Low dose exogenous melatonin plus evening dim light and time in bed scheduling advances circadian phase irrespective of measured or estimated dim light melatonin onset time: preliminary findings.

STUDY OBJECTIVES: The purpose of the present study was to preliminarily evaluate whether knowing the dim light melatonin onset (DLMO) time is advantageous when treating delayed sleep-wake phase disorder (DSWPD) with low dose melatonin treatment plus behavioral interventions (i.e., evening dim light and time in bed (TIB) scheduling). METHODS: In this randomized, controlled, double-blind trial, 40 adults with DSWPD were randomly assigned to 4 weeks of 0.5 mg timed to be administered either 3 hours before the DLMO (measured DLMO group, n = 20) or 5 hours before sleep onset time per actigraphy (estimated DLMO group, n = 20), in conjunction with behavioral interventions. The primary outcome was change in the DLMO (measured in-home). Secondary outcomes included sleep parameters per diary and actigraphy (sleep onset and offset times and total sleep time), Morningness-Eveningness Questionnaire (MEQ), Multidimensional Fatigue Inventory (MFI), PROMIS-Sleep Disturbance (SD), PROMIS-Sleep Related Impairment (SRI), and Pittsburgh Sleep Quality Index (PSQI). Mixed effects models tested for group differences in these outcome. RESULTS: After applying the Bonferroni correction for multiple comparisons (significant p-value set at ˂ .004), there were significant main effects for visit on all outcomes except PSQI and total sleep time per wrist actigraphy and diary. There were no group by visit interactions for any of the outcomes (p > .004). CONCLUSIONS: Scheduled low dose melatonin plus behavioral interventions may improve many circadian and sleep parameters regardless of whether melatonin administration is scheduled based on estimated or measured DLMO. A larger-scale trial is needed to confirm these preliminary findings. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03715465; Name: The Clinical Utility of Measuring the Circadian Clock in Treatment of Delayed Sleep-Wake Phase Disorder; URL: https://clinicaltrials.gov/study/NCT03715465.

Trajectories of Sleep Over Midlife and Incident Cardiovascular Disease Events in the Study of Women's Health Across the Nation.

BACKGROUND: Up to 50% of women report sleep problems in midlife, and cardiovascular disease (CVD) is the leading cause of death in women. How chronic poor sleep exposure over decades of midlife is related to CVD risk in women is poorly understood. We tested whether trajectories of insomnia symptoms or sleep duration over midlife were related to subsequent CVD events among SWAN (Study of Women's Health Across the Nation) participants, whose sleep was assessed up to 16 times over 22 years. METHODS: At baseline, SWAN participants (n=2964) were 42 to 52 years of age, premenopausal or early perimenopausal, not using hormone therapy, and free of CVD. They completed up to 16 visits, including questionnaires assessing insomnia symptoms (trouble falling asleep, waking up several times a night, or waking earlier than planned ≥3 times/week classified as insomnia), typical daily sleep duration, vasomotor symptoms, and depressive symptoms; anthropometric measurements; phlebotomy; and CVD event ascertainment (ie, fatal or nonfatal myocardial infarction, stroke, heart failure, revascularization). Sleep trajectories (ie, insomnia, sleep duration) were determined by means of group-based trajectory modeling. Sleep trajectories were tested in relation to CVD in Cox proportional hazards models (multivariable models: site, age, race and ethnicity, education, CVD risk factors averaged over visits; additional covariates: vasomotor symptoms, snoring, depression). RESULTS: Four trajectories of insomnia symptoms emerged: low insomnia symptoms (n=1142 [39% of women]), moderate insomnia symptoms decreasing over time (n=564 [19%]), low insomnia symptoms increasing over time (n=590 [20%]), and high insomnia symptoms that persisted (n=668 [23%]). Women with persistently high insomnia symptoms had higher CVD risk (hazard ratio, 1.71 [95% CI, 1.19, 2.46], P=0.004, versus low insomnia; multivariable). Three trajectories of sleep duration emerged: persistently short (~5 hours: n=363 [14%]), moderate (~6 hours: n=1394 [55%]), and moderate to long (~8 hours: n=760 [30%]). Women with persistent short sleep had marginally higher CVD risk (hazard ratio, 1.51 [95% CI, 0.98, 2.33], P=0.06, versus moderate; multivariable). Women who had both persistent high insomnia and short sleep had significantly elevated CVD risk (hazard ratio, 1.75 [95% CI, 1.03, 2.98], P=0.04, versus low insomnia and moderate or moderate to long sleep duration; multivariable). Relations of insomnia to CVD persisted when adjusting for vasomotor symptoms, snoring, or depression. CONCLUSIONS: Insomnia symptoms, when persistent over midlife or occurring with short sleep, are associated with higher CVD risk among women.

