A pathogenic cycle between insomnia and cognitive arousal fuels perinatal depression: exploring the roles of nocturnal cognitive arousal and perinatal-focused rumination

Study ObjectivesDepression is among the most prevalent perinatal complications, yet modifiable risk factors remain elusive. Over half of perinatal women endorse clinical insomnia symptoms, which are etiologically implicated in depression in nonperinatal samples. Yet, prospective data on perinatal insomnia and depression are mixed. We sought to clarify temporal associations of insomnia and depression during peripartum, and to investigate cognitive arousal as a potential mechanism facilitating this relationship.MethodsSeventy pregnant women completed sociodemographic information and baseline sleep and mood symptoms between gestational weeks 25 and 30. Beginning at gestational week 30, participants completed 17 weekly online surveys assessing insomnia, depression, and three cognitive arousal indices (nocturnal cognitive arousal, perseverative thinking, and perinatal-focused rumination). Mixed effects models were conducted to test hypotheses.ResultsWomen were at risk for depression when experiencing insomnia (odds ratio [OR] = 2.36, 95% confidence interval [CI] = 1.28 to 4.35), nocturnal cognitive arousal (OR = 3.05, 95% CI = 1.60 to 5.79), perinatal-focused rumination (OR = 2.05, 95% CI = 1.11 to 3.79), and perseverative thinking (OR = 7.48, 95% CI = 3.90 to 14.32). Prospective analyses revealed bidirectional effects between insomnia and cognitive arousal, and both predicted future depression. Nocturnal cognitive arousal mediated 23–43% of the effect of insomnia on depression. Insomnia mediated 12%–18% of the effect of nocturnal cognitive arousal on depression. A similar pattern was observed with perinatal-focused rumination. Depression did not predict insomnia.ConclusionNocturnal cognitive arousal, including ruminating on perinatal concerns while trying to fall asleep, fuels insomnia. In turn, lying awake at night provides an opportunity for nocturnal cognitive arousal. This cycle feeds perinatal depression. Daytime cognitive arousal may indirectly disrupt sleep as perseverating during the day persists into the night.     

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health

Study ObjectivesInsomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking.MethodsWe analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems.ResultsParticipants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15–3.66 and OR = 2.18, 95% CL = 1.07–4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01–3.75 and OR = 2.33, 95% CL = 1.07–5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30–1.76 and OR = 0.75, 95% CL = 0.21–2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42–2.74 and OR = 0.76, 95% CL = 0.16–3.57, respectively).ConclusionsInsomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.     

Gender differences in the association of insomnia symptoms and coronary artery calcification in the multi-ethnic study of atherosclerosis

Study ObjectivesTo quantify the gender-specific associations between insomnia symptoms and subclinical atherosclerosis, measured by coronary artery calcium (CAC) scores, which has strong predictive value for incident cardiovascular disease.MethodsWe analyzed data from 1,429 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Participants completed standardized questionnaires and underwent polysomnography (PSG) and 7-day actigraphy. Insomnia symptoms were defined as: self-reported trouble falling, staying or returning to sleep, early-morning awakenings, or hypnotic use, for ≥5 nights/week. MESA assessed CAC using computed tomography. We employed multivariable linear regression to model the probability of CAC >0 overall and to model the linear continuous effect among those with nonzero CAC.ResultsOur sample was a mean age of 68.1 ± 9.1 years, 53.9% female, and 36.2% white, 28.0% black, 24.2% Hispanic, and 11.5% Chinese-American. Insomnia symptoms were present in 49.7% of men and 47.2% of women. In multivariable-adjusted analyses, insomnia symptoms was associated with an 18% higher prevalence of CAC (PR 1.18, 95% CI 1.04, 1.33) among females, but no association was observed among males (PR 1.00, 95% CI 0.91, 1.08). There was no evidence that the association between insomnia symptoms and prevalence of CAC >0 differed by objective sleep duration status (by single-night PSG or multi-night actigraphy) in females or males.ConclusionsWe found that among women, insomnia symptoms were associated with an 18% higher prevalence of CAC compared to no insomnia. Insomnia symptoms were not associated with CAC prevalence in men. Additionally, there was no evidence that the association between insomnia symptoms and CAC score >0 differed by objective short sleep duration status.     

