Content analysis of insomnia questionnaires: A step to better evaluate the complex and multifaceted construct of insomnia disorder.

Insomnia disorder is a mental disorder that includes various types of symptoms (e.g., insomnia initiating, worries, mood disturbances) and impairments (e.g., distress related to sleep alterations). Self-report questionnaires are the most common method for assessing insomnia but no systematic quantified analysis of their content and overlap has been carried out. We used content analysis and a visualization method to better identify the different types of clinical manifestations that are investigated by nine commonly used insomnia questionnaires for adults and the Jaccard index to quantify the degree to which they overlap. Content analysis found and visualized 16 different clinical manifestations classified into five dimensions ("Insomnia symptoms", "Insomnia-related symptoms", "Daytime symptoms", "Insomnia-related impairments", "Sleep behaviors"). The average Jaccard Index was 0.409 (moderate overlap in content). There is a lack of distinction between symptoms and impairments, and the assessment of sleep duration and hyperarousal symptoms remains overlooked. This preliminary analysis makes it possible to visualize the content of each of the nine questionnaires and to select the most appropriate questionnaire based on the issue to be addressed. Suggestions are made regarding the development of future questionnaires to better distinguish symptoms and impairments, and the different phenotypes of insomnia disorder.

Predictors of users' adherence to a fully automated digital intervention to manage insomnia complaints.

OBJECTIVE: Fully automated digital interventions show promise for disseminating evidence-based strategies to manage insomnia complaints. However, an important concept often overlooked concerns the extent to which users adopt the recommendations provided in these programs into their daily lives. Our objectives were evaluating users' adherence to the behavioral recommendations provided by an app, and exploring whether users' perceptions of the app had an impact on their adherence behavior. MATERIAL AND METHODS: Case series study of individuals completing a fully automated insomnia management program, conducted by a virtual agent, during December 2020 to September 2022. Primary outcome was self-reported adherence to the behavioral recommendations provided. Perceptions of the app and of the virtual agent were measured with the Acceptability E-Scale and ECA-Trust Questionnaire. Insomnia was evaluated with the Insomnia Severity Index at baseline (phase 1), after 7 days of sleep monitoring (phase 2) and post-intervention (phase 3). RESULTS: A total of 824 users were included, 62.7% female, mean age 51.85 (±12.55) years. Of them, 32.7% reported having followed at least one recommendation. Users' trust in the virtual agent and acceptance of the app were related to a pre-intervention effect in insomnia severity (phase 2). In turn, larger pre-intervention improvements predicted better adherence. Mediational analyses showed that higher levels of trust in the virtual agent and better acceptance of the app exerted statistically significant positive effects on adherence (ß = 0.007, 95% CI, 0.001-0.017 and ß = 0.003, 95% CI 0.0004-0.008, respectively). DISCUSSION: Users' adherence is motivated by positive perceptions of the app's features and pre-intervention improvements. CONCLUSIONS: Determinants of adherence should be assessed, and targeted, to increase the impact of fully automated digital interventions.

From improved sleep regularity to reduced sleep complaints and mental health conditions: a population-based interventional study using a smartphone-based virtual agent.

STUDY OBJECTIVES: To explore the effect of sleep regularity on sleep complaints and mental health conditions (i.e. insomnia, fatigue, anxiety, and depressive symptoms) in a population-based interventional study using a smartphone-based virtual agent. METHODS: A populational cohort based on the Kanopée application, which provided interactions with a virtual companion to collect data on sleep and make personalized recommendations to improve sleep over 17 days. A pre-intervention sleep diary and interview were used for cross-sectional analysis (n = 2142), and a post-intervention sleep diary and interview were used for longitudinal analysis (n = 732). The intra-individual mean (IIM) and standard deviation (ISD) of total sleep time (TST) were calculated to measure sleep quantity and sleep regularity. RESULTS: The mean age at baseline was 49 years, 65% were female, 72% reported insomnia, 58% fatigue, 36% anxiety, and 17% depressive symptoms. Before the intervention, irregular and short sleep was associated with a higher likelihood of insomnia (Relative risk [RR] = 1.26 [1.21-1.30] for irregular TST and RR = 1.19 [1.15-1.23] for short TST), fatigue, anxiety, and depressive symptoms. After the intervention, the IIM of the TST increased while the ISD of the TST and sleep complaints and mental health conditions decreased. More regular TST was associated with reduced insomnia and depressive symptoms (RR = 1.33 [1.10-1.52] and RR = 1.55 [1.13-1.98], respectively). CONCLUSIONS: Our results reveal a longitudinal association between sleep regularity and sleep complaints and mental health conditions. Policymakers, health professionals, and the general population should be aware that, beyond its positive effect on sleep health, regular sleep could promote mental health.