An independent comparison of the Novolytix salivary melatonin radioimmunoassay with the new Novolytix salivary melatonin enzyme-linked immunosorbent assay.

The dim light melatonin onset (DLMO) is the current gold standard biomarker of the timing of the central circadian clock in humans and is often assessed from saliva samples. To date, only one commercially available salivary melatonin assay is considered accurate at the low daytime levels required to accurately detect the DLMO (Novolytix RIA RK-DSM2). The aim of this study was to conduct the first independent evaluation of a newly improved enzyme-linked immunosorbent assay (ELISA; Novolytix MLTN-96) and compare it with the recommended radioimmunoassay (RIA)-both in terms of melatonin concentrations and derived DLMOs. Twenty participants (15 females, 18-59 years old) provided saliva samples every 30 min in dim light starting 6 h before their habitual bedtime, yielding a total of 260 saliva samples. Both the RIA and ELISA yielded daytime melatonin concentrations <2 pg/mL, indicating adequate accuracy to detect the DLMO. The melatonin concentrations from the two assays were highly correlated (r = .94, p < .001), although the RIA yielded lower levels of melatonin concentration than the ELISA, on average by 0.70 pg/mL (p = .006). Seventeen DLMOs were calculated from the melatonin profiles and the DLMOs from both assays were not statistically different (p = .36) and were highly correlated (r = .97, p < .001). Two DLMOs derived from the RIA occurred more than 30 min earlier than the DLMO derived from the ELISA. These results indicate that the new Novolytix ELISA is an appropriate assay to use if the Novolytix RIA is not feasible or available.

Reducing cognitive arousal and sleep effort alleviates insomnia and depression in pregnant women with DSM-5 insomnia disorder treated with a mindfulness sleep program.

Objectives: Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depression via a mindfulness sleep program for pregnant women. Methods: Secondary analysis from a proof-of-concept trial of 12 pregnant women with DSM-5 insomnia disorder who were treated with Perinatal Understanding of Mindful Awareness for Sleep (PUMAS), which places behavioral sleep strategies within a mindfulness framework. Data were collected across eight weekly assessments: pretreatment, six sessions, and posttreatment. Measures included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC), and the Glasgow sleep effort scale (GSES). We used linear mixed modeling to test cognitive arousal and sleep effort as concurrent and prospective predictors of insomnia and depression. Results: Most patients reported high cognitive arousal before PUMAS (75.0%), which decreased to 8.3% after treatment. All insomnia remitters reported low cognitive arousal after treatment, whereas half of nonremitters continued reporting high cognitive arousal. Both nocturnal cognitive arousal and sleep effort were associated with same-week changes in insomnia throughout treatment, and sleep effort yielded a prospective effect on insomnia. Lower levels of nocturnal cognitive arousal and sleep effort prospectively predicted reductions in depression. Conclusions: The present study offers preliminary evidence that reducing sleep effort and nocturnal cognitive arousal may serve as key mechanisms for alleviating insomnia and depression via mindfulness-based insomnia therapy. ClinicalTrials.gov ID: NCT04443959.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy.

OBJECTIVES: Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal. METHODS: A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale. RESULTS: Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components. CONCLUSION: Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression. GOV ID: NCT04443959.

Circadian Interventions as Adjunctive Therapies to Cognitive-Behavioral Therapy for Insomnia.

The circadian system plays a key role in the sleep-wake cycle. A mismatch between the behavioral timing of sleep and the circadian timing of sleepiness/alertness can contribute to insomnia. Patients who report primarily difficulty falling asleep or early morning awakenings may benefit from circadian interventions administered adjunctively to cognitive-behavioral therapy for insomnia. Specific circadian interventions that clinicians may consider include bright light therapy, scheduled dim light, blue-blocking glasses, and melatonin. Implementation of these interventions differs depending on the patient's insomnia subtype. Further, careful attention must be paid to the timing of these interventions to ensure they are administered correctly.

