Diagnosis Of Insomnia Disorder Research Articles

Multimodal transformer graph convolution attention isomorphism network (MTCGAIN): a novel deep network for detection of insomnia disorder.

In clinic, the subjectivity of diagnosing insomnia disorder (ID) often leads to misdiagnosis or missed diagnosis, as ID may have the same symptoms as those of other health problems. A novel deep network, the multimodal transformer graph convolution attention isomorphism network (MTGCAIN) is proposed in this study. In this network, graph convolution attention (GCA) is first employed to extract the graph features of brain connectivity and achieve good spatial interpretability. Second, the MTGCAIN comprehensively utilizes multiple brain network atlases and a multimodal transformer (MT) to facilitate coded information exchange between the atlases. In this way, MTGCAIN can be used to more effectively identify biomarkers and arrive at accurate diagnoses. The experimental results demonstrated that more accurate and objective diagnosis of ID can be achieved using the MTGCAIN. According to fivefold cross-validation, the accuracy reached 81.29% and the area under the receiver operating characteristic curve (AUC) reached 0.8760. A total of nine brain regions were detected as abnormal, namely right supplementary motor area (SMA.R), right temporal pole: superior temporal gyrus (TPOsup.R), left temporal pole: superior temporal gyrus (TPOsup.L), right superior frontal gyrus, dorsolateral (SFGdor.R), right middle temporal gyrus (MTG.R), left middle temporal gyrus (MTG.L), right inferior temporal gyrus (ITG.R), right median cingulate and paracingulate gyri (DCG.R), left median cingulate and paracingulate gyri (DCG.L). The brain regions in the default mode network (DMN) of patients with ID show significant impairment (occupies four-ninths). In addition, the functional connectivity (FC) between the right middle occipital gyrus and inferior temporal gyrus (ITG) has an obvious correlation with comorbid anxiety (P=0.008) and depression (P=0.005) among patients with ID.

Assessment and management of chronic insomnia disorder: an algorithm for primary care physicians

BackgroundPrimary care physicians often lack resources and training to correctly diagnose and manage chronic insomnia disorder. Tools supporting chronic insomnia diagnosis and management could fill this critical gap. A survey was conducted to understand insomnia disorder diagnosis and treatment practices among primary care physicians, and to evaluate a diagnosis and treatment algorithm on its use, to identify ways to optimize it specifically for these providers.MethodsA panel of experts developed an algorithm for diagnosing and treating chronic insomnia disorder, based on current guidelines and experience in clinical practice. An online survey was conducted with primary care physicians from France, Germany, Italy, Spain, and the United Kingdom, who treat chronic insomnia patients, between January and February 2023. A sub-sample of participants provided open-ended feedback on the algorithm and gave suggestions for improvements.ResultsOverall, 106 primary care physicians completed the survey. Half (52%, 55/106) reported they did not regularly screen for insomnia and half (51%, 54/106) felt they did not have enough time to address patients’ needs in relation to insomnia or trouble sleeping. The majority (87%,92/106) agreed the algorithm would help diagnose chronic insomnia patients and 82% (87/106) agreed the algorithm would help improve their clinical practice in relation to managing chronic insomnia. Suggestions for improvements were making the algorithm easier to read and use.ConclusionThe algorithm developed for, and tested by, primary care physicians to diagnose and treat chronic insomnia disorder may offer significant benefits to providers and their patients through ensuring standardization of insomnia diagnosis and management.

The nucleus accumbens functional connectivity in patients with insomnia using resting-state fMRI.

The aim of this study was to investigate the functional abnormalities between the nucleus accumbens (NAc) and the whole brain in individuals with Insomnia Disorder (ID) using resting-state functional magnetic resonance imaging (fMRI). Additionally, the study aimed to explore the underlying neural mechanisms of ID. We enrolled 18 participants with ID and 16 normal controls (NC). Resting-state functional connectivity (FC) between the NAc and the whole brain voxels was calculated and compared between the two groups to identify differential brain region. Receiver operating characteristic (ROC) curve analysis was employed to assess the ability of differential features to distinguish between groups. Furthermore, Pearson correlation analysis was performed to examine the relationship between neurocognitive scores and differential features. The ID group exhibited significantly reduced FC values in several brain regions, including the right supplementary motor area, the bilateral middle frontal gyrus, the bilateral median cingulate and paracingulate gyri and the left precuneus. The area under the curve (AUC) of the classification model based on FC in these brain regions was 83.3%. Additionally, the abnormal functional changes observed in ID patients were positively correlated with the Fatigue Severity Scale (R = 0.650, p = 0.004). These findings suggest that the NAc may play a crucial role in the diagnosis of ID and could serve as a potential imaging biomarker, providing insights into the underlying neural mechanisms of the disorder.

