Chronic Insomnia Disorder (ID) is characterized by hyperarousal, a key pathophysiological feature. While Cognitive-Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment, its physiological effects on sleep-related hyperarousal remain underexplored. This study assessed the impact of CBT-I on cortical hyperarousal using quantitative EEG (qEEG) during non-REM (NREM) sleep, with the delta/beta ratio as the primary outcome. Secondary aims included evaluating changes in sleep stability and exploring phenotypic differences in treatment response. Ninety-eight ID patients across five centers completed a 6-8-week CBT-I program. Pre-and post-treatment assessments included polysomnography (PSG), sleep diaries, and Insomnia Severity Index (ISI). Cortical hyperarousal was indexed by the NREM delta/beta ratio; sleep stability (Sstab) was derived from a transition probability matrix. Patients were categorized as insomnia with short (ISSD) or normal sleep duration (INSD) based on PSG-derived total sleep time (median TST = 347.3 min). CBT-I significantly improved ISI and sleep parameters (sleep onset latency, wake after sleep onset, time in bed, sleep efficiency) in both self-reported and PSG, with smaller effects in the latter. qEEG analyses revealed a significant increase in the delta/beta ratio post-CBT-I (baseline:13.4 ± 4.9, end-of-treatment:14.6 ± 5.9; p = 0.002), indicating reduced cortical hyperarousal, with no center effects. Sstab improved significantly (p = 0.005), though it was not correlated with delta/beta changes. ISSD showed greater delta/beta improvements than INSD (p = 0.014), suggesting phenotypic differences. CBT-I reduces cortical hyperarousal in ID, as reflected by increased delta/beta ratio. The dissociation from sleep stability suggests distinct mechanisms. These findings support qEEG biomarkers as valuable tools for understanding the neurophysiological mechanisms of insomnia treatment and guiding precision medicine approaches.

The most effective treatments of prolonged grief disorder (PGD) result in clinically relevant effects in only about half of the patients and can be emotionally taxing. This points to the importance of improving currently available treatment options. One promising target for enhancing the efficacy of the treatment of PGD is insomnia. Sleep disturbances are very common in bereavement and are proposed to play a causal role in maintaining PGD symptoms. Therefore, targeting sleep problems may be an effective treatment for people with PGD and insomnia disorder. This protocol presents a study, registered in the Dutch Trial Register (NL86238.042.24) that will evaluate the effects of cognitive behavioral therapy for insomnia (CBT-I) in individuals with comorbid PGD and insomnia using a replicated single-case experimental design (R-SCED). Twenty adults meeting diagnostic criteria for both disorders will be randomized to complete baseline between 5 and 14 weeks, after which they will receive CBT-I. Weekly PGD and insomnia symptom measures will be administered throughout the baseline (5–14 weeks), intervention (7–8 weeks) and post-intervention phase (4–13 weeks). Outcomes will be examined using visual inspection, Tau-U indices, and randomization tests. Results: We expect CBT-I to reduce both insomnia and PGD symptoms. This study will form the first systematic evaluation of CBT-I for PGD. Findings may help establish a novel, less emotionally demanding treatment option for bereaved individuals.

Borderline personality disorder (BPD) is often associated with insomnia, which may contribute to a vicious cycle of reciprocal exacerbation of sleep disturbance and BPD symptoms. Online cognitive behavioral therapy for insomnia (iCBT-I) has shown promise for treating insomnia in BPD patients. This study evaluated the key determinants, underlying processes, and change mechanisms of successful implementation of guided iCBT-I in BPD patients. In the context of our clinical trial, we conducted this mixed-method process evaluation in 30 patients with BPD and comorbid insomnia complaints (mean age 29.5 years ± 8.72) that received guided iCBT-I. Our process evaluation was guided by four dimensions of the theoretical RE-AIM framework: Reach (e.g., reason participation), Effectiveness (e.g., perceived symptom reduction), Implementation (e.g., treatment delivery), Maintenance (e.g., sustained adherence). We combined insights from quantitative patient-reported evaluation of treatment satisfaction and adherence and therapist log data, with qualitative exploration of patient experiences through in-depth interviews in a subsample of five patients. 21 patients (70%) completed the intervention. Patients appreciated the online modality and emphasized the importance of responsive and personalized (videocall) therapist guidance and active reminders. Patients found behavioral strategies, such as fixed bedtimes and an evening winding-down routine particularly helpful, while more introspective and cognitive techniques were often perceived as challenging. Qualitative effectiveness evaluations aligned with clinical trial outcomes on BPD, insomnia and arousal-related symptoms. Finally, patients expressed a strong desire for more and well-integrated sleep treatment into regular BPD care trajectories. Guided iCBT-I proved a feasible and promising intervention for patients with BPD, with successful implementation contingent upon personalized guidance, focus on behavioral strategies tailored to individual needs, and solid integration into BPD care.