Sleep timing, sleep regularity, and psychological health in early late life women: Findings from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVES: To examine the associations of actigraphy-assessed sleep timing and regularity with psychological health in early late life women, whose circadian rhythms may be impacted by aging. DESIGN: Cross-sectional. PARTICIPANTS: A racially/ethnically diverse sample of 1197 community-dwelling women (mean age 65 years) enrolled in the Study of Women's Health Across the Nation. MEASURES: Actigraphy-assessed sleep measures included timing (mean midpoint from sleep onset to wake-up) and regularity (standard deviation of midpoint in hours). Psychological health measures included a composite well-being score, the Center for Epidemiological Studies Depression Scale, and the Generalized Anxiety Disorder-7 Scale. Linear and logistic regression models, adjusted for covariates (including sleep duration), tested associations between sleep and psychological health measures. RESULTS: After covariate adjustment, a sleep midpoint outside of 2:00-4: 00 AM was significantly associated with depressive symptoms (ß = 0.88, 95% CI = 0.06, 1.70) and scoring above the cut-point for clinically significant depressive symptoms (OR = 1.72, 95% CI = 1.15, 2.57). Sleep irregularity was significantly associated with lower psychological well-being (ß = -0.18, 95% CI = -0.33, -0.03), depressive (ß = 1.36, 95% CI = 0.29, 2.44) and anxiety (ß = 0.93, 95% CI = 0.40, 1.46) symptoms, and scoring above the cut-point for clinically significant depressive (OR = 1.68, 95% CI = 1.01, 2.79) and anxiety (OR = 1.62, 95% CI = 1.07, 2.43) symptoms. CONCLUSION: Above and beyond sleep duration, a sleep midpoint outside of 2:00-4:00 AM was associated with depressive symptoms while sleep irregularity was associated with multiple psychological health domains in late life women.

Enhanced Adoption of Measurement-Based Care in a Psychiatry Outpatient Clinic After High-Reliability Process Changes.

OBJECTIVE: This study examined the impact of high-reliability changes to how measurement-based care questionnaires were administered to patients on rates of questionnaire completion. METHODS: Medical record data were abstracted from 44,305 adult outpatient return visits to a psychiatry outpatient clinic within two 10-month periods (before and after process changes were implemented). Linear mixed models tested the change in questionnaire completion rates and the interaction effects between time and age, sex, and race. RESULTS: Patient completion of questionnaires increased by 79% after process changes. Women were more likely to complete questionnaires regardless of the process. After process changes, older patients and White patients were more likely to complete questionnaires. CONCLUSIONS: High-reliability process changes to measurement-based care questionnaire administration were associated with higher questionnaire completion rates. Racial, age, and sex disparities in questionnaire completion rates were notable and deserve attention in future measurement-based care implementation efforts.

DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection.

Study Objectives: The study had three primary goals. First, we estimated survey-assessed DSM-5 insomnia disorder rates in pregnancy, and described associated sociodemographics, and sleep-wake and mental health symptoms. Second, we derived cutoffs for detecting DSM-5 insomnia disorder using common self-report measures of sleep symptoms. Third, we identified clinically relevant cut-points on measures of nocturnal cognitive and somatic arousal. Methods: Ninety-nine women (85.9% in the 2nd trimester) completed online surveys including DSM-5 insomnia disorder criteria, the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Presleep Arousal Scale's Cognitive (PSASC) and Somatic (PSASS) factors, and Edinburgh Postnatal Depression Scale. Results: DSM-5 insomnia disorder rate was 19.2%. Insomnia was associated with depression, suicidality, nocturnal cognitive and somatic arousal, and daytime sleepiness. An ISI scoring method that aligns with DSM-5 criteria yielded excellent metrics for detecting insomnia disorder and good sleep. Regarding quantitative cutoffs, ISI ≥ 10 and ISI ≥ 11 (but not ISI ≥ 15) were supported for detecting DSM-5 insomnia, whereas ISI ≤ 7 and ISI ≤ 9 performed well for detecting good sleep. PSQI cutoff of 5 was supported for detecting insomnia and good sleep. The optimal cutoff for nocturnal cognitive arousal was PSASC ≥ 18, whereas the optimal cutoff for somatic arousal was PSASS ≥ 13. Conclusions: Insomnia disorder affects a large segment of pregnant women. Empirically derived cutoffs for insomnia, good sleep, cognitive arousal, and somatic arousal may inform case identification and future perinatal sleep research methodology.

