Population-based epidemiologic studies have uncovered the high prevalence and wide severity spectrum of undiagnosed obstructive sleep apnea, and have consistently found that even mild obstructive sleep apnea is associated with significant morbidity. Evidence from methodologically strong cohort studies indicates that undiagnosed obstructive sleep apnea, with or without symptoms, is independently associated with increased likelihood of hypertension, cardiovascular disease, stroke, daytime sleepiness, motor vehicle accidents, and diminished quality of life. Strategies to decrease the high prevalence and associated morbidity of obstructive sleep apnea are critically needed. The reduction or elimination of risk factors through public health initiatives with clinical support holds promise. Potentially modifiable risk factors considered in this review include overweight and obesity, alcohol, smoking, nasal congestion, and estrogen depletion in menopause. Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. A focus on weight control is especially important given the expanding epidemic of overweight and obesity in the United States. Primary care providers will be central to clinical approaches for addressing the burden and the development of cost-effective case-finding strategies and feasible treatment for mild obstructive sleep apnea warrants high priority.

Epidemiology of obstructive sleep apnea: a population health perspective.

The detection of psychiatric illness by questionnaire

OBJECTIVE —To estimate the odds and prevalence of clinically relevant depression in adults with type 1 or type 2 diabetes. Depression is associated with hyperglycemia and an increased risk for diabetic complications; relief of depression is associated with improved glycemic control. A more accurate estimate of depression prevalence than what is currently available is needed to gauge the potential impact of depression management in diabetes. RESEARCH DESIGN AND METHODS —MEDLINE and PsycINFO databases and published references were used to identify studies that reported the prevalence of depression in diabetes. Prevalence was calculated as an aggregate mean weighted by the combined number of subjects in the included studies. We used χ 2 statistics and odds ratios (ORs) to assess the rate and likelihood of depression as a function of type of diabetes, sex, subject source, depression assessment method, and study design. RESULTS —A total of 42 eligible studies were identified; 20 (48%) included a nondiabetic comparison group. In the controlled studies, the odds of depression in the diabetic group were twice that of the nondiabetic comparison group (OR = 2.0, 95% CI 1.8–2.2) and did not differ by sex, type of diabetes, subject source, or assessment method. The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%). CONCLUSIONS —The presence of diabetes doubles the odds of comorbid depression. Prevalence estimates are affected by several clinical and methodological variables that do not affect the stability of the ORs.

https://care.diabetesjournals.org/content/diacare/24/6/1069.full.pdf

The Prevalence of Comorbid Depression in Adults With Diabetes: A meta-analysis

https://www.commed.vcu.edu/Chronic_Disease/2012/cochranrvwrschbias.pdf

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

Statistical Methods for Health Care Research

A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong.

INSUFFICIENT SLEEP AND IRREGULAR SLEEP-WAKE SCHEDULES AMONG ADOLESCENTS HAS BECOME A MAJOR INTERNATIONAL HEALTH CONCERN. Self-report studies show that many adolescents do not obtain adequate sleep; they tend to stay up late during school nights and “sleep in” on weekends.1–7 The evidence suggests that teenagers in Japan and Korea are more severely sleep deprived than those in Western countries and Mainland China. In a survey study of 3478 Japanese high school students, Tagaya and colleagues found that 10th through 12th graders slept an average of 6.3 hr, going to bed at 00:03 and rising at 06:33.1 A survey of 1457 grade 5 to 12 students in Korea showed that 11th and 12th grade students only slept 5.4 hr on school nights, and 9th and 10th graders slept approximately 6.6 hr. The school night bedtime for 9th and 10th graders and 11th and 12th graders was 00:00 and 00:54, respectively.2

Wolfson and Carskadon assessed the sleep-wake habits of 3120 high school students aged 13–19 years in the United States. They found that the average school night sleep duration was 7.3 hr. The school night bedtime and rise time were 22:33 and 06:05; during weekends, the bedtime and rise time were delayed until 00:25 and 09:32.3 Liu and colleagues reported data on 1365 high school students in Mainland China. Similar to U.S. figures, the mean sleep duration during the previous month was 7.6 hr.4 In another study, Lazaratou and colleagues found that the weeknight sleep duration of 713 senior high school students in Greece was 7 hr.5 In a survey of 9567 secondary school students in New Zealand, Dorofaeff and Denny found that the amount students slept was 8.7 hr during the week and 9.4 hr during the weekend. The bedtime and rise times during weekdays were 22:17 and 06:57; on the weekend, their bedtime and rise times were 00:09 and 09:31.6 In another study, Gibson and colleagues found that the school night sleep duration of 3235 high school students in Canada was 7.8 hr.7 The amount of sleep on school nights during adolescence decreases with age1–3 and is substantially less than 9.2 hr.1–7 This contrasts with the evidence that, when given a nocturnal sleep opportunity of 10 hr per night in laboratory assessments, those going through puberty recorded a total sleep time unchanged at 9.2 hr.8

