Showing papers on "Sleep disorder published in 2008"

The Epidemiology of Adult Obstructive Sleep Apnea

Abstract: Obstructive sleep apnea is a chronic condition characterized by frequent episodes of upper airway collapse during sleep. Its effect on nocturnal sleep quality and ensuing daytime fatigue and sleepiness are widely acknowledged. Increasingly, obstructive sleep apnea is also being recognized as an independent risk factor for several clinical consequences, including systemic hypertension, cardiovascular disease, stroke, and abnormal glucose metabolism. Estimates of disease prevalence are in the range of 3% to 7%, with certain subgroups of the population bearing higher risk. Factors that increase vulnerability for the disorder include age, male sex, obesity, family history, menopause, craniofacial abnormalities, and certain health behaviors such as cigarette smoking and alcohol use. Despite the numerous advancements in our understanding of the pathogenesis and clinical consequences of the disorder, a majority of those affected remain undiagnosed. Simple queries of the patient or bed-partner for the symptoms and signs of the disorder, namely, loud snoring, observed apneas, and daytime sleepiness, would help identify those in need of further diagnostic evaluation. The primary objective of this article is to review some of the epidemiologic aspects of obstructive sleep apnea in adults.

Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults

Abstract: Insomnia is the most prevalent sleep disorder in the general population, and is commonly encountered in medical practices. Insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.1 Insomnia may present with a variety of specific complaints and etiologies, making the evaluation and management of chronic insomnia demanding on a clinician's time. The purpose of this clinical guideline is to provide clinicians with a practical framework for the assessment and disease management of chronic adult insomnia, using existing evidence-based insomnia practice parameters where available, and consensus-based recommendations to bridge areas where such parameters do not exist. Unless otherwise stated, "insomnia" refers to chronic insomnia, which is present for at least a month, as opposed to acute or transient insomnia, which may last days to weeks.

Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia.

Abstract: DIFFICULTY INITIATING AND/OR MAINTAINING SLEEP IS COMMON IN MAJOR DEPRESSIVE DISORDER (MDD) BUT IS OFTEN INADEQUATELY ADDRESSED. Subjective and objective (electroencephalographic) sleep disturbances are associated with slower and lower rates of remission from depression.1–3 Depressed patients with abnormal sleep profiles have significantly poorer clinical outcomes with respect to symptom ratings, attrition and remission rates, and the stability of response to treatment than those with more normal sleep profiles.2,4 Patients with MDD who experience sleep continuity disturbance and early morning awakening are also more likely to have suicidal ideation than those without such disturbances.5 Collectively, these findings indicate that insomnia symptoms hinder response to antidepressant treatment. Sleep disturbance does not always resolve with antidepressant treatment. Sleep difficulties are also common residual symptoms in individuals who have responded to depression treatment.6–10 Continued insomnia following the acute phase of antidepressant therapy poses a significant risk for relapse. For example, two-thirds of patients with persistent insomnia at the end of treatment with nortriptyline and interpersonal psychotherapy relapsed within one year after switching to pill placebo. In contrast, 90% of patients with good sleep at the end of the acute treatment remained well during the first year after discontinuing antidepressants.11 Additionally, there are indications that insomnia may be a first-occurring prodromal symptom in previously depression-remitted persons.12 Thus, insomnia is often more than merely a correlate or symptom of the depressive illness; it also affects the course of the illness, response to treatment, and when unresolved, it is a risk factor for relapse. The prevailing model for the development of insomnia is based on the diathesis-stress model whereby a “stressor” precipitates insomnia in predisposed individuals. This model posits that, with time, conditioned insomnia develops and persists even after the stressor is removed. Specifically, as anxiety about not being able to sleep grows, it can lead to cognitive and/or somatic arousal that further interferes with sleep and perpetuates the sleep problem.13 When these sleep difficulties become associated with significant distress or impairment of function in significant domains, all criteria for a diagnosis of insomnia are met and the individual experiences comorbid MDD and insomnia. Thus, insomnia is no longer simply a symptom of depression, but has become an independent disease process and a comorbid disorder that can subsequently hinder antidepressant response. Cognitive-behavioral therapy for insomnia (CBTI) is a skill-based, nonpharmacological intervention with many attributes that make it appealing for addressing insomnia in the context of MDD. Extensive research summarized in several meta-analyses14–17 has shown that CBTI produces improvements in primary insomnia equivalent to those achieved during acute treatment with hypnotic medications18,19 in terms of reducing nocturnal wakefulness, increasing sleep efficiency, and improving subjective sleep quality.14,20 There is also some evidence that CBTI is effective for insomnia that is comorbid with depression.21–25 Most important, sleep improvements achieved during CBTI endure up to 2 years after the course of CBTI is completed.26 This attribute of CBTI is particularly important in the context of depression, as patients who remain insomnia free are likely to remain depression free for longer periods of time than those whose insomnia recurs.12,27 The aim of the present randomized controlled pilot study was to evaluate the feasibility, acceptability, and indications of efficacy of combining an antidepressant medication (escitalopram) with CBTI in people with MDD and insomnia. The main outcome measure was remission from MDD, which is considered the ultimate goal of depression treatment.28