Examining Patient Feedback and the Role of Cognitive Arousal in Treatment Non-response to Digital Cognitive-behavioral Therapy for Insomnia during Pregnancy.

OBJECTIVE: Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a perinatal sample associated with poor response to CBTI, and characterize patient feedback to identify areas of insomnia therapy to tailor for the perinatal experience. PARTICIPANTS: Secondary analysis of 46 pregnant women with insomnia symptoms who were treated with digital CBTI in a randomized controlled trial. METHODS: We assessed insomnia, cognitive arousal, and depression before and after prenatal treatment, then 6 weeks postpartum. Patients provided feedback on digital CBTI. RESULTS: Residual cognitive arousal after treatment was the most robust factor associated with treatment non-response. Critically, CBTI responders and non-responders differed on no other sociodemographic or pretreatment metrics. After childbirth, short sleep (<6 hrs/night) was associated with maternal reports of poor infant sleep quality. Patient feedback indicated that most patients preferred online treatment to in-person treatment. Although women described digital CBTI as convenient and helpful, many patients indicated that insomnia therapy would be improved if it addressed sleep challenges unique to pregnancy and postpartum. Patients requested education on maternal and infant sleep, flexibility in behavioral sleep strategies, and guidance to manage infant sleep. CONCLUSIONS: Modifying insomnia therapy to better alleviate refractory cognitive arousal and address the changing needs of women as they progress through pregnancy and early parenting may increase efficacy for perinatal insomnia.Name: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum DepressionURL: clinicaltrials.govRegistration: NCT03596879.

Influence of the menopausal transition on polysomnographic sleep characteristics: a longitudinal analysis.

STUDY OBJECTIVES: To evaluate how change in menopausal status related to spectral analysis and polysomnographic measures of sleep characteristics. METHODS: The Study of Women's Health Across the Nation (SWAN) Ancillary Sleep Study evaluated sleep characteristics of 159 women who were initially pre- or early perimenopausal and repeated the assessment about 3½ years later when 38 were pre- or early perimenopausal, 31 late perimenopausal, and 90 postmenopausal. Participants underwent in-home ambulatory polysomnography for two to three nights. Average EEG power in the delta and beta frequency bands was calculated during NREM and REM sleep, and sleep duration, wake after sleep onset (WASO), and apnea hypopnea index (AHI) were based on visually-scored sleep. RESULTS: The women who transitioned to postmenopause had increased beta NREM EEG power at the second assessment, compared to women who remained pre-or early premenopausal; no other sleep measures varied by change in menopausal status. In multivariate models the associations remained; statistical controls for self-reported hot flashes did not explain findings. In secondary analysis, NREM beta power at the second assessment was greater among women who transitioned into the postmenopause after adjustments for initial NREM beta power. CONCLUSIONS: Sleep duration and WASO did not vary by menopause transition group across assessments. Consistent with prior cross-sectional analysis, elevated beta EEG power in NREM sleep was apparent among women who transitioned to postmenopause, suggesting that independent of self-reported hot flashes, the menopausal transition is associated with physiological hyperarousal during sleep.

Snoring and depression symptoms in pregnant women.

OBJECTIVE: Pregnant patients are vulnerable to both depression and sleep-disordered breathing, and both convey risks for maternal and fetal outcomes. Previous research has indicated that sleep-disordered breathing is associated with depression, but further information related to the risk of depression based on timing of onset of snoring is needed. DESIGN: When presenting to clinic for their initial prenatal visit, pregnant patients completed a packet of questionnaires, which included measures related to depression (Edinburgh Postnatal Depression Scale) and snoring. Habitual snoring was defined as snoring 3 or more nights per week. RESULTS: In total, 1367 women were included and 34.1% reported habitual snoring, either chronic (24.4%) or pregnancy-onset (9.8%), with increased frequency of pregnancy-onset habitual snoring in later stages of pregnancy. Unadjusted analyses suggested increased odds of depressive symptoms in chronic and pregnancy-onset habitual snoring groups relative to nonsnorers (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.39, 2.92, P < .01; OR: 2.50, 95% CI: 1.54, 4.07, P < .01, respectively). These findings were maintained after adjusting for maternal age, marital status, gestational age, and parity (chronic habitual snoring OR: 1.69, 95% CI: 1.14, 2.53, P < .01; pregnancy-onset habitual snoring OR: 2.79, 95% CI: 1.35, 5.78, P < .01). CONCLUSIONS: Maternal snoring may be a risk factor for prenatal depressive symptoms. Pregnancy-onset habitual snoring confers additional risk for depression compared to not snoring during pregnancy.