The burden of untreated insomnia disorder in a sample of 1 million adults: a cohort study

BackgroundInsomnia disorder is a highly prevalent, significant public health concern associated with substantial and growing health burden. There are limited real-world data assessing the burden of insomnia disorder on daytime functioning and its association with comorbidities. The objective of this study was to leverage large-scale, real-world data to assess the burden of untreated insomnia disorder in terms of daytime impairment and clinical outcomes.MethodsThis United States medical claims database study compares patients diagnosed with insomnia disorder but not receiving treatment (‘untreated insomnia’ cohort) to patients without an insomnia disorder diagnosis and without treatment (‘non-insomnia’ cohort). International Classification of Disease, Tenth Revision codes were used as a proxy to represent the three symptom domains (Sleepiness, Alert/Cognition, Mood) of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ), a newly developed and validated tool used in clinical studies to assess daytime functioning in insomnia disorder. Chronic Fatigue (R53.83) and Other Fatigue (R53.83), Somnolence (R40.0) and Disorientation (R41.0) were selected as categories representing one or more IDSIQ domains. Clinical outcomes included cardiovascular events, psychiatric disorders, cognitive impairment and metabolic disorders.ResultsApproximately 1 million patients were included (untreated insomnia: n = 139,959; non-insomnia: n = 836,975). Compared with the ‘non-insomnia’ cohort, the ‘untreated insomnia’ cohort was more likely to experience daytime impairments, with mean differences in occurrences per 100 patient-years for: (a) fatigue, at 27.35 (95% confidence interval [CI] 26.81, 27.77, p < 0.01); (b) dizziness, at 4.66 (95% CI 4.40, 4.90, p < 0.01); (c) somnolence, at 4.18 (95% CI 3.94, 4.43, p < 0.01); and (d) disorientation, at 0.92 (95% CI 0.77, 1.06, p < 0.01). During the 1-year look-back period, patients in the ‘untreated insomnia’ cohort were also more likely to have been diagnosed with arterial hypertension (40.9% vs. 26.3%), psychiatric comorbidities (40.1% vs. 13.2%), anxiety (29.2% vs. 8.5%), depression (26.1% vs. 8.1%) or obesity (21.3% vs. 11.1%) compared with those in the ‘non-insomnia’ cohort.ConclusionsThis large-scale study confirms the substantial burden of insomnia disorder on patients in a real-world setting, with significant daytime impairment and numerous comorbidities. This reinforces the need for timely insomnia disorder diagnosis and treatments that improve both sleep, as well as daytime functioning.

