = .044; actigraphy: b=0.66, p = .021). CONCLUSIONS: More inconsistent sleep duration and sleep timing may be a correlate of poorer mental health. Future experimental work should examine whether stabilizing sleep patterns can improve mental health outcomes.

Improve accessibility to evidence-based treatment for insomnia disorder.

The Society of Behavioral Medicine supports increasing access to evidence-based treatment of insomnia by addressing barriers at the patient, provider, and systemic levels including support from government agencies to raise awareness about sleep and sleep disorders, health payors providing fair reimbursement for evidence-based insomnia assessment and therapy consistent with standard of care recommendations, and relevant training programs (e.g. psychologists, nurses, physicians, social workers, licensed professional counselors) to prioritize sleep health education.

The Society of Behavioral Medicine supports making treatment for insomnia more available to people who need it. This could include using several solutions that target different people who can make a difference. One solution could be public health campaigns that increase awareness of the treatment options for insomnia among patients and providers. A second solution could include encouraging training programs for behavioral health providers to focus more on learning how to offer insomnia treatment. A third solution could be advocating with insurance companies to provide higher financial support for these services from well-trained providers.

Interventions to Improve Long-Term Adherence to Physical Rehabilitation: A Systematic Review.

OBJECTIVE: To evaluate the impact of physical rehabilitation interventions, supplemented with one or more adherence-enhancing components, on outcomes among adults with hip or knee osteoarthritis or chronic lower back pain. DESIGN: Primary literature search from inception of each database to July 27, 2021, guided by relevant search terms and keywords to search titles and abstracts. All articles meeting eligibility criteria were included for data abstraction. DATA SOURCES: MEDLINE, CINAHL Complete, and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized and nonrandomized trials evaluating adherence-focused intervention components conducted in addition to an index usual care or usual care-like physical rehabilitation program among adults with hip or knee osteoarthritis or chronic low back pain. Eligible studies included a comparator group of the same index physical rehabilitation intervention without the adjunctive adherence components. Included studies measured outcomes at least 3 months after the rehabilitation course. RESULTS: Of the 10 studies meeting inclusion criteria, 6 interventions were delivered concurrent to an index rehabilitation program and 4 were delivered sequentially. Of the 3 studies that reported a positive effect on long-term adherence, only 1 was a low risk of bias study. There is very limited evidence of a beneficial treatment effect of adjunct adherence interventions on long-term physical function, self-efficacy, or adverse events. CONCLUSION: We found inadequate evidence evaluating adherence-enhancing interventions for the specific promotion of long-term adherence to home rehabilitation programs. Future studies should consider testing interventions specifically built to target behavioral maintenance of home rehabilitation programs.

Behavioral and psychological treatments for NREM parasomnias: A systematic review.

BACKGROUND: Non-rapid eye movement (NREM) parasomnias are often benign and transient, requiring no formal treatment. However, parasomnias can also be chronic, disrupt sleep quality, and pose a significant risk of harm to the patient or others. Numerous behavioral strategies have been described for the management of NREM parasomnias, but there have been no published comprehensive reviews. This systematic review was conducted to summarize the range of behavioral and psychological interventions and their efficacy. METHODS: We conducted a systematic search of the literature to identify all reports of behavioral and psychological treatments for NREM parasomnias (confusional arousals, sexsomnia, sleepwalking, sleep terrors, sleep-related eating disorder, parasomnia overlap disorder). This review was conducted in line with PRISMA guidelines. The protocol was registered with PROSPERO (CRD42021230360). The search was conducted in the following databases (initially on March 10, 2021 and updated February 24, 2023): Ovid (MEDLINE), Cochrane Library databases (Wiley), CINAHL (EBSCO), PsycINFO (EBSCO), and Web of Science (Clarivate). Given a lack of standardized quantitative outcome measures, a narrative synthesis approach was used. Risk of bias assessment used tools from Joanna Briggs Institute. RESULTS: A total of 72 publications in four languages were included, most of which were case reports (68%) or case series (21%). Children were included in 32 publications and adults in 44. The most common treatment was hypnosis (33 publications) followed by various types of psychotherapy (31), sleep hygiene (19), education/reassurance (15), relaxation (10), scheduled awakenings (9), sleep extension/scheduled naps (9), and mindfulness (5). Study designs and inconsistent outcome measures limited the evidence for specific treatments, but some evidence supports multicomponent CBT, sleep hygiene, scheduled awakenings, and hypnosis. CONCLUSIONS: This review highlights the wide breadth of behavioral and psychological interventions for managing NREM parasomnias. Evidence for the efficacy of these treatments is limited by the retrospective and uncontrolled nature of most research as well as the infrequent use of validated quantitative outcome measures. Behavioral and psychological treatments have been studied alone and in various combinations, and recent publications suggest a trend toward preference for multicomponent cognitive behavioral therapies designed to specifically target priming and precipitating factors of NREM parasomnias.