Traumatic brain injury (TBI) in the U.S. military can result in lasting health issues, with insomnia being a common symptom that worsens recovery, cognitive function, and performance, especially when combined with common co-occurring conditions like chronic pain, post-traumatic stress disorder (PTSD), and depression. Insomnia may be an important intervention target for managing post-concussive symptoms and overall functioning in service members who have sustained a TBI. However, the standard of care for the treatment of insomnia, Cognitive Behavioral Therapy for Insomnia (CBTI), is not widely available in military health care settings. The aim of this paper is to describe the design and analysis plan of the clinical trial to evaluate and compare two methods for delivering CBTI including in-person CBTI or CBTI delivered remotely via a clinician-supervised digital platform in a sample of active-duty service members presenting for care in a military TBI specialty clinic. This is a phase II, randomized clinical trial designed to evaluate and compare the effects of CBTI (in-person or via a digital health platform) on sleep, behavioral health, and cognitive functions relative to treatment as usual among a sample of service members with a history of TBI. The effectiveness of in-person CBTI and CBTI delivered via a digital health platform, relative to treatment as usual, will be compared at baseline, after the six-week intervention, and again three months later on symptoms of insomnia, sleep quality, post-concussive symptoms, neurocognitive functioning, and psychological health. TBI is common in military personnel, often leading to insomnia that affects health and performance. While CBTI is the first-line recommended treatment for insomnia, CBTI is rarely implemented as the standard of care in military TBI specialty clinics, highlighting the need to assess its role in treating post-concussion symptoms and related issues. Clinical trials evaluating insomnia treatment in U.S. military service members with a history of TBI are essential to inform clinical practice for military TBI patients affected by insomnia and to potentially improve recovery, duty readiness, and cognitive function in this population. ClinicalTrials.gov: NCT06867666. Registered on 2/26/2025.

Outcomes from a combined cognitive behavioral therapy for insomnia (CBT-I) and sleep-related medication and substance use reduction treatment.

The effect of a tailored digital cognitive behavioural therapy for insomnia in people with co-morbid insomnia and sleep apnoea (COMISA): A pilot randomised controlled trial

Sober sleep? Cognitive behavioral therapy for insomnia across the spectrum of alcohol use disorder

For Veterans living with a serious mental illness (SMI), insomnia is prevalent and harmful. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment, but Veterans with SMI experience significant environmental, psychological, and systemic barriers to receiving and benefiting from it. There is limited clinical guidance on using CBT-I with Veterans with SMI. We developed provider guidelines and patient materials for conducting CBT-I when these barriers are present for people with SMI (CBT-I for SMI) and evaluated the acceptability and preliminary efficacy of CBT-I for SMI in an assessor-blind randomized controlled trial. Forty-seven Veterans with insomnia and SMI were randomized to either CBT-I for SMI (n = 26) or Health and Wellness (HW; n = 21), an active control condition. At baseline, post-treatment, and 3-month follow-up, participants completed: actigraphy and daily sleep diaries for two weeks and self-report measures of insomnia and functioning. At 3-month follow-up, participants completed satisfaction ratings of treatment. CBT-I for SMI participants had high treatment satisfaction and attendance. At post, compared to HW, CBT-I caused statistically significantly greater reductions in diary-measured time-in-bed, increases in diary-measured sleep efficiency, reductions in actigraphy-measured time-in-bed and total sleep time, and improvements in self-reported insomnia severity and sleep-related functioning; relative to CBT-I, HW improved community participation. CBT-I for SMI is acceptable to Veterans with SMI and improves sleep and functioning. Future research should examine how sleep mediates effective functional gains, identify how CBT-I could be integrated within recovery centers, and develop preventative interventions to curtail insomnia-associated functional decline. People with serious mental illnesses experience challenges to receiving and benefiting from Cognitive Behavioral Therapy for Insomnia. To support providers and patients, we developed guidelines and materials for navigating these challenges while conducting Cognitive Behavioral Therapy for Insomnia with people with serious mental illness. In the first study to compare Cognitive Behavioral Therapy for Insomnia conducted with our materials and guidelines to an active treatment control, we found that our guideline-led Cognitive Behavioral Therapy for Insomnia improved self-reported insomnia severity, sleep-related functioning, and actigraphy and diary-measured sleep of Veterans with serious mental illness and insomnia. Veterans with serious mental illness can participate in, derive satisfaction from, and benefit from Cognitive Behavioral Therapy for Insomnia when this treatment is appropriately tailored.

