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Objective: The study aimed to investigate secular trends in sleep and circadian problems in Hong Kong Chinese adolescents., Methods: This study analyzed cross-sectional data from two large-scale school-based sleep surveys conducted in 2011-2012 and 2017-2019. Sleep and circadian problems, including sleep-wake pattern, insomnia, chronotype, social jetlag, daytime sleepiness, and other sleep-related factors, were compared between two survey years., Results: A total of 8082 adolescents (5639 students in 2011-2012 [Mean age: 14.4 years, 50.9% boys] and 2443 students in 2017-2019 [Mean age: 14.7 years, 54.0% boys]) were included in this 7-year study. The average time in bed of Hong Kong adolescents decreased from 8.38 hours to 8.08 hours from 2011-2012 to 2017-2019. There was a 0.28-hour delay in weekday bedtime, 0.54-hour advance in weekend wake-up time, and a 0.36-hour decline in average time in bed, resulting in increased trends of sleep loss (Time in bed <8h: OR = 2.06, 95%CI: 1.44-2.93, p < 0.01; Time in bed <7h: OR = 2.73, 95%CI: 1.92-3.89, p < 0.01), daytime sleepiness (OR = 1.70, 95%CI: 1.34-2.16, p < 0.01), and evening chronotype (OR = 1.26, 95%CI: 1.08-1.48, p < 0.01). The increased trend in insomnia disorder, however, was insignificant when covariates were adjusted., Conclusion: A secular trend of reduced time in bed, delay in weekday bedtime, advance in weekend wake-up time, increase in evening chronotype and daytime sleepiness from 2011-2012 to 2017-2019 were observed. There is a timely need for systematic intervention to promote sleep health in adolescents., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Prof Yun Kwok Wing reported financial support provided by Eisai Co., Ltd, Lundbeck HK Ltd and Aculys Pharma, Inc. Dr Joey Wing Yan Chan reported financial support provided by Eisai Co., Ltd. Dr Ji-hui Zhang reported financial support provided by BestCare SuMian BioTech Co., Ltd. The remaining authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

There is an emerging potential for digital assessment of depression. In this study, Chinese patients with major depressive disorder (MDD) and controls underwent a week of multimodal measurement including actigraphy and app-based measures (D-MOMO) to record rest-activity, facial expression, voice, and mood states. Seven machine-learning models (Random Forest [RF], Logistic regression [LR], Support vector machine [SVM], K-Nearest Neighbors [KNN], Decision tree [DT], Naive Bayes [NB], and Artificial Neural Networks [ANN]) with leave-one-out cross-validation were applied to detect lifetime diagnosis of MDD and non-remission status. Eighty MDD subjects and 76 age- and sex-matched controls completed the actigraphy, while 61 MDD subjects and 47 controls completed the app-based assessment. MDD subjects had lower mobile time (P = 0.006), later sleep midpoint (P = 0.047) and Acrophase (P = 0.024) than controls. For app measurement, MDD subjects had more frequent brow lowering (P = 0.023), less lip corner pulling (P = 0.007), higher pause variability (P = 0.046), more frequent self-reference (P = 0.024) and negative emotion words (P = 0.002), lower articulation rate (P < 0.001) and happiness level (P < 0.001) than controls. With the fusion of all digital modalities, the predictive performance (F1-score) of ANN for a lifetime diagnosis of MDD was 0.81 and 0.70 for non-remission status when combined with the HADS-D item score, respectively. Multimodal digital measurement is a feasible diagnostic tool for depression in Chinese. A combination of multimodal measurement and machine-learning approach has enhanced the performance of digital markers in phenotyping and diagnosis of MDD., (© 2024. The Author(s).)