Intraindividual variability in sleep duration and college degree attainment.

The objective of the current study was to examine the relationship between sleep characteristics and college degree attainment. Participants were 968 college students (72% female; mean age 19.7 [1.7]). Participants completed a psychosocial and sleep questionnaire battery followed by one week of daily sleep diaries. Academic degree completion data was obtained from the university registrar 10 years later. Logistic regression examined whether mean and variability in sleep duration and sleep efficiency and insomnia symptoms predicted degree attainment, adjusting for age, gender, semester, grade point average (GPA), and perceived stress. The strongest predictors of degree attainment were female gender (OR = 0.67), greater age (OR = 1.32), GPA (OR = 1.97), and lower intraindividual variability in sleep duration (OR = 0.99). Results highlight the importance of examining variability in sleep duration in addition to mean sleep duration in predicting college retention. Future research should use a combination of objective and subjective measures to explore the impact of sleep factors, including variability, on degree completion and other academic metrics.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial.

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.

Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder.

STUDY OBJECTIVES: To examine beliefs about prescription sleep medications (hypnotics) among individuals with insomnia disorder seeking cognitive behavioral therapy for insomnia and predictors of wishing to reduce use. METHODS: Baseline data was collected from 245 adults 50 years and older enrolled in the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study. T-tests compared characteristics of prescription sleep medication users with those of nonusers. Linear regression assessed predictors of patients' beliefs about sleep medication necessity and hypnotic-related concerns. Among users, we examined predictors of wishing to reduce sleep medications, including perceived hypnotic dependence, beliefs about medications, and demographic characteristics. RESULTS: Users endorsed stronger beliefs about the necessity of sleep medications and less concern about potential harms than nonusers (P < .01). Stronger dysfunctional sleep-related cognitions predicted greater beliefs about necessity and concern about use (P < .01). Patients wishing to reduce sleep medications reported greater perceived hypnotic dependence than those disinterested in reduction (P < .001). Self-reported dependence severity was the strongest predictor of wishing to reduce use (P = .002). CONCLUSIONS: Despite expressing strong beliefs about necessity, and comparatively less concern about taking sleep medications, three-quarters of users wished to reduce prescription hypnotics. Results may not generalize to individuals with insomnia not seeking nonpharmacological treatments. Upon completion, the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study will provide information about the extent to which therapist-led and digital cognitive behavioral therapy for insomnia contribute to prescription hypnotic reduction. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING); URL: https://clinicaltrials.gov/ct2/show/NCT03532282; Identifier: NCT03532282. CITATION: Tully IA, Kim JP, Simpson N, et al. Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder. J Clin Sleep Med. 2023;19(7):1247-1257.

Using a frequentist and Bayesian approach to examine video game usage, substance use, and sleep among college students.

Video games are a popular form of entertainment. However, there is mixed evidence for the association between video game usage and poor sleep quality, short sleep duration, or delayed sleep timing. The current study examined associations between daily sleep behaviours and video game usage via a Bayesian and frequentist statistical approach. Caffeine and alcohol consumption were also assessed as moderators, as these behaviours may co-occur with video game usage and poor sleep. 1032 (72% female) undergraduate students were recruited between 2006-2007. Participants completed questionnaires examining video game and substance use, as well as sleep diaries for 1 week. Frequentist analyses revealed that video game usage was related to increased variability in the total sleep time, and a later average sleep midpoint, but not sleep efficiency. Alcohol use moderated the relationships between video game usage and both average and variability in total sleep time. Caffeine use was related to shorter average total sleep time and more variability in sleep efficiency. Alcohol consumption was related to more variability in the total sleep time and sleep midpoint, and a later average sleep midpoint. Bayesian models suggested strong evidence that video game playing was associated with later average sleep midpoint. Like the frequentist approach, alcohol consumption moderated the relationship between video game usage and both average and variability in total sleep time, but the evidence was weak. The effect sizes for both approaches tended to be small. Using a rigorous statistical approach and a large sample, this study provides robust evidence that video game usage may not be strongly associated with poor sleep among undergraduate students.

Reliability and validity of the Chinese version of the Nightmare disorder index in adolescents.