Bruxism physiology and pathology: an overview for clinicians*

Abstract: Awake bruxism is defined as the awareness of jaw clenching. Its prevalence is reported to be 20% among the adult population. Awake bruxism is mainly associated with nervous tic and reactions to stress. The physiology and pathology of awake bruxism is unknown, although stress and anxiety are considered to be risk factors. During sleep, awareness of tooth grinding (as noted by sleep partner or family members) is reported by 8% of the population. Sleep bruxism is a behaviour that was recently classified as a 'sleep-related movement disorder'. There is limited evidence to support the role of occlusal factors in the aetiology of sleep bruxism. Recent publications suggest that sleep bruxism is secondary to sleep-related micro-arousals (defined by a rise in autonomic cardiac and respiratory activity that tends to be repeated 8-14 times per hour of sleep). The putative roles of hereditary (genetic) factors and of upper airway resistance in the genesis of rhythmic masticatory muscle activity and of sleep bruxism are under investigation. Moreover, rhythmic masticatory muscle activity in sleep bruxism peaks in the minutes before rapid eye movement sleep, which suggests that some mechanism related to sleep stage transitions exerts an influence on the motor neurons that facilitate the onset of sleep bruxism. Finally, it remains to be clarified when bruxism, as a behaviour found in an otherwise healthy population, becomes a disorder, i.e. associated with consequences (e.g. tooth damage, pain and social/marital conflict) requires intervention by a clinician.

Sleep disorders as core symptoms of depression

Abstract: Links between sleep and depression are strong. About three quarters of depressed patients have insomnia symptoms, and hypersomnia is present in about 40% of young depressed adults and 10% of older patients, with a preponderance in females. The symptoms cause huge distress, have a major impact on quality of life, and are a strong risk factor for suicide. As well as the subjective experience of sleep symptoms, there are well-documented changes in objective sleep architecture in depression. Mechanisms of sleep regulation and how they might be disturbed in depression are discussed. The sleep symptoms are often unresolved by treatment, and confer a greater risk of relapse and recurrence. Epidemiological studies have pointed out that insomnia in nondepressed subjects is a risk factor for later development of depression. There is therefore a need for more successful management of sleep disturbance in depression, in order to improve quality of life in these patients and reduce an important factor in depressive relapse and recurrence.

Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications.

Abstract: The majority of individuals with depression experience sleep disturbances. Depression is also over-represented among populations with a variety of sleep disorders. Although sleep disturbances are typical features of depression, such symptoms sometimes appear prior to an episode of depression. The bidirectional associations between sleep disturbance (especially insomnia) and depression increase the difficulty of differentiating cause-and-effect relationships between them. Longitudinal studies have consistently identified insomnia as a risk factor for the development of a new-onset or recurrent depression, and this association has been identified in young, middle-aged, and older adults. Studies have also observed that the combination of insomnia and depression influences the trajectory of depression, increasing episode severity and duration as well as relapse rates. Fortunately, recent studies have demonstrated that both pharmacological and nonpharmacological interventions for insomnia may favorably reduce and possibly prevent depression. Together, these findings suggest that sleep-related symptoms that are present before, during, andlor after a depressive episode are potentially modifiable factors that may play an important role in achieving and maintaining depression remission.

Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony, and regulation.

Abstract: Despite advances in the treatment of bipolar disorder, a significant proportion of patients experience disabling symptoms between episodes, and relapse rates are high. These circumstances suggest that there is a critical need to achieve a mechanistic understanding of triggers of relapse and to target them with specific, empirically derived treatments. Sleep disturbances are among the most prominent correlates of mood episodes and inadequate recovery, yet sleep has been minimally studied in ways that integrate mechanistic understanding and treatment. In this article, the author seeks to define the limits of current knowledge and to specify preliminary clinical implications. Sleep disturbance is important because it impairs quality of life, contributes to relapse, and has adverse consequences for affective functioning. While sleep disturbance and circadian dysregulation are critical pathophysiological elements in bipolar disorder, many questions about the mechanisms that underpin the association remain. The author presents a model that recognizes a role for genetic vulnerability and suggests that there is a bidirectional relationship between daytime affect regulation and nighttime sleep such that an escalating vicious circle of disturbance in affect regulation during the day interferes with nighttime sleep/circadian functioning, and the effects of sleep deprivation contribute to difficulty in affect regulation the following day.