0358 Prevalence of Insomnia Symptoms and Insomnia Disorder within VA Subacute Rehabilitation

Abstract Introduction Approximately 40% of Veterans report insomnia symptoms and 12% of Veterans have a formal insomnia disorder diagnosis. While these numbers reflect outpatient prevalence rates, there is little data on the prevalence of insomnia symptoms and insomnia disorder among the 32,000 Veterans receiving care within VA Community Living Centers (CLC) (rehabilitation and long-term care facilities) each year. The present analysis provides an initial step in understanding the prevalence of insomnia disorder vs. insomnia symptoms within a local VA CLC subacute rehabilitation unit. This analysis is part of a clinical innovation project that evaluated Veterans’ sleep during admission for the purposes of informing clinical interventions. Methods 67 Veterans were admitted to a VA subacute rehabilitation unit following hospital discharge between March and August 2022. Veterans were asked to complete a brief evaluation within 7 days of admission, including the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), and Epworth Sleepiness Scale (ESS). Sleep disorder diagnoses were obtained through chart reviews. Descriptive statistics were used to evaluate the prevalence of sleep disorders, insomnia severity, sleep need, and daytime sleepiness. Results 48 of 67 (71.6%) Veterans (Mage=72.8±12.0;97.9%male;79.2%white) completed evaluations within 7 days of admission. 52.1% of Veterans reported at least subthreshold insomnia (ISI≥8) with 22.9% reporting moderately severe clinical insomnia (ISI≥15). 50% reported not meeting their sleep need (SNQ≥13) and 33.3% reported at least mild levels of daytime sleepiness (ESS≥11). Chart reviews indicated only 25% of Veterans had a formal sleep disorder diagnosis in their chart and only 4.2% Veterans had a formal diagnosis of insomnia disorder. Conclusion The results of this preliminary analysis highlighted the discrepancy between national outpatient statistics and local inpatient statistics on the prevalence of insomnia symptoms and disorder. While the Veterans admitted to the CLC may be experiencing additional factors influencing their sleep (e.g., environmental disruptors), this does not wholly explain the discrepancy between the local and national ­samples. Future evaluations should include multiple VA sites to obtain a more representative sample of Veterans. Clinically, these findings suggest that insomnia disorder should be considered a standalone diagnosis and added to Veterans’ charts when clinically elevated symptomology is endorsed. Support (if any)

Dual orexin receptor antagonists for the treatment of insomnia: systematic review and network meta-analysis.

Several randomized clinical trials (RCTs) have shown that dual orexin receptor antagonists (DORAs) are effective in the treatment of chronic insomnia. However, the superiority of one particular DORA over the others remains unclear. To perform a network meta-analysis to evaluate the efficacy of different DORAs in patients with chronic insomnia. The Medline, Embase, and Cochrane Central databases were searched for RCTs that compared DORA with placebo in patients ≥ 18 years of age with a diagnosis of insomnia disorder. We pooled outcomes for wake time after sleep onset (WASO), latency to persistent sleep (LPS), total sleep time (TST), and adverse events (AEs). We included 10 RCTs with 7,806 patients, 4,849 of whom received DORAs as the intervention. Overall, we found that DORAs were associated with the improvement of all analyzed efficacy outcomes. Concerning TST, an apparent dose-dependent pattern was noticed, with higher doses relating to a longer TST. Lemborexant 10mg provided the largest reduction in WASO (at month 1) in minutes (standardized mean difference [SMD] = -25.40; 95% confidence interval [95%CI] = -40.02--10.78), followed by suvorexant 20/15mg (SMD = -25.29; 95%CI = -36.42--14.15), which also appeared to provide the largest decrease in long-term WASO (SMD = -23.70; 95%CI = -35.89--11.51). The most frequent AEs were somnolence, nasopharyngitis, and headache, with rates of up to 14.8%. Our results suggest that DORAs are associated with greater efficacy when compared with placebo in the treatment of insomnia, a complex 24-hour sleep disorder. Additionally, dosing might play an important role in the management of chronic insomnia.

Clinical Characteristics of HIV-Infected Patients With Sleep Disturbance

Objective: This study aims to examine clinical characteristics and to identify possible risk factors of sleep disturbances in people living with HIV (PLWH).Methods: All research data of patients who were first diagnosed with HIV/AIDS from January 1, 2012 to December 31, 2021 and complained of sleep disturbance at least once were retrospectively reviewed by the Severance Clinical Research Analysis Portal (SCRAP) service of Severance hospital. The presence of sleep disturbance was evaluated based on whether insomnia disorder diagnosis code was included or whether insomnia medication was prescribed. The patients were divided into either the group with sleep disturbance within 3 months (SDW3) and the group with after 3 months (SDA3). All data were reported using descriptive statistics.Results: Of the 674 patients diagnosed with HIV during the period, 56 patients experienced sleep disturbances at least once and approximately 50% of patients have experienced sleep disturbance in the first 3 months after HIV diagnosis. CD4+ cell count at the time of first onset of sleep disturbance was significantly lower (p=0.03) and HIV viral load at the time of first onset of sleep disturbance was significantly higher (p&lt;0.001) in SDW3 group. SDW3 patients showed higher rates of opportunistic infections compared to SDA3 patients.Conclusion: The current study suggests that further investigation of the underlying pathophysiology of sleep disturbance and association with immunological changes for early diagnosis and treatment of sleep disturbance in PLWH.