Objectives: This study aimed to elucidate the association between sleep and academic performance using standardized academic assessment in a large and representative sample of school children and adolescents in Hong Kong., Methods: This school-based cross-sectional study was conducted in 2016. Students completed territory-wide standardized tests in Chinese, English, and Mathematics and a set of questionnaires covering sleep, academic anxiety and motivation. Parents provided additional information on socioeconomic status and children's study behaviors. Weekday proxy sleep duration was reflected by time-in-bed, the difference between bedtime and wakeup time., Results: The study included 4262 Grade 3 (G.3) (mean age [SD], 9.2 [0.6] years; girls: 49.7%) and 3297 G.9 students (mean age [SD], 15.3 [0.74]; girls: 57.5%) from 77 schools. Apart from showing a general insufficiency of students' sleep in this metropolitan city, there was a significant quadratic relationship (G.3: β = -0.05, p < .001; G.9: β = -0.03, p < .01), indicating that students with an optimal level of sleep (9.5 h and 8.5 h in G.3 and G.9, respectively) tend to have better academic performance. The significant association remained after controlling for socioeconomic and study-related variables in that sleeping too little or too much was associated with poor academic performance., Conclusions: This is the first study to explore the curvilinear association between sleep duration and academic performance by using standardized test and simultaneously examining learning-related controls with a large representative sample in Hong Kong. The findings suggested that there is an inverted U-shaped relationship between sleep duration and academic performance in both school-aged children and adolescents. It is recommended that systematic sleep education and intervention is necessary to encourage the development of optimal sleep pattern, which might have beneficial effect on academic performance for students at both primary and secondary level., Competing Interests: Declaration of competing interest None of the authors reports any conflict of interest as related to the study. Y.K.W. received personal fees from Eisai Co., Ltd for lecture, travel support from Lundbeck HK Limited and J.W.Y.C. received personal fees from Eisai Co., Ltd., which are outside the submitted work., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Chronotype, referred to as an individual's diurnal preference of timing for rest and activity, can be subjectively measured using the Munich Chronotype Questionnaire (MCTQ). However, the validity of MCTQ has yet to be tested in the youth population. In addition, it remains uncertain if MCTQ is a good measure of chronotype in individuals with insomnia. The current study aimed to validate the Chinese version of MCTQ (MCTQ HK ) in the youth population and to explore the utility of MCTQ HK in individuals with insomnia. The original MCTQ was translated into Chinese language using the translation-back-translation method. Part one of this study included 988 youths who completed a battery of self-report questionnaires online consisting of the MCTQ HK and the morningness-eveningness questionnaire (MEQ) for the measures of circadian preference, Insomnia Severity Index (ISI) to assess insomnia symptoms, and Patient Health Questionnaire (PHQ-9) to measure depressive symptoms. Test-retest reliability was examined in 442 participants at one-month follow-up. Of the overall sample, 69 participants were randomly drawn to complete the second part of the study, which included prospective 7-day actigraphy monitoring and a further subset (n = 40) additionally completed a laboratory-based assessment of dim-light melatonin onset (DLMO) as a circadian phase marker. A total of 659 participants with valid responses were finally included in the analyses of the data collected from part one of the study (female = 67.7%; mean age: 20.7 ± 2.02). Results showed that MCTQ parameters, namely the midpoint of sleep on free days (MSF), midpoint of sleep on workdays (MSW), and midpoint of sleep adjusted for sleep debt (MSFsc), were significantly correlated with MEQ score (r = -.514 to -.650, p < .01). Test-retest reliability for MCTQ HK was good (intraclass correlation = 0.75 to 0.84). Later MSFsc was significantly associated with greater insomnia and depressive symptoms after controlling for age and sex. All MCTQ parameters showed significant correlations with actigraphy-based midpoint of sleep and circadian rhythm parameters, i.e., acrophase and L5 onset (r = .362 to .619, p < .01), as well as DLMO (r = .393 to .517, p < .05). The associations remained significant after controlling for age. MSFsc derived from MCTQ was significantly correlated with MEQ score in both the healthy sleepers and participants with insomnia (as defined by ISI > 14), r = -.600, p < .001 and r = -.543, p < .001, respectively. The present study demonstrated that MCTQ HK is suitable for assessing chronotype with good reliability and validity in Chinese youths and supported the utility of MCTQ HK in individuals with insomnia.