Insomnia, a prevalent sleep disorder affecting up to 18% of the population, is associated with significant health risks including depression, anxiety, cardiometabolic disease, and impaired physical and cognitive performance. Clinical guidelines prioritize non-pharmacological strategies such as cognitive-behavioral therapy for insomnia, with pharmacotherapy reserved for refractory cases. Physical activity has emerged as a promising adjunctive behavioral intervention, offering both sleep-specific and broad health benefits. This review synthesizes current evidence on exercise as a non-pharmacological intervention for insomnia, examining randomized controlled trials, epidemiological findings, and mechanistic studies. Across diverse populations, regular moderate-intensity physical activity - particularly aerobic exercise - improves sleep onset latency, efficiency, duration, and subjective quality. Additional benefits are observed with resistance, stretching, and mind-body modalities such as yoga and tai chi. Mechanisms include thermoregulatory cooling, circadian rhythm entrainment, neuroendocrine modulation, anxiety reduction, and enhanced sleep drive. Optimal outcomes are achieved with 150 minutes/week of moderate-intensity exercise, preferably in the morning or early afternoon; vigorous late-evening activity may be counterproductive. Integration with therapy and other treatments can amplify therapeutic effects, while tailoring type, intensity, and timing to patient characteristics enhances adherence and minimizes adverse effects. Given its accessibility, safety profile, and holistic benefits, physical activity should be considered a core component of insomnia management, offering a sustainable alternative or complement to pharmacological approaches.

Shift work has become a structural necessity in modern economies, yet its impact on mental health remains a growing concern. Circadian disruption, a core consequence of working non-standard hours, has been consistently linked to mood instability. This misalignment between internal biological rhythms and externally imposed work schedules affects key physiological systems involved in emotional regulation, including sleep-wake cycles, hormonal rhythms, and neurotransmitter activity. Disturbed sleep architecture, altered cortisol patterns, and impaired serotonergic function all contribute to heightened vulnerability to mood disorders such as depression, anxiety, and emotional lability among shift workers. The relationship between circadian misalignment and mood is not uniform across individuals. Genetic predispositions, diurnal preference, social environment, and occupational conditions play a substantial role in modulating emotional outcomes. Evening chronotypes may adapt more efficiently to night shifts, while certain polymorphisms in circadian genes increase sensitivity to rhythm disruption. Social support and perceived control over work schedules further influence psychological resilience in these populations. Clinical interventions targeting circadian health have shown efficacy in improving emotional outcomes. Light therapy, melatonin, and behavioral strategies such as cognitive behavioral therapy for insomnia have demonstrated benefits in regulating both sleep and mood. Preventive measures, including forward-rotating shift schedules, extended recovery periods, and fatigue risk management systems, also contribute to mitigating psychological harm. Addressing mood instability in shift workers requires a multidimensional approach that considers biological rhythms, individual risk modifiers, and systemic workplace design.

Cancer survivors often experience multiple cooccurring symptoms such as insomnia, pain, fatigue, and anxiety; yet conventional analyses in symptom science typically analyze symptoms one at a time and thus overlook putative clusters of shared symptom experiences. We applied a novel machine learning approach to supporting tailored symptom management to cooccurring symptoms. Bayesian nonparametric (BNP) clustering was applied to discover unique subgroups of symptom profiles in cancer survivors diagnosed with insomnia (N = 160) and with cooccurring pain, fatigue, and anxiety, using secondary symptom data from a clinical trial (clinicaltrials.gov: NCT02356575) comparing cognitive-behavioral therapy for insomnia (CBT-I) and acupuncture. BNP identified survivor subgroups by recognizing shared features in symptoms that contributed to heterogeneous treatment responses at 8 weeks. Simulations evaluated sensitivity to model assumptions. BNP identified three patient subgroups: (1) "insomnia-predominant" (N = 84) with high severity insomnia alone; (2) "insomnia & pain" (n = 21) with high severity of both insomnia and pain; and (3) "high symptom burden" (n = 54) with high severity across all symptoms. CBT-I produced greater insomnia reduction among "insomnia-predominant" patients (posterior mean=-2.45, 95% Bayesian Highest Density Interval: -4.38, -0.35) and among "insomnia & pain" patients (-2.66, 80% HDI: -4.50, -0.50). However, acupuncture produced greater pain reduction among "insomnia & pain" patients (-1.47, 95% HDI: -2.79, -0.18). CBT-I and acupuncture were equally effective for all symptoms among the "high symptom burden" patients. Simulations showed that our main BNP settings accurately identified these subgroups. Unsupervised BNP learning supports interventions tailored to patients' symptom burden and their main concerns. If further validated, BNP learning provides a roadmap for precision symptom management for cancer survivors, and broadly applicable in behavioral medicine data analysis.