Associations between Self-Reported Daily Affect Ratings and Sleep Duration during the First Two Weeks of Antidepressant Therapy.

Background: In the context of a randomized controlled trial evaluating the efficacy of augmenting fluoxetine treatment in young adults with major depressive disorder (MDD) using a modified repeated partial sleep deprivation protocol contrasting 2 weeks of restricted time in bed (i.e., 6 h TIB) to no time in bed restriction (i.e., 8 h TIB) the study examines whether sleep duration and the timing of repeated partial sleep deprivation predicts patient-reported affect ratings. Participants: Participants included 58 young adults with DSM-IV-diagnosed MDD. Methods: Daily ratings of affect and sleep were collected during the first 2 weeks of initiating fluoxetine treatment, yielding 630 person-days. Actigraphy monitoring was employed to assess compliance with time in bed condition. Results: Negative affect ratings and positivity ratios in the morning were more improved among participants assigned to the 6 h TIB condition compared to the 8 h TIB group. Participants whose bedtime was delayed by 2-h nightly demonstrated the most significant improvement in negative affect and positivity ratio during the first 2 weeks of fluoxetine therapy. Moreover, the trajectory of morning negative affect ratings in the first 2 weeks was predictive of remission after 4 weeks of fluoxetine therapy. Conclusions: These findings suggest that monitoring changes in daily affect may be a valuable marker of early treatment response in young adults with MDD.

The effects of COVID-19 stay-at-home order on sleep, health, and working patterns: a survey study of US health care workers.

STUDY OBJECTIVES: By March 2020, COVID-19 forced much of the world to stay at home to reduce the spread of the disease. Whereas some health care workers transitioned to working from home, many continued to report to work in person as essential employees. We sought to explore changes in sleep, health, work, and mood in health care workers during the stay-at-home orders. METHODS: We developed a cross-sectional online survey administered to health care workers. The survey assessed changes in sleep, work, screen time, media exposure, diet, exercise, substance use, and mood. The survey data were collected between March 28, 2020, and April 29, 2020. RESULTS: A total of 834 of 936 individuals completed the entire survey. Respondents were from 41 US states. Mood after the stay-at-home orders worsened, and screen time and substance use increased. Total sleep time shortened in those continuing to work in person (P < .001), whereas it was unchanged in those working from home (P = .73). Those working from home went to bed later, woke up later, and worked fewer hours. Reduced total sleep time and increased screen time before bed were associated with worse mood and screen time. Longer sleep time was associated with better mood. CONCLUSIONS: Health care workers' mood worsened regardless of whether work was in person or remote, although total sleep time was shorter for those working in person. Those working from home may have shifted their sleep time to be more in line with their endogenous circadian phase. Peer or other support services may be indicated to address sleep, mood, and health behaviors among health care workers during these unprecedented times.

Associations between sleep and cognitive performance in a racially/ethnically diverse cohort: the Study of Women's Health Across the Nation.

STUDY OBJECTIVES: To determine whether actigraphy-assessed indices of sleep are associated with cognitive performance in women, and explore whether these associations vary by race/ethnicity. METHODS: Participants were 1,126 postmenopausal community-dwelling females (mean age 65 years) from the observational Study of Women's Health Across the Nation (SWAN); 25% were black, 46% white, 13% Chinese, 11% Japanese, and 5% Hispanic. Actigraphy-assessed sleep measures included total sleep time, wake after sleep onset (WASO), and fragmentation. Cognitive measures included immediate and delayed verbal memory, working memory, and information processing speed. All measures were assessed in conjunction with SWAN annual visit 15. RESULTS: Across the sample, after covariate adjustment, greater WASO and fragmentation were concurrently associated with slower information processing speed. Black participants had significantly worse sleep relative to other race/ethnic groups. Significant race/sleep interactions were observed; in black, but not white, participants, greater fragmentation was concurrently associated with worse verbal memory and slower information processing speed, and greater WASO was concurrently associated with slower information processing speed. Sleep-cognitive performance associations were not different in Chinese and Japanese participants relative to white participants. CONCLUSIONS: Greater wakefulness and fragmentation during sleep are concurrently associated with slower information processing. Sleep continuity impacted concurrent cognitive performance in black, but not white, women. This effect may not have been detected in white women because their sleep was largely within the normal range. Future longitudinal studies in diverse samples are critical to further understand whether race/ethnicity moderates the influence of sleep on cognitive performance.