Natural history of insomnia symptoms in the transition from childhood to adolescence: population rates,health disparities,and risk factors

Study ObjectivesTo determine the sociodemographic, behavioral, and clinical risk factors associated with the persistence, remission, and incidence of insomnia symptoms in the transition from childhood to adolescence.MethodsThe Penn State Child Cohort is a random, population-based sample of 700 children (5–12 years at baseline), of whom 421 were followed-up as adolescents (12–23 years at follow-up). Subjects underwent polysomnography, clinical history, physical exam, and parent- and self-reported scales at baseline and follow-up. Insomnia symptoms were defined as a parent- or self-report of difficulty falling and/or staying asleep.ResultsThe 421 subjects with baseline (Mage = 8.8 years) and follow-up (Mage = 17 years) data were 53.9% male and 21.9% racial/ethnic minorities. The persistence of childhood insomnia symptoms (CIS) was 56% (95% CI = 46.5–65.4), with only 30.3% (95% CI = 21.5–39.0) fully remitting. The incidence of adolescent insomnia symptoms was 31.1% (95% CI = 25.9–36.3). Female sex, racial/ethnic minority, and low socioeconomic status as well as psychiatric/behavioral or neurological disorders, obesity, smoking, and evening chronotype were associated with a higher persistence or incidence of insomnia symptoms.ConclusionsCIS are highly persistent, with full remission occurring in only a third of children in the transition to adolescence. Sex-, racial/ethnic-, and socioeconomic-related disparities in insomnia occur as early as childhood, while different mental/physical health and lifestyle/circadian risk factors play a key role in the chronicity of CIS versus their incidence in adolescence. CIS should not be expected to developmentally remit and should become a focus of integrated pediatric/behavioral health strategies.     

Insomnia with Short Sleep Duration and Mortality: The Penn State Cohort

Study Objectives:

Because insomnia with objective short sleep duration is associated with increased morbidity, we examined the effects of this insomnia subtype on all-cause mortality.

Design:

Longitudinal.

Setting:

Sleep laboratory.

Participants:

1,741 men and women randomly selected from Central Pennsylvania.

Measurements:

Participants were studied in the sleep laboratory and were followed-up for 14 years (men) and 10 years (women). “Insomnia” was defined by a complaint of insomnia with duration ≥ 1 year. “Normal sleeping” was defined as absence of insomnia. Polysomnographic sleep duration was classified into two categories: the “normal sleep duration group” subjects who slept ≥ 6 h and the “short sleep duration group” subjects who slept < 6 h. We adjusted for age, race, education, body mass index, smoking, alcohol, depression, sleep disordered breathing, and sampling weight.

Results:

The mortality rate was 21% for men and 5% for women. In men, mortality risk was significantly increased in insomniacs who slept less than 6 hours compared to the “normal sleep duration, no insomnia” group, (OR = 4.00, CI 1.14-13.99) after adjusting for diabetes, hypertension, and other confounders. Furthermore, there was a marginally significant trend (P = 0.15) towards higher mortality risk from insomnia and short sleep in patients with diabetes or hypertension (OR = 7.17, 95% CI 1.41-36.62) than in those without these comorbid conditions (OR = 1.45, 95% CI 0.13-16.14). In women, mortality was not associated with insomnia and short sleep duration.

Conclusions:

Insomnia with objective short sleep duration in men is associated with increased mortality, a risk that has been underestimated.

Citation:

Vgontzas AN; Liao D; Pejovic S; Calhoun S; Karataraki M; Basta M; Fernández-Mendoza J; Bixler EO. Insomnia with short sleep duration and mortality: the Penn State Cohort. SLEEP 2010;33(9):1159-1164.     