Behavioral symptoms in patients with breast cancer and survivors.

Abstract: Behavioral symptoms are a common adverse effect of breast cancer diagnosis and treatment and include disturbances in energy, sleep, mood, and cognition. These symptoms cause serious disruption in patients' quality of life and may persist for years after treatment. Patients need accurate information about the occurrence of these adverse effects as well as assistance with symptom management. This review considers four of the most common behavioral sequelae of breast cancer, namely fatigue, sleep disturbance, depression, and cognitive impairment. Research on the prevalence, mechanisms, and treatment of each symptom is described, concluding with recommendations for future studies.

Sleep disturbances in patients with schizophrenia : impact and effect of antipsychotics.

Abstract: Difficulties initiating or maintaining sleep are frequently encountered in patients with schizophrenia. Disturbed sleep can be found in 30–80% of schizophrenic patients, depending on the degree of psychotic symptomatology. Measured by polysomnography, reduced sleep efficiency and total sleep time, as well as increased sleep latency, are found in most patients with schizophrenia and appear to be an important part of the pathophysiology of this disorder. Some studies also reported alterations of stage 2 sleep, slow-wave sleep (SWS) and rapid eye movement (REM) sleep variables, i.e. reduced REM latency and REM density. A number of sleep parameters, such as the amount of SWS and the REM latency, are significantly correlated to clinical variables, including severity of illness, positive symptoms, negative symptoms, outcome, neurocognitive impairment and brain structure. Concerning specific sleep disorders, there is some evidence that schizophrenic patients carry a higher risk of experiencing a sleep-related breathing disorder, especially those demonstrating the known risk factors, including being overweight but also long-term use of antipsychotics. However, it is still unclear whether periodic leg movements in sleep or restless legs syndrome (RLS) are found with a higher or lower prevalence in schizophrenic patients than in healthy controls. There are no consistent effects of first-generation antipsychotics on measuresof sleep continuity and sleep structure, including the percentage of sleep stages or sleep and REM latency in healthy controls. In contrast to first-generation antipsychotics, the studied atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, ziprasidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity, with an increase in either total sleep time (TST) or sleep efficiency, and individually varying effects on other sleep parameters, such as an increase in REM latency observed for olanzapine, quetiapine and ziprasidone, and an increase in SWS documented for olanzapine and ziprasidone in healthy subjects. The treatment of schizophrenic patients with first-generation antipsychotics is consistently associated with an increase in TST and sleep efficiency, and mostly an increase in REM latency, whereas the influence on specific sleep stages is more variable. On the other hand, withdrawal of such treatment is followed by a change in sleep structure mainly in the opposite direction, indicating a deterioration of sleep quality. On the background of the rather inconsistent effects of first-generation antipsychotics observed in healthy subjects, it appears possible that the high-potency drugs exert their effects on sleep in schizophrenic patients, for the most part, in an indirect way by suppressing stressful psychotic symptomatology. In contrast, the available data concerning second-generation antipsychotics (clozapine, olanzapine, risperidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity in patients and healthy subjects, with an increase in TST and sleep efficiency or a decrease in wakefulness. Additionally, clozapine and olanzapine demonstrate comparable influences on other sleep variables, such as SWS or REM density, in controls and schizophrenic patients. Possibly, the effects of second-generation antipsychotics observed on sleep in healthy subjects and schizophrenic patients might involve the action of these drugs on symptomatology, such as depression, cognitive impairment, and negative and positive symptoms. Specific sleep disorders, such as RLS, sleep-related breathing disorders, night-eating syndrome, somnambulism and rhythm disorders have been described as possible adverse effects of antipsychotics and should be considered in the differential diagnosis of disturbed or unrestful sleep in this population.

The subjective meaning of sleep quality: a comparison of individuals with and without insomnia.