Sleep health disparities are well documented, whereas racial differences in treatment response to sleep interventions, are not. This single arm sleep intervention study explored treatment-response differences in sleep behaviors, quality of life, well-being, depressive symptoms, and daytime sleepiness between White and Underrepresented racial groups, as well as racial differences in pre-treatment sleep-relevant characteristics. Middle-aged adults at risk for the metabolic syndrome with short sleep duration (N = 41; 49% Underrepresented racial group [n = 20], 51% White [n = 21]) participated in a virtually-delivered, 12-week personalized systematic sleep time extension informed by cognitive behavioral therapy for insomnia. Sleep behaviors were estimated using wrist actigraphy. Quality of life, emotional well-being, daytime sleepiness, chronotype preference, daytime sleepiness, depressive symptoms, quality of life, and well-being were assessed using validated surveys. Sleep environment, race, and socio-demographic characteristics were self-reported. Underrepresented participants had a greater increase in fragmentation indexes and a greater improvement in emotional well-being from pre to post-intervention compared to their White counterparts of medium and medium-to-large magnitude, respectively. Within each racial group, statistically and clinically significant improvements in sleep duration and daytime sleepiness were found. Within the Underrepresented group, the sleep regularity index increased and sleep onset times advanced significantly. These exploratory findings suggest that future studies with larger samples should investigate the modulating effects of chronotype on sleep intervention treatment response for Underrepresented racial groups and the upstream contextual and systemic factors impacting sleep.Trial registration numberTrial registration number ClincalTrials.gov NCT03596983.

Background: Sleep is a foundational pillar of health, influenced by numerous genetic, behavioral, lifestyle, and environmental factors. As non-pharmacologic strategies gain prominence, evidence-based approaches are needed to guide clinical practice. Methods: This expert narrative review synthesizes findings from observational studies, randomized trials, meta-analyses, and clinical guidelines, emphasizing the importance of lifestyle and behavioral interventions for sleep enhancement. Topics include sleep hygiene, circadian rhythm regulation, cognitive behavioral therapy for insomnia (CBT-I), exercise, nutrition, substance use, menopause, and consumer sleep technology. Results: Key findings support the importance of circadian alignment through light exposure, sufficient sleep quantity and timing, and behavior modification in sleep health. Exercise and weight management benefit general sleep quality and specific conditions like obstructive sleep apnea. While nutrition shows mixed direct effects on sleep, Mediterranean and low-glycemic diets are associated with fewer insomnia symptoms. CBT-I is a first-line treatment for chronic insomnia. Substances such as alcohol, cannabis, and caffeine exert varied and potentially deleterious effects on sleep regulation. Conclusion: Sleep is critical in health. Multidimensional behavioral interventions offer significant potential for improving both sleep quality and quantity. Clinicians should integrate these low-risk strategies into patient care to address the growing burden of sleep disorders and to promote overall well-being.

ABSTRACT Objectives This study assessed public knowledge about insomnia treatments, particularly Cognitive Behavioral Therapy for Insomnia (CBT-I), and examined whether familiarity varied by gender or race. The primary aim was to quantify what proportion of adults in the United States are familiar with and use CBT-I. Methods A nationally representative sample of 3080 U.S. adults (Mage = 39.5 years, SDage = 12.9) was surveyed. Approximately 48.3% identified as women. Participants reported their familiarity with various insomnia treatments, including pharmacological and behavioral options, and whether they had used prescription medications, over-the-counter sleep aids, or CBT-I within the past year or at any point in their lifetime. Results Participants were substantially more familiar with pharmacological treatments than behavioral therapies, with notably low recognition of CBT-I. Treatment utilization patterns supported that people tend to have a greater reliance on pharmacological interventions, particularly over-the-counter options, than CBT-I. Demographic differences emerged, with women and White participants reporting greater awareness of insomnia treatments than men and individuals from other racial groups. Age related differences were also observed, though, these varied by treatment approach. Conclusions This study identified major gaps in public awareness of CBT-I and highlighted disparities in treatment knowledge. Addressing these gaps is critical for improving treatment access and promoting CBT-I as a first-line, evidence-based treatment for insomnia.