0863 A Unique case of sleep state misperception in an elderly patient

Abstract Introduction Insomnia is a widespread condition, especially in the elderly population. While the International Classification of Sleep Disorders (ICSD) third edition appropriately removed primary insomnia subtypes from the classification, our case illustrates the importance of these factors in considering a chronic insomnia disorder diagnosis. We present a case of severe subjective insomnia with no apparent objective findings, instead with evidence of excellent sleep efficiency on the contrary. Report of Cases: A 76-year-old male with a past medical history of anxiety and a recent diagnosis of early Parkinson's disease presented to the Sleep medicine clinic with two years of insomnia which started after his retirement. The patient felt difficulty with falling asleep every night. He underwent a sleep study and was found to have sleep-disordered breathing, which responded well to Bilevel positive airway pressure (BiPAP) therapy. However, insomnia symptoms persisted and were resistant to multiple medications, including Mirtazapine, Melatonin, and Suvorexant. He was referred for Cognitive Behavioral Therapy with minimal to no improvement in his symptoms. Conversely, a one-week Actigraphy recording on Bipap therapy surprisingly revealed an excellent sleep efficiency with near-continuous seven to eight hours of sleep every night. The etiology of chronic insomnia is poorly understood but is typically multifactorial, as described in the second edition of ICSD. In this case, paradoxical insomnia played a significant role in the patient's clinical presentation. Paradoxical insomnia is defined as thoughts or perceptions of time asleep as wakefulness, with objective measures documenting normative amounts of sleep. Previous work suggests that alterations in the sleep/arousal system may contribute to this apparent mismatch between conventional objective sleep measures and subjective reports. Conclusion This case demonstrates the challenge of effectively diagnosing and managing chronic insomnia. While the new classification guidelines from the ICSD appropriately remove insomnia subtypes from the diagnostic paradigm, familiarity with these previously described subtypes may aid clinical decisions. Crucial to this discussion is that previously described "secondary" or "subtypes" of primary insomnia may develop an independent clinical course that may require further attention. Support (If Any) ICSD 2nd,3rd editions.

Insomnia disorder: State of the science and challenges for the future.

Insomnia disorder comprises symptoms during night and day that strongly affect quality of life and wellbeing. Prolonged sleep latency, difficulties to maintain sleep and early morning wakening characterize sleep complaints, whereas fatigue, reduced attention, impaired cognitive functioning, irritability, anxiety and low mood are key daytime impairments. Insomnia disorder is well acknowledged in all relevant diagnostic systems: Diagnostic and Statistical Manual of the American Psychiatric Association, 5th revision, International Classification of Sleep Disorders, 3rd version, and International Classification of Diseases, 11th revision. Insomnia disorder as a chronic condition is frequent (up to 10% of the adult population, with a preponderance of females), and signifies an important and independent risk factor for physical and, especially, mental health. Insomnia disorder diagnosis primarily rests on self-report. Objective measures like actigraphy or polysomnography are not (yet) part of the routine diagnostic canon, but play an important role in research. Disease concepts of insomnia range from cognitive-behavioural models to (epi-) genetics and psychoneurobiological approaches. The latter is derived from knowledge about basic sleep-wake regulation and encompass theories like rapid eye movement sleep instability/restless rapid eye movement sleep. Cognitive-behavioural models of insomnia led to the conceptualization of cognitive-behavioural therapy for insomnia, which is now considered as first-line treatment for insomnia worldwide. Future research strategies will include the combination of experimental paradigms with neuroimaging and may benefit from more attention to dysfunctional overnight alleviation of distress in insomnia. With respect to therapy, cognitive-behavioural therapy for insomnia merits widespread implementation, and digital cognitive-behavioural therapy may assist delivery along treatment guidelines. However, given the still considerable proportion of patients responding insufficiently to cognitive-behavioural therapy for insomnia, fundamental studies are highly necessary to better understand the brain and behavioural mechanisms underlying insomnia. Mediators and moderators of treatment response/non-response and the associated development of tailored and novel interventions also require investigation. Recent studies suggest that treatment of insomnia may prove to add significantly as a preventive strategy to combat the global burden of mental disorders.