Abstract: GOOD SLEEP QUALITY IS ASSOCIATED WITH A WIDE RANGE OF POSITIVE OUTCOMES SUCH AS BETTER HEALTH, LESS DAYTIME SLEEPINESS, GREATER well-being and better psychological functioning.1 Poor sleep quality is one of the defining features of chronic insomnia.2 Although the construct of sleep quality is widely used, a review of the empirical literature suggests that it is not yet fully understood. Indeed, Akerstedt, Hume, Minors, and Waterhouse3 noted that “there seems to be very little systematic knowledge as to what actually constitutes subjectively good sleep and how this should be measured” and Buysse et al.4 referred to sleep quality as a “complex phenomenon that is difficult to define and measure objectively.” Indeed, the empirical results highlight the complexity of sleep quality, particularly as it relates to patients with insomnia. Research studies have reported that “a history of chronic insomnia does not predict poor EEG sleep.”5 Similarly, sleep quality is not directly associated with sleep quantity. For example, a common finding in the literature is that self-reported sleep does not correlate well with PSG defined sleep.6 Indeed, Edinger and colleagues7 distinguished between two groups: a subjective insomnia group who met criteria for insomnia but had normal/nondisturbed sleep on PSG and a subjective normal sleeper group who met criteria for a “normal sleeper” but had objectively disturbed sleep. Psychological variables were found to distinguish between these two groups: the subjective insomnia group exhibited more depressed mood, anxiety and they held more dysfunctional beliefs about sleep, relative to the subjective normal sleeper. These findings highlight the complexity of sleep quality and the importance of understanding the subjective meaning of sleep quality. Accordingly, the broad aim of the present study was to contribute new data to improving understanding of the subjective meaning of sleep quality. The primary focus of previous research has been to identify correlates of sleep quality. A wide range of factors have been investigated that, for ease of description, can be grouped into three clusters. First, there have been a handful of investigations of the correlation between perceived sleep quality and PSG-measured sleep parameters. These studies have included older female normal sleepers,8 older adults with insomnia,9 young adult good and poor sleepers,10 and individuals with unipolar depression.11 The consensus to emerge is that poor sleep quality estimates are associated with reduced Stage 1 sleep and more Stages 3 and 4 sleep. Second, other studies have investigated the association between sleep quality and the subjective perception of sleep parameters. The results suggest that sleep quality is associated with subjective estimates of the ease of sleep onset,12 sleep maintenance,13–15 total sleep time,14 and early awakening.13,15 In addition, restlessness during the night,3,13,16 movement during sleep,15,17 and anxiety, tension, or calmness when trying to sleep15 have also been reported to be associated with sleep quality. Moreover, perceived depth of sleep is important with less perceived light sleep and more perceived deep sleep being associated with higher sleep quality.18 Finally, several studies have examined correlations between sleep quality and how the individual feels immediately on waking and during the day. The results indicate that sleep quality is associated with ease of waking,19 tiredness, sense of balance and coordination,19 clear-headedness,18 how rested, restored and refreshed one feels,13 and mood and physical feelings15 on waking. During the day, feelings of tiredness predicted poorer sleep quality and alertness predicted better sleep quality.19 Taken together, although some consensus has emerged from studies of PSG-measured sleep parameters, there have been few consistent results from the studies that have focused on subjectively estimated aspects of sleep. The variability in the results obtained to date may be attributable to differences across studies in (1) the list of potential correlates evaluated, (2) the vague use of terminology, with some studies using terms like “sleep satisfaction” or “depth of sleep” and others referring to “sleep quality” and (3) the samples employed; the majority of previous studies have recruited good or normal sleepers, with only a handful based on poor sleepers or individuals with insomnia. Gaining an improved understanding of the subjective meaning of sleep quality among individuals with insomnia is important. For example, although differences in Rechtschaffen and Kales scored EEG sleep may not always be evident in patients with insomnia, relative to normal sleepers,5 it is possible that a more sophisticated understanding of the subjective meaning of sleep quality may produce a better measure of sleep quality, which may correlate better with EEG sleep. Alternatively, objective and subjective assessments of sleep quality may reflect different processes and not be directly related.19 In addition, understanding the meaning of sleep quality for individuals with insomnia may turn out to be important for a full recovery from insomnia. This suggestion is made based on cognitive theories which highlight the importance of the perception of or meaning or interpretation attached an event as the critical cause of distress, as opposed to the event itself.20 To summarize, the broad aim of the present study was to conduct a detailed and systematic investigation of the subjective meaning of sleep quality among individuals who meet diagnostic criteria for insomnia compared with a group of normal sleepers. We sought (1) to determine which sleep quality variables are judged to be most important, (2) to use a qualitative approach to determine whether there are important variables influencing perception of sleep quality not covered in the existing research literature, and (3) to compare the insomnia and normal sleeper groups on the meaning of sleep quality. Three different but complementary empirical approaches were employed to index the meaning of sleep quality: (1) a “Speak Freely” procedure in which participants were asked to describe a night of good and a night of poor quality sleep, (2) a “Sleep Quality Interview” in which participants rated the importance of variables included in previous research on sleep quality, and (3) sleep diaries in which participants also answered questions about their sleep quality over seven consecutive nights. These methods were selected to give a varied view of the meaning of sleep quality from both retrospective and prospective viewpoints and to capitalize on the advantages of procedures that require participants to endorse items versus procedures that require responses to be generated.