Nurse-led brief sleep education intervention aimed at parents of school-aged children with neurodevelopmental and mental health disorders: Results from a pilot study.

PURPOSE: To test the effects of a single-session parent sleep educational intervention, led by a pediatric nurse, on sleep in a group of school-aged children attending a National Health Service mental health clinic in Murcia, Spain. DESIGN AND METHODS: Parents/caregivers of 26 children (mean age = 8.58 years; standard deviation = 0.58; 80.8% male) with neurodevelopmental or mental health disorders (84.6% pervasive developmental disorder), and with a suspicion of a behavioral sleep problem, participated in a 45-min group educational session about healthy sleep practices, supplemented by a written handout. The main outcome measures were derived from items of the Pediatric Sleep Questionnaire and included an insomnia composite score, a daytime sleepiness composite score, average sleep onset latency, and sleep duration on both weekdays and weekends. Outcome variables were assessed before and 3 months after the intervention. RESULTS: After the educational intervention, the insomnia and daytime composite scores decreased significantly (ps < 0.03). Weekday and weekend sleep duration significantly increased ( ps < 0.01). No statistically significant difference was observed in sleep onset latency before and after the intervention. PRACTICE IMPLICATIONS: A brief and relatively inexpensive single sleep educational session can positively impact sleep in children with neurodevelopmental and mental health disorders. Thus, this intervention meets the characteristics of a successful "entry level" treatment in a stepped-care approach. The stepped-care model places nurses in a pivotal position to ensure that their patients will receive the least complex and most accessible intervention, from which they are likely to get some benefit, and that a sizeable number of patients who need treatment may receive it. Thus, it is important for nurses in all types of practice settings to have an understanding of healthy sleep patterns, as well as sleep disorders in children. Pediatric nurses, regardless of their setting, are in a unique position to screen children and adolescents for sleep behavior problems or sleep disorders, to educate families about healthy sleep practices, provide guidance and feedback, and recommend referral to pediatric specialized care for more complex assessment and management.

Cosleeping and Behavioral Sleep Problems in School-aged Children with Neurodevelopmental and Mental Health Disorders.

The aim of this study was to explore the presence of sleep-related complaints and their relationship to cosleeping in a sample of 57 children with mental health disorders. Information about the practice of cosleeping was collected through an interview and behavioral sleep problems were evaluated with a subset of items from the Spanish version of the Pediatric Sleep Questionnaire (PSQ). Controlling for age, cosleepers scored higher on insomnia, daytime sleepiness and poor sleep scheduling, compared to solitary sleepers. Therefore, mental health professionals should explore the child's sleep environment and, when necessary, use appropriate interventions to address such problems.

Cognitive-behavioral therapy for the management of insomnia comorbid with mental disorders.

Insomnia is frequently comorbid with psychiatric conditions, mostly depression and anxiety disorders. Because disturbed sleep is a symptom of most major mental disorders, it has been traditionally assumed that effective treatment of the psychiatric condition will resolve the coincident insomnia also. However, insomnia often persists after successful treatment of the comorbid mental disorder, suggesting that insomnia often warrants separate treatment attention. Cognitive-behavioral therapy (CBT) is a well established and efficacious treatment for insomnia. Most evidence supporting the efficacy of CBT comes from studies conducted with patients suffering from primary insomnia, yet over the past 20 years there has been growing support for the use of cognitive-behavioral insomnia intervention for patients with comorbid psychiatric conditions. Overall, promising results have been obtained from these studies, not only with regard to insomnia improvement but also concurrent improvements in comorbid psychiatric conditions. In this article we review recent studies in this area with particular focus on treatment of insomnia in the context of depression, post-traumatic stress disorder, and alcohol dependence.