Academic pressure was cited as a major reason for the profound sleep deprivation in Japanese and Korean teenagers.1,2 However, there are also extensive biological, personal, and psychosocial influences on adolescent sleep.9 Such sleep disturbance manifested as insomnia, daytime sleepiness, tiredness, and other symptoms is frequently found in adolescents. Although the actual prevalence of insomnia symptoms recorded varies depending on the methodology and country sampled, most estimates range from 10% to 30%.10–15 Ohayon et al. reported data on 1125 adolescents from France, Great Britain, Germany, and Italy. In this study, 25.7% of the 15 to 18-year-old adolescents had difficulty initiating or maintaining sleep, early morning wakening, or nonrestorative sleep in the previous 4 weeks; daytime sleepiness was reported by nearly 20% of the adolescents.10 In a U.S. sample, 12.4% of 5118 ninth grade students met insomnia criteria on almost every day of the preceding month11 while Roberts et al. reported that 26.8% of 11 to 17-year-olds had nonrestorative sleep or experienced difficulty initiating or maintaining sleep.12 In the Middle East and Japan, a sizeable percentage of adolescents also struggle to sleep. In a study of 5044 Kuwaiti adolescents aged 14 to 19 years old, 17.5% of the adolescents had problems getting to sleep during the previous month, and the prevalence of repeated wakening and early morning wakening was 12.3% and 33.8% respectively.13 Of 106,297 high school students in Japan, approximately 16% had difficulty falling asleep during the previous month.14 In another group of 102451 Japanese high school students, the prevalence of difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening was 14.8%, 11.3%, and 5.5%, respectively; with 23.5% having one or more insomnia symptoms.15

Clearly there is a copious supply of data describing the extent of sleep deprivation, insomnia, and daytime sleepiness in adolescents. However, studies on their impact are few. Cross-sectional studies have found insomnia to be linked with behavioral and emotional problems, such as anxiety, depression, daytime sleepiness, poor social competence, and substance abuse.16,17 The one prospective study carried out to date confirmed an association between insomnia and impaired interpersonal and psychological functioning at one-year follow-up.18 Together the existing data suggest that adolescents with daytime sleepiness are likely to experience impairment in mood, performance, learning, and other daytime functioning,19 making excessive sleepiness among adolescents a significant public health concern.

Adolescents in Hong Kong, similar to teenagers in other countries, are under biological, personal, and psychosocial influences that may leave them susceptible to inadequate sleep, irregular sleep-wake schedules, and sleep disturbance. Some cross-sectional surveys on sleep problems have been carried out among adults and children in Hong Kong,20,21 however no comprehensive countrywide assessment of adolescents has been conducted. We therefore performed the first systematic study of sleep-wake patterns and sleep disturbance among secondary school students in Hong Kong. Sleep disturbance manifested as poor sleep and daytime sleepiness was assessed. We recorded the age and sex differences in sleep-wake patterns and sleep disturbance among adolescents aged 12-19 years. We investigated the factors associated with irregular sleep-wake habits and sleep disturbance. The relationship of sleep-wake variables and academic performance was also examined. The findings could add to the database on sleep disturbance in different ethnic groups and would be useful for local preventive sleep medicine programs.

Sleep-Wake Patterns and Sleep Disturbance among Hong Kong Chinese Adolescents

Assessing insomnia in adolescents: Comparison of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index

Sleep-wake disturbance in interepisode bipolar disorder and high-risk individuals: a systematic review and meta-analysis.

Background
Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are widely practised. However, it remains unclear whether current evidence is rigorous enough to support acupuncture for the treatment of insomnia.

Objectives
To determine the efficacy and safety of acupuncture for insomnia.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts International, CINAHL, AMED, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the World Health Organization (WHO) Trials Portal (ICTRP) and relevant specialised registers of the Cochrane Collaboration in October 2011. We screened reference lists of all eligible reports and contacted trial authors and experts in the field.

Selection criteria
Randomised controlled trials evaluating any form of acupuncture for insomnia. They compared acupuncture with/without additional treatment against placebo or sham or no treatment or same additional treatment. We excluded trials that compared different acupuncture methods or acupuncture against other treatments.

Data collection and analysis
Two review authors independently extracted data and assessed risk of bias. We used odds ratio (OR) and mean difference for binary and continuous outcomes respectively. We combined data in meta-analyses where appropriate.

Main results
Thirty-three trials were included. They recruited 2293 participants with insomnia, aged 15 to 98 years, some with medical conditions contributing to insomnia (stroke, end-stage renal disease, perimenopause, pregnancy, psychiatric diseases). They evaluated needle acupuncture, electroacupuncture, acupressure or magnetic acupressure.

Compared with no treatment (two studies, 280 participants) or sham/placebo (two studies, 112 participants), acupressure resulted in more people with improvement in sleep quality (compared to no treatment: OR 13.08, 95% confidence interval (CI) 1.79 to 95.59; compared to sham/placebo: OR 6.62, 95% CI 1.78 to 24.55). However, when assuming that dropouts had a worse outcome in sensitivity analysis the beneficial effect of acupuncture was inconclusive. Compared with other treatment alone, acupuncture as an adjunct to other treatment might marginally increase the proportion of people with improved sleep quality (13 studies, 883 participants, OR 3.08, 95% CI 1.93 to 4.90). On subgroup analysis, only needle acupuncture but not electroacupuncture showed benefits. All trials had high risk of bias and were heterogeneous in the definition of insomnia, participant characteristics, acupoints and treatment regimen. The effect sizes were generally small with wide confidence intervals. Publication bias was likely present. Adverse effects were rarely reported and they were minor.

Authors' conclusions
Due to poor methodological quality, high levels of heterogeneity and publication bias, the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia. Larger high-quality clinical trials are required.

Ka Fai Chung

Papers

A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong.

Sleep-Wake Patterns and Sleep Disturbance among Hong Kong Chinese Adolescents

Assessing insomnia in adolescents: Comparison of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index

Sleep-wake disturbance in interepisode bipolar disorder and high-risk individuals: a systematic review and meta-analysis.

Acupuncture for insomnia.