Sleep Problems in Children With Attention-Deficit/Hyperactivity Disorder Prevalence and the Effect on the Child and Family

Abstract: Objectives: To determine the prevalence of sleep problems in children with attention-deficit/hyperactivity disorder (ADHD) and their associations with child quality of life (QOL), daily functioning, and school attendance; caregiver mental health and work attendance; and family functioning. Design: Cross-sectional survey. Setting: Pediatric hospital outpatient clinic, private pediatricians’ offices, and ADHD support groups in Victoria, Australia. Participants: Schoolchildren with ADHD. Main Exposure: Attention-deficit/hyperactivity disorder.

Randomized Controlled Clinical Effectiveness Trial of Cognitive Behavior Therapy Compared With Treatment As Usual for Persistent Insomnia in Patients With Cancer

Abstract: Purpose Persistent insomnia is a common complaint in cancer survivors, but is seldom satisfactorily addressed. The adaptation to cancer care of a validated, cost-effective intervention may offer a practicable solution. The aim of this study was to investigate the clinical effectiveness of protocol-driven cognitive behavior therapy (CBT) for insomnia, delivered by oncology nurses. Patients and Methods Randomized, controlled, pragmatic, two-center trial of CBT versus treatment as usual (TAU) in 150 patients (103 females; mean age, 61 years.) who had completed active therapy for breast, prostate, colorectal, or gynecological cancer. The study conformed to CONSORT guidelines. Primary outcomes were sleep diary measures at baseline, post-treatment, and 6-month follow-up. Actigraphic sleep, health-related quality of life (QOL), psychopathology, and fatigue were secondary measures. CBT comprised five, small group sessions across consecutive weeks, after a manualized protocol. TAU represented normal clinical pract...

Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression

Abstract: Objective This study is an examination of sleep, pain, depression, and physical functioning at baseline and 1-year followup among patients with fibromyalgia syndrome (FMS). Although it is clear that these symptoms are prevalent among FMS patients and that they are related, the direction of the relationship is unclear. We sought to identify and report sleep problems in this population and to examine their relationship to pain, depression, and physical functioning. Methods Patients diagnosed with fibromyalgia were recruited from a Southern California health maintenance organization and evaluated according to American College of Rheumatology criteria in the research laboratory. Six hundred patients completed the baseline assessment and 492 completed the 1-year assessment. Measures included the Center for Epidemiologic Studies Depression Scale, the McGill Pain Questionnaire, the Pittsburgh Sleep Quality Index, and the Fibromyalgia Impact Questionnaire. Results The majority of the sample (96% at baseline and 94.7% at 1 year) scored within the range of problem sleepers. Path analyses examined the impact of baseline values on 1-year values for each of the 4 variables. No variable of interest predicted sleep, sleep predicted pain (β = 0.13), pain predicted physical functioning (β = −0.13), and physical functioning predicted depression (β = −0.10). Conclusion These findings highlight the high prevalence of sleep problems in this population and suggest that they play a critical role in exacerbating FMS symptoms. Furthermore, they support limited existing findings that sleep predicts subsequent pain in this population, but also extend the literature, suggesting that sleep may be related to depression through pain and physical functioning.

Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women.