Associations of insomnia symptoms with subsequent health services use among community-dwelling U.S. older adults

Study ObjectivesDetermine the association of insomnia symptoms with subsequent health services use, in a representative sample of U.S. older adults.MethodsParticipants were 4,289 community-dwelling Medicare beneficiaries who had continuous fee-for-service Medicare coverage 30 days before, and 1 year after the National Health and Aging Trends Study (NHATS) Round 1 interview. Participants reported past-month insomnia symptoms (i.e. sleep onset latency >30 min, difficulty returning to sleep) which we categorized as 0, 1, or 2 symptoms. Outcomes were health services use within 1 year of interviews from linked Medicare claims: emergency department (ED) visits, hospitalizations, 30-day readmissions, home health care (all measured as yes/no), and number of hospitalizations and ED visits.ResultsOverall, 18.5% of participants were hospitalized, 28.7% visited the ED, 2.5% had a 30-day readmission, and 11.3% used home health care. After adjustment for demographics, depressive and anxiety symptoms, medical comorbidities, and BMI, compared to participants with no insomnia symptoms, those with two insomnia symptoms had a higher odds of ED visits (odds ratio [OR) = 1.60, 95% confidence interval [CI] = 1.24–2.07, p < 0.001), hospitalizations (OR = 1.29, 95% CI = 1.01–1.65, p < 0.05), and 30-day readmissions (OR = 1.88, 95% CI = 1.88–3.29, p < 0.05). Reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits and hospitalizations (incidence rate ratio (IRR) = 1.52, 95% CI = 1.23–1.87, p < 0.001; IRR = 1.21, 95% CI = 1.02–1.44, p < 0.05, respectively) after adjusting for demographic and health characteristics.ConclusionsAmong older adults, insomnia symptoms are associated with greater health services use, including emergency department use, hospitalization, and 30-day readmission. Targeting insomnia may lower health services use.     

Association between new-onset liver cirrhosis and suicide risk in South Korea: A nationwide cohort study

Background/AimsCurrent evidence suggests that liver cirrhosis (LC) causes severe psychological stress and depression, which are risk factors for suicide. Although previous studies reported the association between LC and suicidal thoughts, little is known of its effect on suicidal deaths. Therefore, this study was undertaken to investigate the effect of new-onset LC on suicide.MethodsFrom the National Health Insurance Service-National Sample Cohort of South Korea, 5,809 incident LC patients and 11,618 risk-set controls matched by propensity score were selected for follow-up. The incidence rate of suicide was estimated using a generalized estimating equation with a Poisson distribution. Effect size was presented as a hazard ratio (HR) using Cox’s proportional hazards model.ResultsThe incidence rate of suicide was 143.3 cases per 100,000 person years (95% confidence interval [CI], 100.2–205.1) among the LC cohort. The LC patients were 2.37 times more likely to commit suicide compared with matched controls (HR, 2.37; 95% CI, 1.44–3.88). Increased suicide risk was evident within the first 2 years of the follow-up period (HR, 2.59; 95% CI, 1.20–5.60) and among the 18–49-year-old age group (HR, 3.72; 95% CI, 1.45–9.56).ConclusionsOur study found increased risk of suicide in patients with new onset LC, especially during the early period following diagnosis and in younger patients. To decrease this suicide risk, a regular and continuous social support system is required.     

The Mediating Effect of Insomnia on the Relationship between Panic Symptoms and Depression in Patients with Panic Disorder

BackgroundThis study aimed to determine if sleep disturbances may mediate the relationship between panic symptoms and depression in patients with panic disorder (PD).MethodsElectronic medical records were retrospectively reviewed for 110 consecutive patients with diagnosed PD in an outpatient clinic between October 2018 and December 2019. Measurements include the PD Severity Scale, Beck Depression Inventory-II (BDI-II) and Insomnia Severity Index (ISI). Statistical analyses were performed to assess any potential relationship between PD, insomnia and depression.ResultsOf the PD patients, 88 (80%) and 89 (80.9%) had comorbid depression (BDI-II ≥ 14) and insomnia (Korean version of the ISI ≥ 8), respectively. In a mediation model using insomnia as the mediating variable, the total effect of panic symptom severity on depression was significant (t = 7.23, P < 0.001). There were significant effects of panic symptoms on insomnia (t = 4.62, P < 0.001) and of insomnia on depression (t = 6.69, P < 0.001). The main effect of panic symptom severity on depression was also significant, after controlling for the effect of insomnia (t = 5.10, P < 0.001), suggesting partial mediation.ConclusionBoth depressive symptoms and insomnia are common in patients with PD and depression was partially mediated by insomnia in these patients. These results suggest that an intervention for insomnia in patients with PD might help prevent the development of depression.     