Perinatal Insomnia and Mental Health: a Review of Recent Literature.

PURPOSE OF REVIEW: The perinatal period is a time of high risk for insomnia and mental health conditions. The purpose of this review is to critically examine the most recent literature on perinatal insomnia, focusing on unique features of this period which may confer specific risk, associations with depression and anxiety, and emerging work on perinatal insomnia treatment. RECENT FINDINGS: A majority of perinatal women experience insomnia, which may persist for years, and is associated with depression and anxiety. Novel risk factors include personality characteristics, nocturnal perinatal-focused rumination, and obesity. Mindfulness and physical activity may be protective. Cognitive-behavioral therapy for insomnia is an effective treatment. Perinatal insomnia is exceedingly common, perhaps due to factors unique to this period. Although closely linked to perinatal mental health, more work is needed to establish causality. Future work is also needed to establish the role of racial disparities, tailor treatments, and determine whether insomnia treatment improves perinatal mental health.

Sleep disturbance as a moderator of the association between physical activity and later pain onset among American adults aged 50 and over: evidence from the Health and Retirement Study.

OBJECTIVE: To examine whether sleep disturbance modifies the association between physical activity and incident pain. DESIGN: Prospective population-based study. SETTING: Health and Retirement Study. PARTICIPANTS: American adults aged ≥50 years who reported no troublesome pain in 2014 were re-assessed for pain in 2016. Of 9828 eligible baseline respondents, 8036 (82%) had complete follow-up data for adjusted analyses (weighted analysis population N=42 407 222). EXPOSURES: Physical activity was assessed via interview with questions about time spent in moderate and vigorous physical activity. Sleep disturbance, assessed using a modified form of the Jenkins Sleep Scale, was examined as a potential moderator. MAIN OUTCOME MEASURE: Troublesome pain. RESULTS: In weighted analyses, 37.9% of the 2014 baseline pain-free sample participated in moderate or vigorous physical activity once a week or less, with an overall mean Physical Activity Index Score of 9.0 (SE=0.12). 18.6% went on to report troublesome pain in 2016. Each one-point higher on the Physical Activity Index Score was associated with a reduced odds ratio (OR) of incident pain for those who endorsed sleep disturbance never/rarely (OR=0.97, 95% CI 0.94 to 0.99), but not for those who endorsed sleep disturbance sometimes (OR=0.99, 95% CI 0.97 to 1.01) or most of the time (OR=1.01, 95% CI 0.99 to 1.03). The analysis of possible interaction demonstrated that frequency of sleep disturbance moderated the physical activity and incident pain association (Wald test: p=0.02). CONCLUSIONS: The beneficial association of physical activity on reduced likelihood of later pain was only observed in persons who endorsed low levels of sleep disturbance.

A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women.

OBJECTIVE: Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven care, a critical need exists to increase its accessibility. This RCT examined the efficacy internet-based digital CBTI in pregnant women with insomnia. METHODS: Single-site RCT. A total of 91 pregnant women (29.03 ± 4.16 years) nearing/entering the third trimester who screened positive for clinical insomnia on the Insomnia Severity Index (ISI) were randomized to digital CBTI or digital sleep education control. The ISI, Pittsburgh Sleep Quality Index (PSQI), Edinburgh Postnatal Depression Scale (EPDS), and Pre-Sleep Arousal Scale's Cognitive factor (PSAS-C) served as study outcomes, which were collected before treatment and after treatment during pregnancy, then six weeks after childbirth. RESULTS: From pre to posttreatment, CBTI patients reported reductions in ISI (-4.91 points, p < 0.001) and PSQI (-2.98 points, p < 0.001) and increases in nightly sleep duration by 32 min (p = 0.008). Sleep symptoms did not change during pregnancy in the control group. After childbirth, CBTI patients, relative to controls, slept longer by 40 min per night (p = 0.01) and reported better sleep maintenance. No pre or postnatal treatment effects on depression or cognitive arousal were observed. CONCLUSIONS: Digital CBTI improves sleep quality and sleep duration during pregnancy and after childbirth. To better optimize outcomes, CBTI should be tailored to meet the changing needs of women as the progress through pregnancy and early parenting. NAME: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum Depression. URL: clinicaltrials.gov. Registration: NCT03596879.