Management of chronic insomnia using hypnotics: a friend or a foe?

Epidemiological studies suggest that 10-15% adults meet the present criteria for the diagnosis of insomnia disorder; however, there may be geographical variations. Untreated insomnia disorders have a number of adverse health consequences in addition to economic burden caused by it. Available guidelines mention that CBT-I should be preferred over hypnotics. However, several patients of chronic insomnia are not candidate for CBT-I and for them, hypnotics are the only answer. This paper reviews the literature to answer following questions: What is the current understanding regarding place of hypnotics for in management of insomnia disorder? How many patients misuse or abuse hypnotics, especially benzodiazepines, as commonly believed? Do we have data from human studies regarding low-dose benzodiazepine dependence? What does hypnotics produce-withdrawal insomnia, rebound insomnia or end of dose phenomenon? Are adverse effects of benzodiazepines worse than other psychotropic medications? Is prescription of hypnotics more troublesome than untreated insomnia disorder? Available literature suggests that there is an unreasonable negative bias attached to the use of hypnotics. Only a sub-set of patients who are prescribed hypnotics, meet the criteria for "dependence" in long term. Other patients either discontinue it (as insomnia remits) or change to occasional use (since insomnia may be relapsing remitting disorder), or continue using it in low dose (since insomnia reappears as hypnotics are discontinued, similar to increase in blood sugar after hypoglycemics are discontinued). Meta-analysis shows that adverse effects of hypnotics are comparable to that of other psychotropic medications. Considering the consequences and risks associated with untreated insomnia disorder, even long-term use of hypnotics is justified, however with the careful watch that patients are not increasing the dose. This approach is especially important in geographical areas where trained CBT-I therapists are not available.

Occurrence and Long-Term Prognosis of Insomnia Disorder among Survivors of Acute Respiratory Distress Syndrome in South Korea.

Rationale: As the most common type of sleep disorder, insomnia disorder can develop as a sequela among acute respiratory distress syndrome (ARDS) survivors. However, insomnia prevalence, its associated factors, and its impact on long-term survival remain controversial. Objectives: This study aimed to investigate insomnia prevalence and its associated factors among ARDS survivors. We also examined the association between insomnia and 2-year all-cause mortality. Methods: The National Health Insurance Database of South Korea was used for this nationwide cohort study. We included adult patients (⩾18 years of age) admitted to intensive care units for ARDS treatment from January 1, 2010, to December 31, 2018, and who survived for ⩾1 year after diagnosis, defined as ARDS survivors. ARDS survivors who received a diagnosis of insomnia disorder before ARDS diagnosis were defined as the pre-ARDS insomnia disorder group, whereas those who had no history of insomnia disorder but received a new diagnosis of insomnia disorder within 1 year of diagnosis of ARDS were defined as the post-ARDS insomnia disorder group. Results: A total of 4,452 ARDS survivors were included in this study, with 895 patients (20.1%) in the pre-ARDS insomnia disorder group and 536 (12.6%) patients in the post-ARDS insomnia disorder group. In the multivariable logistic regression analysis, delirium occurrence (odds ratio [OR],1.61; 95% confidence interval [CI], 1.24-2.10; P < 0.001), underlying anxiety disorder (OR, 1.34; 95% CI, 1.08-1.66; P = 0.007), depression (OR, 1.48; 95% CI, 1.17-1.86; P = 0.001), and substance abuse (OR, 1.51; 95% CI, 1.01-2.26; P = 0.042) were associated with a higher prevalence of post-ARDS insomnia disorder. In multivariable Cox regression analysis, the pre-ARDS insomnia disorder and post-ARDS insomnia disorder groups were associated with 1.33-fold (hazard ratio, 1.33; 95% CI, 1.08-1.64; P = 0.007) and 1.36-fold (hazard ratio, 1.36; 95% CI, 1.06-1.74; P = 0.016) increased prevalence of 2-year all-cause mortality among ARDS survivors, respectively. Conclusions: At 1 year after diagnosis of ARDS, 12.6% of ARDS survivors received a new diagnosis of insomnia disorder in South Korea. Delirium and underlying psychiatric illness (anxiety disorder, depression, and substance abuse) were potential risk factors for the diagnosis of post-ARDS insomnia disorder. Moreover, both pre- and post-ARDS insomnia disorders were associated with 2-year all-cause mortality among ARDS survivors.