Abstract: TWO RELATIVELY CONSISTENT FINDINGS HAVE EMERGED FROM EPIDEMIOLOGIC STUDIES OF SLEEP DISTURBANCES: THAT SUBJECTIVE REPORTS OF difficulty sleeping are more prevalent in women than men and that the prevalence of this difficulty increases with aging.1,2 A female preponderance in the prevalence of self-reported sleep problems is evident by midlife.3–7 Data presented at the NIH State-of-the-Science Conference on Management of Menopause-Related Symptoms8 indicated that sleep problems are reported by 16%-42% of premenopausal women, 39%-47% of perimenopausal women, and 35%-60% of postmenopausal women. In the Study of Women's Health Across the Nation (SWAN) cross-sectional survey of more than sixteen thousand women aged 40–55 years, 38% experienced difficulty sleeping within the 2 weeks preceding the interview.9 Relative to being premenopausal, being perimenopausal was associated with difficulty sleeping even after adjusting for multiple relevant covariates. Both age and hormonal changes can contribute to disturbed sleep in middle-aged women undergoing the menopausal transition.10–14 Whereas the increase in sleep difficulties that emerge at midlife suggest an aging effect,10,11,14 gender differences at midlife suggest that the role of aging per se must be distinguished from sleep disturbances due to other age-related risk factors.13 In the initial SWAN report,9 we may have found no “age effect” because we only included women in a narrow age range during a period of marked hormonal transition when ovarian age may be more informative than chronological age. Attributes of the menopausal transition may confer risk for sleep disturbances beyond the effects of age alone, but studies examining these factors have tended to be cross-sectional. Potential precipitating factors during the menopausal transition include onset and exacerbation of vasomotor symptoms (VMS; hot flashes, night sweats, cold sweats)15 and changing reproductive hormone levels (especially follicle stimulating hormone; FSH).16 The etiology of perimenopausal-related sleep changes and whether onset of these changes is associated with hormonal changes and VMS that occur during this transition are not well understood.17,18 VMS are highly prevalent in peri- and postmenopausal women (35%-80%),8,19 and there is considerable overlap between VMS and sleep difficulties.20 Whereas sleep disturbance and VMS are strongly associated, these 2 symptoms are not perfectly correlated, and sleep difficulties may continue long after hot flashes have subsided.21 Menopausal hormonal changes may plausibly be related to acute sleep disturbances, but evidence relating self-reported sleep difficulties to hormonal changes, independent of VMS, during the menopausal transition has been mixed.22 In SWAN,16 FSH concentrations, but not FSH-adjusted estradiol levels, are strongly related to VMS. Others have shown that in women aged 35–49 years, poor sleep quality is associated with lower follicular phase plasma estradiol.23 Data from SWAN's Daily Hormone Study (daily collection of first morning urine for up to 50 days and self-reported sleep difficulties) showed that compared with premenopausal women, early perimenopausal women had 29% higher odds of reporting trouble sleeping.12 This increased reporting was associated with levels of the urinary progesterone metabolite, pregnanediol glucuronide, in perimenopausal women and with FSH levels in premenopausal women, independent of VMS.12 An additional, though largely unexplored issue, is the type of sleep difficulty most prevalent during the menopausal transition. An examination of sleep problems over 12 months in the National Comorbidity Survey Replication, a nationally representative household survey of men and women 18 years and older, showed little variation in types of reported problems: 16.4% had difficulty initiating sleep, 19.9% had difficulty maintaining sleep, and 16.7% had early morning awakenings.24 However, these cross-sectional data were not reported by age or sex. Little is known about the prevalence of these 3 types of disturbed sleep during and after the menopausal transition and how they vary over long periods of time. We undertook a longitudinal analysis of data from an ethnically diverse cohort of midlife women to determine how each type of sleep continuity difficulty changes as they progressed through the menopausal transition. Specifically, we examined whether three aspects of the menopausal transition, i.e., changes in bleeding patterns, reproductive hormone levels, and VMS, affected sleep symptom reports after accounting for the effects of aging and a variety of health and psychosocial factors. We also examined whether the associations varied among the 5 racial/ethnic groups represented in SWAN.

The Children's Sleep Habits Questionnaire in toddlers and preschool children.

Abstract: :Objective:Twenty to 40% of young children are reported to have behavioral insomnias of childhood. Concerns about sleep at these ages are the most common problem expressed to pediatricians at the time of well child visits. A screening questionnaire, the Children's Sleep Habits Questionnaire

Sleep Disturbance Preceding Completed Suicide in Adolescents

Abstract: We examined sleep difficulties preceding death in a sample of adolescent suicide completers as compared with a matched sample of community control adolescents. Sleep disturbances were assessed in 140 adolescent suicide victims with a psychological autopsy protocol and in 131 controls with a similar semistructured psychiatric interview. Rates of sleep disturbances were compared between groups. Findings indicate suicide completers had higher rates of overall sleep disturbance, insomnia, and hypersomnia as compared with controls within both the last week and the current affective episode. Group differences in overall sleep disturbance (both within the last week and present episode), insomnia (last week), and hypersomnia (last week) remained significant after controlling for the differential rate of affective disorder between groups. Similarly, overall sleep disturbance (last week and present episode) and insomnia (last week) distinguished completers in analyses accounting for severity of depressive symptoms. Only a small percentage of the sample exhibited changes in sleep symptom severity in the week preceding completed suicide, but of these, a higher proportion were completers. These findings support a significant and temporal relationship between sleep problems and completed suicide in adolescents. Sleep difficulties should therefore be carefully considered in prevention and intervention efforts for adolescents at risk for suicide.