The effect of sleep–wake intraindividual variability in digital cognitive behavioral therapy for insomnia: a mediation analysis of a large-scale RCT

Study ObjectivesDigital cognitive behavioral therapy for insomnia (dCBT-I) is an effective treatment for insomnia. However, less is known about mediators of its benefits. The aim of the present study was to test if intraindividual variability in sleep (IIV) was reduced with dCBT-I, and whether any identified reduction was a mediator of dCBT-I on insomnia severity and psychological distress.MethodsIn a two-arm randomized controlled trial (RCT), 1720 adults with insomnia (dCBT-I = 867; patient education about sleep = 853) completed the Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS) and sleep diaries, at baseline and 9-week follow-up. Changes in IIV were analyzed using linear mixed modeling followed by mediation analyses of ISI, HADS, and IIV in singular sleep metrics and composite measures (behavioral indices (BI-Z) and sleep disturbance indices (SI-Z)).ResultsdCBT-I was associated with reduced IIV across all singular sleep metrics, with the largest between-group effect sizes observed for sleep onset latency (SOL). Reduced IIV for SOL and wake after sleep onset had the overall greatest singular mediating effect. For composite measures, SI-Z mediated change in ISI (b = −0.74; 95% confidence interval (CI) −1.04 to −0.52; 13.3%) and HADS (b = −0.40; 95% CI −0.73 to −0.18; 29.2%), while BI-Z mediated minor changes.ConclusionReductions in IIV in key sleep metrics mediate significant changes in insomnia severity and especially psychological distress when using dCBT-I. These findings offer important evidence regarding the therapeutic action of dCBT-I and may guide the future development of this intervention.Clinical trials Name: Overcoming Insomnia: Impact on Sleep, Health and Work of Online CBT-I Registration number: NCT02558647 URL: https://clinicaltrials.gov/ct2/show/NCT02558647?cond=NCT02558647&draw=2&rank=1     

Mendelian randomization highlights insomnia as a risk factor for pain diagnoses

Study ObjectiveInsomnia has been linked to acute and chronic pain conditions; however, it is unclear whether such relationships are causal. Recently, a large number of genetic variants have been discovered for both insomnia and pain through genome-wide association studies (GWASs) providing a unique opportunity to examine the evidence for causal relationships through the use of the Mendelian randomization paradigm.MethodsTo elucidate the causality between insomnia and pain, we performed bidirectional Mendelian randomization analysis in FinnGen, where clinically diagnosed ICD-10 categories of pain had been evaluated. In addition, we used measures of self-reported insomnia symptoms. We used endpoints for pain in the FinnGen Release 5 (R5) (N = 218,379), and a non-overlapping sample for insomnia (UK Biobank (UKBB) and 23andMe, N = 1,331,010 or UKBB alone N = 453,379). We assessed the robustness of results through conventional Mendelian randomization sensitivity analyses.ResultsGenetic liability to insomnia symptoms increased the odds of reporting pain (odds ratio (OR) [95% confidence interval (CI)] = 1.47 [1.38–1.58], p = 4.12 × 10⁻²⁸). Manifested pain had a small effect on increased risk for insomnia (OR [95% CI] = 1.04 [1.01–1.07], p < 0.05). Results were consistent in sensitivity analyses.ConclusionsOur findings support a bidirectional causal relationship between insomnia and pain. These data support a further clinical investigation into the utility of insomnia treatment as a strategy for pain management and vice versa.     

Treating insomnia symptoms with medicinal cannabis: a randomized,crossover trial of the efficacy of a cannabinoid medicine compared with placebo