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.

Prevalence, Impact, and Burden of Insomnia and Discussing It With Patients.

Insomnia is the most prevalent sleep-wake disorder, with about one in ten individuals meeting diagnostic criteria. Associated with significant impairment in daytime function, insomnia has a vast societal burden and impact on public health. To arrive at an accurate diagnosis of insomnia disorder, clinicians should conduct an effective interview with patients to assess the complaint and sleep history and use assessment tools as part of the evaluation.

Prevalence of insomnia disorder and sleep apnea in a sample of veterans at risk for cardiovascular disease.

The objectives of this study were to examine the proportion of study participants screening positive for insomnia disorder and/or sleep apnea in veterans engaged in routine health care and known to be at risk for cardiovascular disease and to compare these proportions with those previously documented in medical records. This was a cross-sectional analysis of baseline data from a randomized clinical intervention trial for patients at risk of cardiovascular disease and a review of study participants' medical records. Participants were veterans ≥ 40 years of age, enrolled in Veterans Affairs primary care, and diagnosed with hypertension and/or hypercholesterolemia. Self-report outcomes were the proportion of patients screening positive for an insomnia disorder and sleep apnea, self-reporting a sleep apnea diagnosis, and endorsing undertreated sleep apnea. Medical record outcomes were the proportion of patients diagnosed with insomnia and sleep apnea. Participants (n = 420) were veterans (84.8% male) with a mean age of 61.1 years. More than half of the sample (52.1%) screened positive for sleep apnea without prior self-reported diagnosis. More than one-third of the sample (39%) screened positive for an insomnia disorder. Medical records revealed considerably lower rates, with 3.8% diagnosed with insomnia, 20.5% diagnosed with sleep apnea, and about 1% diagnosed with both conditions. Undiagnosed and undertreated sleep disorders are common among veterans at risk for cardiovascular disease. Most of the sample (82%) screened positive for, or met, study criteria for sleep apnea or an insomnia disorder. Limitations include the use of self-reported sleep apnea treatment adherence, an insomnia disorder diagnosis based on questionnaire score, and a sample comprised primarily of male veterans. Routine sleep disorders screening in veterans at risk for cardiovascular disease could help to identify those at even greater risk because of the adverse effects of undiagnosed or undertreated sleep disorders. Registry; ClinicalTrials.gov; Name: Cardiovascular Intervention Improvement Telemedicine Study; URL: https://clinicaltrials.gov/ct2/show/NCT01142908; Identifier: NCT01142908.

Validation of the Insomnia Severity Index (ISI) for identifying insomnia in young adult cancer survivors: comparison with a structured clinical diagnostic interview of the DSM-5 (SCID-5)

ObjectivesInsomnia is a common problem affecting young adult cancer survivors (YACS) even years after treatment, yet it often goes unidentified and untreated. The Insomnia Severity Index is a widely-used insomnia measure, but has not been studied as an insomnia screener for YACS. The goal of this study was to validate the ISI in YACS by determining its utility in identifying YACS with insomnia disorder diagnosed with the Structured Clinical Interview for the DSM-5 (SCID-5). Methods250 YACS completed the ISI and SCID-5 Insomnia Module. Area under the curve (AUC) was calculated to reflect the ISI's discrimination between YACS with and without SCID-5 insomnia disorder. An ISI cut-off score with sensitivity ≥0.85 and specificity ≥0.75 was deemed acceptable. ResultsOf 250 participants, 52 met criteria for SCID-5 insomnia disorder diagnosis. The ISI had excellent discrimination, with an AUC = 0.91. A cut-off score ≥8 met study clinical screening criteria with sensitivity of 0.85 and specificity of 0.77. A cut-off score ≥7 with a higher sensitivity (0.96) but lower specificity (0.70) was noted as a potential alternative. Cut-off scores ≥12 and ≥ 14 were recommended for applications prioritizing overall accuracy. ConclusionsResults support validity of the ISI for identifying YACS with insomnia disorder. For clinical screening, data support the use of an ISI cut-off score ≥8 in YACS, and additional cut-off scores were found for research purposes or higher sensitivity. Results of this study and prior studies of the ISI offer important reminders that cut-off scores derived from different populations are not generalizable.