Objectives: To investigate the association of insomnia and chronotype preference with daytime impairment and psychopathology in a community sample of adolescents in Hong Kong., Methods: This was a cross-sectional study that included seven local secondary schools in Hong Kong. A total of 1667 adolescents (mean age: 14.8 ± 1.6 years old; boys: 56.5%) returned a battery of self-report questionnaires including Insomnia Severity Index (ISI) and reduced Horne and Östberg Morningness and Eveningness Questionnaire (rMEQ) for assessing insomnia symptoms and chronotype preference, respectively. A subset of adolescent samples (n = 768) were additionally assessed for suicidal ideation. Potential confounders including age, gender and sleep duration were controlled for in the analyses., Results: The prevalence of insomnia symptoms and eveningness chronotype was 37% and 25.6%, respectively. Regression models indicated that insomnia and eveningness were independently associated with excessive daytime sleepiness (insomnia: adjusted OR [AdjOR] = 3.8; 95% confidence interval [C.I.] = 2.9-5.0; eveningness: AdjOR = 2.6; 95% C.I. = 1.9-3.7), and an increased risk of depression (insomnia: AdjOR = 3.5, 95% C.I. = 2.5-5.0; eveningness: AdjOR = 2.0, 95% C.I. = 1.3-3.2). The odds ratio increased to 8.7 (95% C.I. = 6.1-12.3, p < 0.001) for excessive daytime sleepiness and 4.8 (95% C.I. = 3.2-7.2, p < 0.001) for depression among adolescents with both insomnia and eveningness. Insomnia symptoms, but not eveningness, were associated with anxiety symptoms (AdjOR = 5.8; 95% C.I. = 3.6-9.4) and suicidal ideation (AdjOR = 2.1, 95% C.I. = 1.4-3.2)., Conclusions: The present study provided further evidence that insomnia and eveningness uniquely contributed to poor daytime functioning and mood related outcomes, while the co-existence of these two conditions could confer a greater risk in adolescents. However, insomnia, but not eveningness, was significantly linked to suicidality after controlling for mood symptoms. Our findings highlighted the necessity of timely management of sleep and circadian issues in adolescents., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To determine the familial aggregation of idiopathic rapid eye movement sleep behavior disorder (iRBD), neurodegenerative diseases, and related biomarkers., Methods: A total of 404 and 387 first-degree relatives of 102 patients with iRBD and of 89 controls were recruited, respectively. Among them, 204 and 208 relatives of patients and controls underwent face-to-face clinical assessment, whereas 97 and 75 relatives underwent further video-polysomnographic assessment, respectively., Results: Compared with relatives of controls, relatives of patients demonstrated higher levels of RBD features, including chin tonic electromyography activity (mean = 1.5 ± 7.5 vs 0.3 ± 1.0, p = 0.04) and behavioral events (n [weighted %] = 12 [11.3] vs 2 [1.9], adjusted hazard ratio [aHR] = 7.69, 95% confidence interval [CI] = 1.54-33.33, p = 0.009) during rapid eye movement sleep, probable diagnosis (n [%] = 57 [14.9] vs 20 [4.9], aHR = 3.45, 95% CI = 1.96-6.25, p < 0.001), and definite diagnosis (n [weighted %] = 10 [8.4] vs 2 [1.4], aHR = 5.56, 95% CI = 1.16-25.00, p = 0.03). They also had higher risks of Parkinson disease (3.1% vs 0.5%, aHR = 5.88, 95% CI = 1.37-25.00, p = 0.02), dementia (6.9% vs 2.6%, aHR = 2.44, 95% CI = 1.15-5.26, p = 0.02), constipation (8.3% vs 2.4%, adjusted odds ratio = 4.21, 95% CI = 1.34-13.17, p = 0.01), and motor dysfunction (Movement Disorders Society Unified Parkinson's Disease Rating Scale part III motor score, mean = 1.9 ± 3.2 vs 0.9 ± 2.3, p = 0.002). The unaffected relatives of patients demonstrated a higher likelihood ratio of prodromal Parkinson disease (median [interquartile range] = 0.27 [1.19] vs 0.22 [0.51], p = 0.03)., Interpretation: iRBD is familially aggregated from isolated features to full-blown sleep disorder. Relatives of patients carry a higher risk of alpha-synucleinopathy in terms of neurodegenerative diseases and prodromal markers, suggesting a familial aggregation and staging pathology of alpha-synucleinopathy. Ann Neurol 2019;85:582-592., (© 2019 American Neurological Association.)

Objectives: To examine the prevalence and correlates of excessive daytime sleepiness (EDS) among Hong Kong children and adolescents. We investigated the potential roles of sex and puberty in modulating the occurrence of EDS., Methods: A total of 10,086 students (male, 48.1%) aged 6-18 (mean ± SD: 12.3 ± 3.2) years old participated in this cross-sectional survey. EDS was defined by a total score >18 on the Pediatric Daytime Sleepiness Scale. Sociodemographic characteristics, time in bed, chronotypes, sleep problems, emotional and behavioral difficulties, mental health, and pubertal stages were assessed., Results: The overall prevalence of EDS was 29.2%, and increased from 19.8% at Tanner stage 1 (pre-puberty) to 47.2% at Tanner stage 5 (post-puberty). Female predominance emerged at Tanner stage 3 (mid-puberty). EDS was significantly associated with short weekday time in bed, both long and short weekend time in bed, eveningness chronotype, insomnia symptoms, and sleep-disordered breathing symptoms. Females were more likely to have short weekday time in bed and eveningness chronotype than males. Children and young adolescents at pre and mid-puberty were protected against EDS by morningness chronotype. EDS was independently associated with daytime napping, alcohol and energy beverage consumption, emotional and behavioral difficulties, as well as poor mental health even after adjusting for potential confounding factors., Conclusions: EDS is prevalent among children and adolescents with the emergence of female preponderance at mid-puberty and independent association with pervasive adverse emotional and behavioral problems. The mechanisms underlying the modulation effects of sex and puberty on EDS merit further investigation., (Copyright © 2018 Elsevier B.V. All rights reserved.)