The Nightmare Disorder Index Questionnaire (NDI) was developed to measure the impact of nightmares. The purpose of this study was to investigate the psychometric properties of NDI among Chinese adolescents. This study investigated the validity and internal consistency of the Nightmare Disorder Index Chinese (NDI-CV) among 6014 Chinese adolescents who completed the NDI-CV, Nightmare Distress Questionnaire-Chinese Version (NDQ-CV), Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Chinese Adolescent Daytime Sleepiness Scale (CADSS), Generalized Anxiety Disorder-7 Questionnaire (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). In addition, we investigated the test-retest reliability of the NDI-CV among 423 adolescents who completed a retest of the NDI-CV after a 2-week interval. Finally, NDI-CV demonstrated good psychometric properties in a sample of Chinese adolescents (Cronbach's α coefficient of 0.876), and the 95% confidence interval for the 2-week retest correlation coefficient was 0.675-0.977 (p < 0.001).

Daily reactivity to stress and sleep disturbances: unique risk factors for insomnia.

STUDY OBJECTIVES: To naturalistically measure sleep disturbances following stress exposure (i.e. sleep reactivity) and stress responses following sleep disturbances (i.e. stress reactivity) at the daily level and prospectively examine these reactivity measures as individual risk factors for insomnia. METHODS: The study assessed 392 nurses' sleep and stress for 14 days using daily diaries and actigraphy. Self-reported insomnia symptoms were assessed at the end of the 14 days, as well as 6 and 11 months later. RESULTS: In multilevel modeling, while negative fixed effects indicated that shorter total sleep time (TST) and lower sleep efficiency led to greater stress and vice versa, significant random effects indicated individual variability in sleep reactivity and stress reactivity. In latent score change modeling, greater sleep reactivity (lower diary-determined sleep efficiency following greater stress) and greater stress reactivity (greater stress following shorter diary-determined TST) at baseline were associated with greater insomnia symptoms at 11 months (b = 10.34, p = .026; b = 7.83, p = .03). Sleep reactivity and stress reactivity also interacted to predict insomnia symptoms, such that sleep reactivity was significantly associated with insomnia symptoms for those with high (+1 SD) stress reactivity (b = 17.23, p = .001), but not for those with low (-1 SD) stress reactivity (b = 5.16, p = .315). CONCLUSIONS: Baseline stress reactivity and sleep reactivity independently as well as jointly predict greater insomnia symptoms 11 months later. The findings delineate processes underlying the stress-diathesis model of insomnia and highlight the utility of longitudinal and naturalistic measures of sleep and stress reactivity.

Implicit and Explicit Stigma of Chronotype in Emerging Adults.

BACKGROUND: Individuals with poor sleep (e.g., insomnia) and mental health (e.g., depression) experience negative stigma but no studies have examined the relationship between stigma and evening chronotype. The present mixed methods study aimed to assess and describe explicit and implicit attitudes about evening and morning chronotypes in a sample of emerging adults. PARTICIPANTS: 49 undergraduates (Mage = 19.9 [SD = 1.5], 83.7% female). METHODS: Participants completed self-reports of demographics and chronotype. Attitudes about "night owls" and "early birds" were measured with self-report questionnaires (explicit attitudes) and an Implicit Association Task (implicit attitudes). Participants described associations with evening and morning chronotypes in free-text responses, which were qualitatively coded. RESULTS: We found evidence of implicit bias against night owls and for early birds. The positive mean implicit d score was 0.57 (SD = 0.47), indicating a moderate implicit bias for pairing "bad" with "night owl" and "good" with "early bird." No baseline characteristics, including chronotype, were significantly associated with implicit bias. Analyses of explicit bias revealed participants perceived night owls as significantly more lazy, unhealthy, undisciplined, immature, creative, and young. Analysis of free-text responses provided further evidence of these associations. CONCLUSIONS: Consistent with hypothesis, undergraduates demonstrated predominantly negative implicit and explicit stigma toward evening chronotypes compared to morning types. As stigma can lead to adverse consequences, future studies should assess the impact of negative societal and self-stigma on evening types. Consideration of societal stigma within clinical intervention contexts could have the potential to reduce shame or other emotions that interfere with sleep.

Daytime napping and nighttime sleep in pregnant individuals with insomnia disorder.