Causes and Consequences of Chronic Sleep Deficiency and the Role of Orexin.

Sleep is one of the pillars of health. Experimental models of acute sleep loss, of chronic partial sleep deprivation, and of sleep fragmentation in healthy sleepers are helpful models of sleep deficiency produced by insufficient sleep duration, sleep timing, and sleep disorders. Sleep deficiency is associated with changes in markers associated with risk for disease. These include metabolic, inflammatory, and autonomic markers of risk. In addition, sleep disruption and sleep deficits lead to mood instability, lack of positive outlook, and impaired neurobehavioral functioning. On a population level, insufficient sleep is associated with increased risk for hypertension and diabetes. Sleep disturbance is very common, and about half the population will report that they have experienced insomnia at some time in their lives. Approximately 10% of the population describe daytime impairment due to sleep disturbance at night, consistent with a diagnosis of insomnia disorder. The hypothalamic neuropeptides, orexin-A and orexin-B, act through G-protein-coupled receptors (orexin-1 and orexin-2 receptors). Dual and selective orexin-2 receptor antagonists have shown efficacy in inducing sleep in men and women with insomnia disorder by accelerating sleep onset and improving sleep efficiency and total sleep time. Further study comparing these medications, in short- and longer-term use models, is recommended. Greater understanding of comparative effects on mood, neurobehavioral, and physiological systems will help determine the extent of clinical utility of dual versus selective orexin receptor antagonists.

The European Portuguese version of the insomnia severity index.

Insomnia is the most prevalent sleep complaint, but remains largely an unidentified public health issue. The Insomnia Severity Index (ISI) is a brief self-report questionnaire to assess insomnia, long-established both in clinical and research settings. The present study aimed to analyse the reliability, validity, and accuracy of the ISI European Portuguese version. After the translation protocol, 1,274 participants (65.54% female), with a mean (SD, range) age of 37.52(16.82, 18-95)years, completed the ISI. This sample included 250 patients with insomnia from a Sleep Medicine Centre, presenting a diagnosis of insomnia disorder (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; International Classification of Sleep Disorders, Third Edition), and 1,024 individuals from the community. A group of 30 patients with obstructive sleep apnea (OSA) was also recruited. Cronbach's α was 0.88 (internal consistency), and corrected item-total correlations ranged from 0.56 to 0.83. An exploratory factor analysis (oblique rotation) revealed a two-factor solution for both clinical and community samples. The ISI total score significantly differentiated insomnia disorder, no insomnia, and OSA subgroups with a large effect size (η 2 =0.42). The correlation between ISI and Pittsburgh Sleep Quality Index supported concurrent validity (0.82), and discriminant validity was confirmed by a moderate correlation between ISI and Beck Depression Inventory Second Edition (0.32). The area under the curve was 0.88, and the optimal cut-off to detect clinical insomnia was 14 (82.1% sensitivity, 79.5% specificity). In conclusion, the Portuguese version of the ISI is a reliable and valid measure of insomnia in clinical and non-clinical populations. Our present study also contributes to relevant data for the international literature regarding the cut-off score of the scale for the detection of clinical insomnia.

Insomnia disorder diagnosis and treatment patterns in primary care: A cross-sectional analysis of electronic medical records data.