Study ObjectivesThis randomized, double-blind, placebo-controlled, crossover study was conducted to evaluate the safety and efficacy of 2 weeks of nightly sublingual cannabinoid extract (ZTL-101) in treating chronic insomnia (symptoms ≥3 months).MethodsCo-primary study endpoints were safety of the medication based on adverse event reporting and global insomnia symptoms (Insomnia Severity Index [ISI]). Secondary endpoints included: self-reported (sleep diary), actigraphy-derived, and polysomnography measurements of sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), sleep efficiency (SE); and self-reported assessments of sleep quality (sSQ) and feeling rested upon waking. Adjusted mean differences between placebo and ZTL-101 were calculated.ResultsTwenty-three of 24 randomized participants (n = 20 female, mean age 53 ± 9 years) completed the protocol. No serious adverse events were reported. Forty mild, nonserious, adverse events were reported (36 during ZTL-101) with all but one resolving overnight or soon after waking. Compared to placebo, ZTL-101 decreased ISI (−5.07 units [95% CI: −7.28 to −2.86]; p = 0.0001) and self-reported SOL (−8.45 min [95% CI: −16.33 to −0.57]; p = 0.04) and increased self-reported TST (64.6 min [95% CI: 41.70 to 87.46]; p < 0.0001), sSQ (0.74 units [95% CI: 0.51 to 0.97]; p < 0.0001), and feeling of being rested on waking (0.51 units [95% CI: 0.24 to 0.78]; p = 0.0007). ZTL-101 also decreased actigraphy-derived WASO (−10.2 min [95% CI: −16.2 to −4.2]; p = 0.002), and increased actigraphy-derived TST (33.4 min [95% CI: 23.07 to 43.76]; p < 0.001) and SE (2.9% [95% CI: 2.0 to 3.8]; p = 0.005).ConclusionsTwo weeks of nightly sublingual administration of a cannabinoid extract (ZTL-101) is well tolerated and improves insomnia symptoms and sleep quality in individuals with chronic insomnia symptoms.Clinical TrialANZCTR; anzctr.org.au; ACTRN12618000078257.     

Habitual Sleep Duration and Insomnia and the Risk of Cardiovascular Events and All-cause Death: Report from a Community-Based Cohort

Study Objectives:

To investigate the relationship between sleep duration and insomnia severity and the risk of all-cause death and cardiovascular disease (CVD) events

Design:

Prospective cohort study

Setting:

Community-based

Participants:

A total of 3,430 adults aged 35 years or older

Intervention:

None

Measurements and Results:

During a median 15.9 year (interquartile range, 13.1 to 16.9) follow-up period, 420 cases developed cardiovascular disease and 901 cases died. A U-shape association between sleep duration and all-cause death was found: the age and gender-adjusted relative risks (95% confidence interval [CI]) of all-cause death (with 7 h of daily sleep being considered for the reference group) for individuals reporting ≤ 5 h, 6 h, 8 h, and ≥ 9 h were 1.15 (0.91–1.45), 1.02 (0.85–1.25), 1.05 (0.88–1.27), and 1.43 (1.16–1.75); P for trend, 0.019. However, the relationship between sleep duration and risk of CVD were linear. The multivariate-adjusted relative risk (95% CI) for all-cause death (using individuals without insomnia) were 1.02 (0.86–1.20) for occasional insomnia, 1.15 (0.92–1.42) for frequent insomnia, and 1.70 (1.16–2.49) for nearly everyday insomnia (P for trend, 0.028). The multivariate adjusted relative risk (95% CI) was 2.53 (1.71–3.76) for all-cause death and 2.07 (1.11–3.85) for CVD rate in participants sleeping ≥9 h and for those with frequent insomnia.

Conclusions:

Sleep duration and insomnia severity were associated with all-cause death and CVD events among ethnic Chinese in Taiwan. Our data indicate that an optimal sleep duration (7–8 h) predicted fewer deaths.

Citation:

Chien K; Chen P; Hsu H; Su T; Sung F; Chen M; Lee Y. Habitual sleep duration and insomnia and the risk of cardiovascular events and all-cause death: report from a community-based cohort. SLEEP 2010;33(2):177–184.     

Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic

Study ObjectivesStressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.MethodsCOVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016–2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.ResultsInsomnia symptoms were significantly associated with COVID-19 related disruptions, and those who previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.ConclusionsThose who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.Clinical Trial Registration{"type":"clinical-trial","attrs":{"text":"NCT02988375","term_id":"NCT02988375"}}NCT02988375     

Asociación entre alteraciones en el sueño y problemas de salud mental en los estudiantes de Medicina durante la pandemia de la COVID-19

IntroductionMedical students are a population vulnerable to poor sleep quality and sleep deprivation; these problems were accentuated during the COVID-19 pandemic. The objective was to evaluate the association between sleep disturbances and the presence of depression and anxiety in medical students during the pandemic.Materials and methodsCross-sectional, analytical study in medical students of a private university in Peru. Data were collected from May 22 to June 14, 2020, after 3 months of mandatory social isolation. The Patient Health Questionnaire (PHQ-9; ≥ 10), the Generalized Anxiety Disorder (GAD-7; ≥ 10) scale and the Insomnia Severity Index (ISI; ≥ 8) were used to assess depression, anxiety and insomnia, respectively. Poisson regressions with robust variance were used to calculate prevalence ratios.ResultsThe prevalence of depression, anxiety and insomnia was 28.5%, 29.5% and 60.1% respectively. It was found that those who had short sleep (RPa: 1.40, CI: 1.05-1.87, p: 0.024), who slept after 2:00 hours (RPa: 2.24, CI: 1.31-3.83, p: 0.003) and who presented insomnia (RPa: 7.12, CI: 3.70-13.73, p: < 0.001) had a higher prevalence of anxiety. Likewise, those who slept after 2:00 hours (RPa: 2.13, CI: 1.24-3.64, p: 0.006) and those who presented insomnia (RP: 8.82, CI: 4.17-18.68, p: < 0.001) had a higher prevalence of depression.ConclusionsShort sleep, bedtime and insomnia are factors associated with the prevalence of depression and anxiety.     

The role of vulnerability in stress‐related insomnia,social support and coping styles on incidence and persistence of insomnia

Individuals who are more prone to experience situational insomnia under stressful conditions may also be at greater risk to develop subsequent insomnia. While cross‐sectional data exist on the link between sleep reactivity (heightened vulnerability to stress‐related insomnia) and insomnia, limited data exist on its predictive value. The aim of the study was to evaluate prospectively whether sleep reactivity was associated with increased risk of incident and persistent insomnia in a population‐based sample of good sleepers. Social support and coping styles were also investigated as potential moderators. Participants were 1449 adults (M_age = 47.4 years, standard deviation = 15.1; 41.2% male) without insomnia at baseline and evaluated four times over 3 years. Sleep reactivity was measured using the Ford Insomnia Response to Stress Test (FIRST). Additional measures included depressive symptoms, the frequency and perceived impact of stressful life events, social support and coping styles. After controlling for prior sleep history, depressive symptoms, arousal predisposition, stressful life events and perceived impact, individuals with higher sleep reactivity had an odds ratio (OR) of 1.56 [95% confidence interval (CI): 1.13–2.16], 1.41 (95% CI: 0.87–2.30) and 2.02 (95% CI: 1.30–3.15) of developing insomnia symptoms, syndrome and persistent insomnia, respectively. Social support and coping styles did not moderate these associations. Results suggest that heightened vulnerability to insomnia is associated with an increased risk of developing new‐onset subsyndromal and persistent insomnia in good sleepers. Knowledge of premorbid differences is important to identify at‐risk individuals, as this may help to develop more targeted prevention and intervention strategies for insomnia.     

Sleep changes following statin therapy: a systematic review and meta-analysis of randomized placebo-controlled polysomnographic trials

Introduction

Statin use might be associated with an increased risk of sleep disturbances including insomnia, but the evidence regarding sleep changes following statin therapy has not been conclusive. Therefore we assessed the impact of statin therapy on sleep changes through a systematic review and meta-analysis of available randomized controlled trials (RCTs).

Material and methods

We searched MEDLINE and SCOPUS up to October 1, 2014 to identify placebo-controlled RCTs investigating the effect of statin therapy on sleep changes. A meta-analysis was performed using either a fixed-effects or a random-effect model according to the I2 statistic. Effect size was expressed as weighted mean difference (WMD) and 95% confidence interval (CI).