Insomnia is a common sleep disorder characterized by difficulty initiating or maintaining sleep, significantly impacting daytime functioning and quality of life. Its chronic nature, high prevalence among older adults, and association with multiple comorbidities make it a pressing health concern. Here, we provide an overview of insomnia in the elderly, highlighting the gap between scientific guidelines and real-world clinical practice and the common pitfalls in managing this fragile patient population. We performed a comprehensive literature review to synthesize recent findings on insomnia pathophysiology, diagnosis, and treatment in the aging population. Insomnia in the elderly is frequently intertwined with comorbidities, which both contribute to and are exacerbated by sleep disturbances. The diagnostic process is complex, requiring differentiation between primary insomnia and conditions influenced by comorbidities, medications, and age-related sleep changes. A comprehensive clinical assessment remains the cornerstone of diagnosis. Treatment prioritizes non-pharmacological strategies, with cognitive-behavioral therapy for insomnia as the first-line approach, though accessibility remains a challenge. Pharmacotherapy should be reserved for short-term use, with careful consideration of adverse effects. However, pharmacological treatment often becomes chronic and deviates from clinical recommendations, relying on off-label medications. Insomnia management is further complicated by polypharmacy, which disrupts sleep and increases the risk of drug interactions and side effects, including falls and cognitive decline. A multidimensional, patient-centered approach is essential for managing insomnia in older adults. Addressing comorbidities, optimizing pharmacological strategies, and improving access to non-pharmacological treatments are crucial steps towards enhancing outcomes and quality of life in this vulnerable population.

Poor sleep is common in Crohn's disease (CD), prospectively predicts worse disease course, and is often attributable to insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia disorder. CBT-I improves sleep and may improve pain intensity, pain interference, and inflammation. We sought to investigate whether CBT-I impacts these factors in patients with active CD. We recruited patients with insomnia and mild-to-moderate CD symptoms from an inflammatory bowel disease center. Exclusion criteria were other sleep disorders, significant psychiatric concerns, and presence of other common influences on sleep. Participants completed baseline assessments of sleep, pain, and inflammation then were randomized to receive CBT-I immediately, or wait 12 weeks and then repeat the baseline assessment and complete CBT-I. Similar assessments occurred immediately post-CBT-I and 1 month later. CBT-I included sleep restriction, stimulus control, sleep hygiene, arousal reduction, and cognitive therapy. A total of 26 participants completed the study. In group × time analyses, CBT-I led to greater reductions in insomnia severity (P < .001) and wake after sleep onset (P = .02) than waitlist. In pre- to post-treatment analyses, participants reported significant improvements in subjective measures of sleep continuity, CD symptom severity, pain intensity, and pain interference. C-reactive protein trended toward improvement. This study provides preliminary evidence of efficacy of CBT-I in people with CD. CBT-I improved self-reported sleep and may improve pain and CD symptoms. The results highlight the importance of addressing sleep concerns in inflammatory bowel disease, particularly in people with persistent pain or fatigue. Future trials powered to detect changes in pain and inflammation are warranted.

Swipe for sleep - a standardized evaluation of mobile health apps for insomnia in children and adolescents.

Emerging neurotechnological approaches to management of sleep disturbances in Parkinson's disease.

Pediatric insomnia is a common condition that can significantly impact a patient's well-being. It typically involves difficulty falling asleep, staying asleep, or both. The prevalence of insomnia is notably higher among children with autism spectrum disorder (ASD) or attention-deficit hyperactivity disorder (ADHD). Two commonly recognized subtypes of pediatric insomnia are behavioral insomnia and psychophysiological insomnia. Because clinical symptoms and physical examination findings are often subtle, pediatricians should be familiar with the diagnosis and management of insomnia. Pediatricians should also consider and rule out underlying disorders such as sleep apnea, anxiety, or other medical conditions that may contribute to or mimic insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is currently regarded as the most effective treatment. While melatonin has shown benefits in children with autism or ADHD, additional research is needed to evaluate the efficacy of other pharmacologic options. Timely intervention is crucial, as pediatric insomnia can become chronic and negatively affect mental health and overall quality of life.

Circadian and gut-brain axis modulation is associated with neuroimmune and symptom recovery after rectal cancer surgery: An exploratory randomized controlled trial.