Depression and suicidal ideation in pregnancy: exploring relationships with insomnia, short sleep, and nocturnal rumination.

BACKGROUND: Sleep problems and depression are highly prevalent in pregnancy. Nocturnal rumination has been linked to insomnia and depression in non-pregnant samples, but remains poorly characterized in pregnancy. This study explored relationships of depression and suicidal ideation with insomnia, short sleep, and nocturnal rumination in mid-to-late pregnancy. METHODS: In this study, 267 pregnant women were recruited from obstetric clinics and completed online surveys on sleep, depression, and nocturnal rumination. RESULTS: Over half (58.4%) of the sample reported clinical insomnia on the Insomnia Severity Index, 16.1% screened positive for major depression on the Edinburgh Postnatal Depression Scale (EPDS), and 10.1% endorsed suicidal ideation. Nocturnal rumination was more robustly associated with sleep onset difficulties than with sleep maintenance issues. Depressed women were at greater odds of sleep onset insomnia (OR = 2.80), sleep maintenance insomnia (OR = 6.50), high nocturnal rumination (OR = 6.50), and negative perinatal-focused rumination (OR = 2.70). Suicidal ideation was associated with depression (OR = 3.64) and negative perinatal-focused rumination (OR = 3.50). A four-group comparison based on insomnia status and high/low rumination revealed that pregnant women with insomnia and high rumination endorsed higher rates of depression (35.6%) and suicidal ideation (17.3%) than good-sleeping women with low rumination (1.2% depressed, 4.9% suicidal). Women with insomnia alone (depression: 3.9%, suicidal: 5.9%) or high rumination alone (depression: 10.7%, suicidal: 7.1%) did not differ from good-sleeping women with low rumination. CONCLUSIONS: High rumination and insomnia are highly common in mid-to-late pregnancy and both are associated with depression and suicidal ideation. Depression and suicidal ideation are most prevalent in pregnant women with both insomnia and high rumination. CLINICALTRIALS. GOV IDENTIFIER: NCT03596879.

Insomnia, Short Sleep, And Snoring In Mid-To-Late Pregnancy: Disparities Related To Poverty, Race, And Obesity.

OBJECTIVE: To characterize sleep habits and parameters among women in mid-to-late pregnancy and to identify disparities associated with poverty, race, and obesity. DESIGN: Cross-sectional. SETTING: Large multi-site health system in Metro Detroit. PARTICIPANTS: A total of 267 pregnant women (27.3% non-Hispanic black; gestational age: 27.99±1.20 weeks) completed online surveys on sleep quality, insomnia symptoms, sleep aid use, signs/symptoms of sleep-disordered breathing, and sociodemographics. Body mass index (BMI) and patient insurance were derived from medical records. RESULTS: As high as 76.2% of the women reported global sleep disturbance, 30.6% endorsed snoring, 24.3% sleep <6 hrs/night, and over half screened positive for clinical insomnia. Yet, only 3.4% of the women reported an insomnia diagnosis and 3.0% reported a sleep apnea diagnosis. In unadjusted models, poverty, Medicaid coverage, self-identifying as black, and obesity before and during pregnancy (BMI ≥ 35) were associated with a wide range of sleep problems. However, adjusted models revealed specificity. Poverty was uniquely related to increased insomnia symptoms and trouble sleeping due to bad dreams. Obesity before pregnancy was related to poor sleep quality, snoring, sleep aids, and short sleep. Black women reported shorter sleep duration than white women but differed on no other sleep parameters. CONCLUSION: Clinical signs of insomnia and sleep-disordered breathing are common in mid-to-late pregnancy, but most cases go undetected. Problematic sleep disproportionately affects women in poverty, who self-identify as black, and who are obese before pregnancy. Poverty-related sleep issues are linked to insomnia, obesity-related disparities center on sleep-related breathing and medication use, and racial disparities relate to short sleep.