Results

Overall, the impact of statin therapy on polysomnography (PSG) indices of sleep was reported in 5 trials comprising 9 treatment arms. Overall, statin therapy had no significant effect on total sleep duration (WMD: –7.75 min, 95% CI: –18.98, 3.48, p = 0.176), sleep efficiency (WMD: 0.09%, 95% CI: –2.27, 2.46, p = 0.940), entries to stage I (WMD: 0.36, 95% CI: –0.91, 1.63, p = 0.580), or latency to stage I (WMD: –1.92 min, 95% CI: –4.74, 0.89, p = 0.181). In contrast, statin therapy significantly reduced wake time (WMD: –4.43 min, 95% CI: –7.77, –0.88, p = 0.014) and number of awakenings (WMD: –0.40, 95% CI: –0.46, –0.33, p < 0.001). Meta-regression did not suggest any correlation between changes in wake time and awakening episodes with duration of treatment and LDL-lowering effect of statins.

Conclusions

The results indicated that statins have no significant adverse effect on sleep duration and efficiency, entry to stage I, or latency to stage I sleep, but significantly reduce wake time and number of awakenings.     

Mode of delivery of Cognitive Behavioral Therapy for Insomnia: a randomized controlled non-inferiority trial of digital and face-to-face therapy

Study ObjectivesDigital Cognitive Behavioral Therapy for Insomnia (dCBT-I) has demonstrated efficacy in reducing insomnia severity in self-referred and community samples. It is unknown, however, how dCBT-I compares to individual face-to-face (FtF) CBT-I for individuals referred to clinical secondary services. We undertook a randomized controlled trial to test whether fully automated dCBT-I is non-inferior to individual FtF CBT-I in reducing insomnia severity.MethodsEligible participants were adult patients with a diagnosis of insomnia disorder recruited from a sleep clinic provided via public mental health services in Norway. The Insomnia Severity Index (ISI) was the primary outcome measure. The non-inferiority margin was defined a priori as 2.0 points on the ISI at week 33.ResultsIndividuals were randomized to FtF CBT-I (n = 52) or dCBT-I (n = 49); mean baseline ISI scores were 18.4 (SD 3.7) and 19.4 (SD 4.1), respectively. At week 33, the mean scores were 8.9 (SD 6.0) and 12.3 (SD 6.9), respectively. There was a significant time effect for both interventions (p < 0.001); and the mean difference in ISI at week 33 was −2.8 (95% CI: −4.8 to −0.8; p = 0.007, Cohen’s d = 0.7), and −4.6 at week 9 (95% CI −6.6 to −2.7; p < 0.001), Cohen’s d = 1.2.ConclusionsAt the primary endpoint at week 33, the 95% CI of the estimated treatment difference included the non-inferiority margin and was wholly to the left of zero. Thus, this result is inconclusive regarding the possible inferiority or non-inferiority of dCBT-I over FtF CBT-I, but dCBT-I performed significantly worse than FtF CBT-I. At week 9, dCBT-I was inferior to FtF CBT-I as the 95% CI was fully outside the non-inferiority margin. These findings highlight the need for more clinical research to clarify the optimal application, dissemination, and implementation of dCBT-I. Clinicaltrials.gov: NCT02044263: Cognitive Behavioral Therapy for Insomnia Delivered by a Therapist or on the Internet: a Randomized Controlled Non-inferiority Trial.     

Combined Effects of Depression and Chronic Disease on the Risk of Mortality: The Korean Longitudinal Study of Aging (2006-2016)

BackgroundThe prevalence of depression is much higher in people with chronic disease than in the general population. Depression exacerbates existing physical conditions, resulting in a higher-than-expected death rate from the physical condition itself. In our aging society, the prevalence of multimorbid patients is expected to increase; the resulting mental problems, especially depression, should be considered. Using a large-scale cohort from the Korean Longitudinal Study of Aging (KLoSA), we analyzed the combined effects of depression and chronic disease on all-cause mortality.MethodsWe analyzed 10-year (2006–2016) longitudinal data of 9,819 individuals who took part in the KLoSA, a nationwide survey of people aged 45–79 years. We examined the association between multimorbidity and depression using chi-square test and logistic regression. We used the Cox proportional hazard model to determine the combined effects of multimorbidity and depression on the all-cause mortality risk.ResultsDuring the 10-year follow up, 1,574 people (16.0%) died. The hazard ratio associated with mild depression increased from 1.35 (95% confidence interval [CI], 1.05–1.73) for no chronic disease to 1.25 (95% CI, 0.98–1.60) for 1 chronic disease, and to 2.00 (95% CI, 1.58–2.52) for multimorbidity. The hazard ratio associated with severe depression increased from 1.73 (95% CI, 1.33–2.24) for no chronic disease, to 2.03 (95% CI, 1.60–2.57) for 1 chronic disease, and to 2.94 (95% CI, 2.37–3.65) for multimorbidity.ConclusionPatients with coexisting multimorbidity and depression are at an increased risk of all-cause mortality than those with chronic disease or depression alone.     