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

Abstract: 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.

The treatment of sleep disorders with melatonin

Abstract: Fifteen children (most of whom were neurologically multiply disabled) with severe, chronic sleep disorders were treated with 2 to 10mg of oral melatonin, given at bedtime. Nine had fragmented sleep patterns, three had delayed sleep onset and three others had non-specific sleep disturbance of unclear aetiology; all had failed to respond to conventional management. Nine patients had ocular or cortical visual impairment. The health, behavioural and social benefits of treatment were significant, and there were no adverse side-effects. While the response was not always complete, the study clearly showed that melatonin has an important role in the treatment of certain types of chronic sleep disorders.

Sleep Disturbance and Depression Recurrence in Community-Dwelling Older Adults : A Prospective Study

Abstract: Objective: A prior depressive episode is thought to increase the risk of depression. However, among older adults with prior depression, it is unclear whether sleep disturbance predicts depression recurrence independent of other depressive symptoms. Method: A 2-year prospective cohort study was conducted with 351 community-dwelling older adults ages 60 years and older: 145 persons with a history of major or nonmajor depression in full remission and 206 without a prior history of depression or any mental illness. The participants were assessed at baseline, 6 weeks, 1 year, and 2 years for depressive episodes, depressive symptoms, sleep quality, and chronic medical disease. Results: Twenty-three subjects (16.9%) with prior depression developed depressive episodes during follow-up, compared to only one person in the group without prior mental illness (0.5%). Within the group with prior depression, depression recurrence was predicted by sleep disturbance, and this association was independent of other depressive symptoms, chronic medical disease, and antidepressant medication use. Conclusions: This study is the first to demonstrate that sleep disturbance acts as an independent risk factor for depression recurrence in community-dwelling older adults. To identify older adults at risk for depression, a two-step strategy can be employed, which involves assessment of the presence of a prior depressive episode along with sleep disturbance.

Sleep problems in children with mental handicap.

Abstract: This paper reports on a longitudinal study of sleep problems in 200 children with severe mental handicap. Sleep problems were extremely common: 51% of children had settling problems, 67% of children had waking problems, and 32% of parents said they rarely got enough sleep. Sleep problems were also very persistent: between a half and two-thirds of children who exhibited sleep problems at Time 1 still had them 3 years later. Sleep problems were associated with a number of child characteristics: poor communication skills, poor academic skills, poor self-help skills, incontinence, daytime behaviour problems and epilepsy. There were no relationships with family variables such as social class, income, family composition or housing tenure. However, maternal stress, maternal irritability and perceived impact on the family were related to sleep problems. A Sleep Index was constructed, and path analysis was used to trace the main causal pathways of the child, family and social characteristics. Ten variables explained 50% of the variance in the Sleep Problems Index. Communication skills played a pivotal role. The implications of the findings for intervention strategies are discussed.

Is Insomnia a Perpetuating Factor for Late-Life Depression in the IMPACT Cohort?