About one in every three US adults is estimated to have insomnia disorder. Consequences of untreated insomnia disorder are debilitating and costly, and primary care providers (PCPs) are uniquely positioned to detect and treat insomnia, thus preventing its adverse outcomes. The goal of this study was to explore the utility of analyzing electronic medical record data to identify patterns in diagnosis and management of insomnia disorder by PCPs. This was a cross-sectional descriptive study. Numbers of medical records containing at least one insomnia disorder diagnosis code, one insomnia-related medication, or both were tabulated. Prevalence and odds ratios (ORs) were determined. Insomnia disorder diagnoses were present in 9.4% of the records; 7.4% contained insomnia-related medication(s), and only 3.9% contained both. Diagnoses and medications were higher among women than men (ORs up to 2.87, depending on age range) and in general and increased with age. The prevalence of insomnia disorder diagnoses in primary care medical records falls below expectation for the population of interest, and less than half of patients with an insomnia disorder diagnosis are prescribed an insomnia-related medication. Electronic medical records provide an efficient window into insomnia disorder diagnosis and management patterns in the primary care setting. Primary care providers may be missing opportunities to detect and treat insomnia disorder as a way of improving overall patient outcomes. Electronic medical record systems may require modification to facilitate more accurate data extraction.

150: Insomnia and obstetric outcomes

Insomnia is common during pregnancy and has been associated with poor maternal and infant outcomes. We evaluated the effect of cognitive behavioral therapy for insomnia (CBTI) during pregnancy on obstetric outcomes, and hypothesized that treatment would result in better obstetric outcomes. This is a pre-planned secondary analysis of obstetric outcomes from a randomized controlled trial (RCT) of CBTI during pregnancy where the primary outcome was the Insomnia Severity Index (ISI). Eligibility for the RCT were a diagnosis of Insomnia Disorder based on Diagnostic and Statistical Manual for Mental Disorders 5th edition criteria, and gestational age of 18-32 weeks at enrollment. Women with comorbid sleep disorders, psychiatric disorders including major depressive disorder, and concomitant treatments that could impact sleep were ineligible. Women were randomized to 5 individual therapy sessions of CBTI or a control treatment. ISI was measured at baseline, weekly during treatment, and monthly post treatment. Obstetric outcomes were extracted from charts and included birthweight, gestational age at delivery, mode of delivery, hypertensive disorders and gestational diabetes, and were compared with ISI scores. 154 women were analyzed. Women whose insomnia remitted (ISI< 8 post-treatment) had a later gestational age at delivery (39.51+1.23 vs. 38.79+2.18 weeks; p=.035); there were no differences in birthweight, operative vaginal delivery, hypertensive disorders or gestational diabetes. Although CBTI resulted in better insomnia outcome (Manber R. et al., Obstet Gynecol 2019), obstetric outcomes were similar between treatment arms (p-values >0.3). Women who underwent cesarean for any reason (29%) had a higher ISI at baseline (15.13+4.23 vs. 17.05+4.55; p=0.019). Lower ISI scores at baseline and insomnia remittance resulted in better obstetric outcomes. Assessment for and treatment of insomnia disorder during pregnancy is important. Future adequately powered studies of CBTI should identify moderators and mediators of its effects on obstetric outcomes.

A moderated mediation model of the link between counterfactual processing at bedtime and insomnia diagnosis: The role of depressive symptoms and nocturnal maladaptive strategies of mental control.

This study investigated the relationship between bedtime counterfactual thoughts, depressive symptoms, nocturnal counterproductive thought-control strategies and insomnia disorder. Six hundred and fifty adults from the general population were recruited and provided data on their counterfactual thoughts' frequency at bedtime, depressive symptoms and use of nocturnal maladaptive strategies of thought control. In addition, all participants followed a face-to-face clinical interview for the diagnosis of insomnia disorder. A model positing moderated mediation was tested using conditional process modelling. Overall, 19% of participants met diagnostic criteria for a chronic insomnia diagnosis. Bootstrapped mediation analyses indicated that the association of bedtime counterfactual processing and insomnia diagnosis is mediated by depressive symptoms (B=0.035, SE=0.007, bootstrapped 95% CI=0.023, 0.051). Furthermore, the effects of such a mediation model were significantly larger among individuals with high levels of aggressive suppression than those with low levels of aggressive suppression (B=0.002, SE=0.001, bootstrapped 95% CI=0.001, 0.004). A second model in which a worry strategy moderates the relationship between bedtime counterfactual processing and depressive symptoms was not statistically significant (B=0.0036, SE=0.013, p=.78). The present study adds to the literature on the importance of self-attacking thoughts and negative affects at bedtime. We recommend the evaluation of the impact of adding self-attacks management strategies to cognitive behavior therapy for individuals with an insomnia disorder.