Efficacy of cognitive behavioural therapy for insomnia or sleep disturbance in pregnant women: A systematic review ad meta-analysis

During pregnancy many women may experience negative emotions and sleep disturbances. This systematic review and meta-analysis was conducted to assess the efficacy of cognitive behavioural therapy for insomnia (CBT-I) or sleep disturbance in pregnant women. From the earliest available publications to 15 April 2022, seven electronic literature databases were searched: PubMed, Web of Science, Cochrane Library, Embase, Chinese National Knowledge Infrastructure, Wanfang Data, and VIP Database for Chinese Science and Technology Journal. Randomised controlled trials of CBT-I in pregnant women with insomnia or sleep disorders were included. The methodological bias of the included studies was assessed using the Cochrane risk of bias tool. The meta-analysis was performed using RevMan 5.4 software. Stata Statistical Software: Release 15 was used for sensitivity analysis and publication bias. We included eight randomised controlled trials involving 743 pregnant women. Meta-analysis showed that, compared with the control group, CBT-I significantly improved the Insomnia Severity Index (mean difference [MD] = −4.25, 95% confidence interval [CI, −6.32, −2.19], p < 0.001), The Pittsburgh Sleep Quality Index (MD = −3.30, 95% CI [−4.81, −1.79], p < 0.001), sleep onset latency (standardised mean difference [SMD] = −1.25, 95% CI [−2.01, −0.50], p = 0.001), anxiety (SMD = −0.99, 95% CI [−1.32, −0.67], p < 0.001), and depression (SMD = −0.40, 95% CI [−0.72, −0.07], p = 0.02). No significant differences were found in total sleep time (SMD = 0.31, 95% CI [−0.54, 1.17], p = 0.47) and sleep efficiency (SMD = 0.80, 95% CI [−0.53, 2.13], p = 0.24). CBT-I significantly improved pregnant women's sleep quality, insomnia severity, depression, and anxiety. This meta-analysis provides evidence that CBT-I is valid for insomnia or sleep disturbances during pregnancy.     

Population-based Analysis for Risk of Suicide Death in Elderly Patients after Osteoporotic Fracture: a Nested Case-Control Study

BackgroundThe purpose of study was to investigate the incidence rate of suicide in elderly patients with osteoporotic fractures in a nested case-control model and to analyze the change in the risk of suicide death over time after each osteoporotic fracture.MethodsWe used the National Health Insurance Service-Senior cohort of South Korea. Suicide cases and controls were matched based on sex and age at the index date. Controls were randomly selected at a 1:5 ratio from the set of individuals who were at risk of becoming a case at the time when suicide cases were selected. Conditional logistic regression analysis was performed to evaluate the association between each type of osteoporotic fracture and the risk of suicide death.ResultsThree thousand seventy suicide cases and 15,350 controls were identified. Patients with hip fracture showed an increased risk of suicide death within 1 year of fracture (adjusted odds ratio [aOR] = 2.64; 95% confidence interval [CI], 1.57–4.46; P < 0.001) compared to controls. However, the increased risk of suicide death in patients with hip fracture lasted up to 2 years (aOR = 1.59; 95% CI, 1.04–2.41; P = 0.031). Spine fracture increased the risk of suicide deaths for all observation periods. There was no evidence that humerus fracture increased the risk of suicide death during the observational period. Radius fracture increased only the risk of suicide death within 2 years of fracture (aOR = 1.43; 95% CI, 0.74–2.77; P = 0.282).ConclusionThere were noticeable differences in both degree and duration of increased suicide risks depending on the type of osteoporotic fracture. Mental stress and suicide risk in elderly patients after osteoporotic fracture should be assessed differently depending on the types of fracture.