STUDY OBJECTIVES: Examine bidirectional associations between daytime napping and nighttime sleep among pregnant individuals with insomnia disorder. METHODS: We used baseline data from a randomized controlled trial of insomnia treatment during pregnancy (n = 116). Participants in their second or third trimester of pregnancy self-reported daytime napping and nighttime sleep parameters using a sleep diary and wore an Actiwatch-2 during the same 7-day period. Linear regression models, accounting for intraindividual correlation, were used to estimate associations between daytime napping and nighttime sleep parameters (duration, efficiency, quality, awakenings). Models were also stratified by trimester of pregnancy. RESULTS: Sixty-three percent of participants reported napping on at least 1 day. Among participants in the second trimester (65%), napping 15-59 minutes was associated with 6.3% greater self-reported sleep efficiency (95% confidence interval: 2.3, 10.2) and 0.5 units greater self-reported sleep quality (95% confidence interval: 0.0, 0.9) that night; napping 60+ minutes was associated with 0.6 hours shorter actigraphy-measured sleep duration (95% confidence interval: -1.0, -0.2). Napping was not associated with nighttime sleep overall or during the third trimester. Nighttime sleep parameters were not associated with napping duration the following day. CONCLUSIONS: Among pregnant individuals with insomnia in the second trimester, short napping duration was associated with higher self-reported sleep efficiency and quality; long napping duration was associated with shorter actigraphy-measured sleep duration. Additional research is needed to examine the interaction between nap duration and nap timing. In the future, these results may lead to more nuanced recommendations for daytime napping among pregnant individuals with insomnia disorder. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Treatment for Insomnia during Pregnancy; URL: https://clinicaltrials.gov/ct2/show/NCT01846585; Identifier: NCT01846585. CITATION: Badon SE, Dietch R, Simpson N, Lyell DJ, Manber R. Daytime napping and nighttime sleep in pregnant individuals with insomnia disorder. J Clin Sleep Med. 2023;19(2):371-377.

Sleep and affect: A conceptual review.

Everyday experience suggests that sleep and affect are closely linked, with daytime affect influencing how we sleep, and sleep influencing subsequent affect. Yet empirical evidence for this bidirectional relationship between sleep and affect in non-clinical adult samples remains mixed, which may be due to heterogeneity in both construct definitions and measurement. This conceptual review proposes a granular framework that deconstructs sleep and affect findings according to three subordinate dimensions, namely domains (which are distinct for sleep and affect), methods (i.e., self-report vs. behavioral/physiological measures), and timescale (i.e., shorter vs. longer). We illustrate the value of our granular framework through a systematic review of empirical studies published in PubMed (N = 80 articles). We found that in some cases, particularly for sleep disturbances and sleep duration, our framework identified robust evidence for associations with affect that are separable by domain, method, and timescale. However, in most other cases, evidence was either inconclusive or too sparse, resulting in no clear patterns. Our review did not find support for granular bidirectionality between sleep and affect. We suggest a roadmap for future studies based on gaps identified by our review and discuss advantages and disadvantages of our granular dimensional framework.

Racial/ethnic variations in inflammatory markers: exploring the role of sleep duration and sleep efficiency.

Individuals from minoritized racial/ethnic groups have higher levels of circulating inflammatory markers. However, the mechanisms underlying these differences remain understudied. The objective of this study was to examine racial/ethnic variations in multiple markers of inflammation and whether impaired sleep contributes to these racial/ethnic differences. Nurses from two regional hospitals in Texas (n = 377; 71.62% White; 6.90% Black; 11.14% Hispanic, 10.34% Asian; mean age = 39.46; 91.78% female) completed seven days of sleep diaries and actigraphy to assess mean and variability in total sleep time (TST) and sleep efficiency (SE). On day 7, blood was drawn to assess 4 inflammatory markers: C-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-1 beta (IL-1ß), and tumor necrosis factor-alpha (TNF-α). Results from regression models showed differences in inflammatory markers by race/ethnicity, adjusting for age and gender. The associations between sleep parameters and inflammatory markers also varied by race/ethnicity. Among White nurses, lower mean and greater variability in actigraphy-determined TST and greater variability in diary-determined TST were associated with higher levels of IL-6. Among Black nurses, lower mean diary-determined SE was associated with higher levels of IL-6 and IL-1ß. Among Hispanic nurses, greater diary-determined mean TST was associated with higher CRP. Among Asian nurses, greater intraindividual variability in actigraphy-determined SE was associated with lower CRP. Among nurses, we did not find racial/ethnic disparities in levels of inflammation. However, analyses revealed differential relationships between sleep and inflammatory markers by race/ethnicity. Results highlight the importance of using a within-group approach to understand predictors of inflammatory markers.