Abstract: LATE-LIFE DEPRESSION AND INSOMNIA ARE SIGNIFICANT PUBLIC HEALTH ISSUES,1 WITH AS MANY AS 42% OF OLDER ADULTS REPORTING TROUBLES associated with sleep.2 A recent review of community and epidemiologic studies conducted exclusively in or including older-age cohorts (total n = 43,070) reported the prevalence of depression to be approximately 9% and that of insomnia to be approximately 17%.3 The estimates were lower in studies with more stringent criteria, approximately 5% and 10% for depression and insomnia, respectively. Longitudinal studies that have evaluated depression and sleep in the elderly have found that insomnia confers an increased risk for depression.4–7 As might be expected, it is not the only significant risk factor. A meta-analysis of studies in older adults found that recent bereavement, with an odds ratio (OR) of 3.3, was the largest risk factor for late-life depression and that sleep disturbance was second (OR 2.6).8 Nonetheless, insomnia has historically been considered a symptom, as opposed to a disorder. When it occurred with psychiatric illness, insomnia was viewed as a natural consequence of mood dysregulation in which sleep-onset insomnia and early-morning insomnia were considered the cardinal symptoms of anxiety and depression. As a symptom, insomnia was often viewed as a secondary phenomenon that would resolve with remission of, or recovery from, the parent disorder. In recent years, this point of view has partially given way to the perspective that insomnia may exist as a primary disorder9,10 and, when it occurs with psychiatric illnesses, it may be viewed as a comorbid condition.9,11 This change in perspective has occurred owing to several considerations. First, to date, one longitudinal study has shown that insomnia symptoms worsen as patients with recurrent major depressive disorder (MDD) approach new-onset episodes of depression,12 suggesting that insomnia may be a prodromal symptom of depression and may trigger or precipitate new episodes. Second, antidepressants can exert their clinical effects without ameliorating the patients' insomnia complaints. e.g., 13–16 For instance, in a fluoxetine trial, disturbed sleep and fatigue were the most common residual symptoms among depression remitters, (present in 44% and 38% of remitters, respectively).15 In a trial of nortriptyline, although depression remitters had significant decreases in mean sleep disturbance scores on the Pittsburgh Sleep Quality Index,17 their mean score remained above the clinical cutoff and higher than that of healthy controls.18 Third, similar findings have been observed in the cognitive behavioral treatment of depression.19,20 For example, in two separate randomized trials comparing cognitive behavioral treatment for depression to antidepressant medication, approximately 50% of those with remitted depression had residual insomnia, and this was evenly distributed between intervention groups.21,22 Fourth, in significant subsets of patients, insomnia becomes chronic, despite successful resolution of the psychiatric illness.23–27 Fifth, Fava et al. recently reported that coadministration of eszopiclone with fluoxetine resulted in greater sleep improvements and antidepressant effects than fluoxetine alone.28 Finally, there are a number of longitudinal studies showing that insomnia confers an increased risk for depression over time frames of between 6 months and 3 years.4–6,12,29–36 There are also studies that show that insomnia can confer risk over periods that extend over decades.7,37,38 In general, patients with persistent insomnia are approximately 3.5 times more likely to develop depression, as compared with subjects without insomnia complaints. Despite a set of findings suggesting that insomnia is more than a symptom of depression, it does not completely rule out the possibility. Another interpretation of the above findings is that cognitive behavioral treatment for depression and a variety of antidepressant medication therapies improve sleep in a large number of patients. It may be impossible to determine whether insomnia is purely a symptom or a marker of depression severity or if it is purely a separate disorder. More realistically, not all depressed individuals have an insomnia complaint, and, for a large percentage of depressed patients with an insomnia complaint, the insomnia does, in fact, resolve. It may be that, for some individuals, insomnia is simply a symptom that does not transition to a persistent comorbid insomnia. For others, insomnia does represent a comorbid condition that may or may not resolve without targeted intervention. One open question, therefore, is whether acutely depressed patients who already demonstrate persistent insomnia are more likely to remain depressed than patients with no insomnia complaints or than patients with only acute or mild insomnia. In the present study, we specifically evaluate the proposition that persistent insomnia may be a perpetuating factor for depression.

The association between sleep duration and obesity in older adults.

Abstract: Reduced sleep has been reported to predict obesity in children and young adults. However, studies based on self-report have been unable to identify an association in older populations. In this study, the cross-sectional associations between sleep duration measured objectively and measures of weight and body composition were assessed in two cohorts of older adults. Wrist actigraphy was performed for a mean (s.d.) of 5.2 (0.9) nights in 3055 men (age: 67–96 years) participating in the Osteoporotic Fractures in Men Study (MrOS) and 4.1 (0.8) nights in 3052 women (age: 70–99 years) participating in the Study of Osteoporotic Fractures (SOF). A subgroup of 2862 men and 455 women also underwent polysomnography to measure sleep apnea severity. Compared to those sleeping an average of 7–8 h per night, and after adjusting for multiple risk factors and medical conditions, a sleep duration of less than 5 h was associated with a body mass index (BMI) that was on average 2.5 kg/m2 (95% confidence interval (CI): 2.0–2.9) greater in men and 1.8 kg/m2 (95% CI: 1.1–2.4) greater in women. The odds of obesity (BMI ⩾30 kg/m2) was 3.7-fold greater (95% CI: 2.7–5.0) in men and 2.3-fold greater in women (95% CI: 1.6–3.1) who slept less than 5 h. Short sleep was also associated with central body fat distribution and increased percent body fat. These associations persisted after adjusting for sleep apnea, insomnia and daytime sleepiness. In older men and women, actigraphy-ascertained reduced sleep durations are strongly associated with greater adiposity.