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Chronic use and cessation of use of most reported substances are associated with significant sleep disturbance. Studies on tobacco and marijuana smokers, cocaine and opiate addiction, and recovering alcoholics all find sleep problems during use and withdrawal. The diagnosis of substance use related insomnia requires that the sleep difficulty be etiologically associated with substance use, but clinically distinct from the acute effects of the substance or symptoms of withdrawal. Indeed, changes in sleep patterns often persist beyond the immediate withdrawal symptoms, suggesting that chronic drug exposure and the development of addiction may interfere with mechanisms involved in sleep regulation. While there is increasing awareness of the protracted sleep difficulty during abstinence, there is scant understanding of the underlying neurophysiology, and treatment options are limited.

Background Veterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans. Methods Veterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions. Results Half of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia. Conclusions This study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.

STUDY OBJECTIVES: Obstructive sleep apnea and other sleep disorders overlap with comorbidities associated with poor outcomes related to severe acute respiratory syndrome coronavirus 2 infection. However, the prevalence of obstructive sleep apnea among patients hospitalized for COVID-19 and relationship to outcomes is poorly characterized, and the relevance of other sleep disorders remains unknown. The objective of this study was to identify the prevalence of pre-existing sleep disorders and association with outcomes related to severe COVID-19 illness. METHODS: Patients with severe acute respiratory syndrome coronavirus 2 infection admitted to the University of Michigan Hospital System were included. Electronic medical records were queried for sleep disorders diagnostic codes. Data were extracted from polysomnography and home sleep testing in a subgroup with previous diagnostic testing at our center. Logistic regression was used to examine the association of sleep disorders with mechanical ventilation requirement, treatment with vasopressors, and death and Cox proportional hazards regression for time to discharge. RESULTS: Among n = 572 adult patients hospitalized for COVID-19, 113 (19.8%) patients had obstructive sleep apnea, 4 patients had central sleep apnea (0.7%), 5 had hypoventilation (0.9%), 63 had insomnia (11.0%), and 22 had restless legs syndrome or periodic limb movements disorder (3.9%). After adjusting for age, sex, body mass index, and race, no significant relationship was apparent between sleep disorders diagnoses or indices of sleep-disordered breathing severity and outcomes. CONCLUSIONS: This is the first study to determine the prevalence of obstructive sleep apnea and other sleep disorders in a well-characterized cohort of patients hospitalized for COVID-19. Once hospitalized, a significant contribution of sleep disorders to outcomes was not identified. Therefore, future evaluations should focus on earlier outcomes, such as infection or clinical manifestations after exposure to severe acute respiratory syndrome coronavirus 2. CITATION: Goldstein CA, Rizvydeen M, Conroy DA, et al. The prevalence and impact of pre-existing sleep disorder diagnoses and objective sleep parameters in patients hospitalized for COVID-19. J Clin Sleep Med. 2021;17(5):1039–1050.

Background: Breakfast skipping has been related to poor mood, but the role of sleep in this relationship remains unclear. Aim: To evaluate whether breakfast skipping associated with mood independently of sleep, and whether sleep interacted with breakfast skipping. Methods: During an in-person research visit, a sample of 329 adults completed questionnaires regarding last night’s sleep, current morning breakfast intake, and mid-morning mood states. Sex-stratified linear regression models examined associations between breakfast skipping and mood and interactions with sleep. Results: Among males, those who did not consume breakfast had less vigor independent of sleep (β=−2.72 with 95% CI −4.91, −0.53). Among females, those who did not consume breakfast had higher feelings of anxiety (β=1.21 with 95% CI −0.04, 2.47). Interaction analyses revealed that males with longer time to fall asleep and longer night-time awake time had higher depression scores in the presence of breakfast skipping, and females with more night-time awake time and shorter duration had higher fatigue and less vigor if they were also breakfast skippers. Conclusion: Breakfast skipping and poor sleep may jointly affect mood.

Background Delayed sleep timing and short sleep duration represent a significant public health burden in adolescents. Whether intake of nutrients affects the pineal gland, where sleep/wake cycles are regulated, remains unclear. Objectives In a cross-sectional analysis, we investigated whether plasma concentrations of DHA and arachidonic acid (AA), long-chain fatty acids that can be obtained through diet, were related to sleep timing and duration in adolescents. Methods The study population included 405 Mexico City adolescents (mean age ± SD = 14.2 ± 2.1 y; 48% males) who took part in a 2015-2016 follow-up visit as a part of an ongoing cohort study. Fatty acid concentrations were measured in plasma using GLC, as a percentage of total fatty acids. Sleep midpoint and duration were assessed with 7-d wrist actigraphy. We categorized DHA and AA plasma concentrations into quartiles (Q1-Q4; Q4 = highest fatty acids). We conducted cross-sectional linear regression analysis with sleep characteristics as separate outcomes and quartiles of DHA and AA as exposures, adjusting for sex, age, and BMI z-scores. Results Mean ± SD plasma DHA (as percentage of total fatty acids) was 1.2 ± 0.4%, whereas mean ± SD plasma AA was 6.2 ± 1.5%. In adjusted analysis, higher plasma DHA was linearly associated with longer sleep duration on the weekends; to illustrate, those in Q4 compared with Q1 had 32 min longer duration (95% CI: 7, 57; P trend = 0.005). Higher DHA was also associated with earlier sleep timing during weekdays and weekends, although in a nonlinear fashion. The largest difference was a 0.75-h (45-min) later sleep midpoint in Q2 compared with Q4 (95% CI: 0.36, 1.14). Conclusions Plasma DHA was associated with earlier sleep timing and longer weekend sleep duration in Mexican adolescents. Whether DHA supplementation improves sleep in adolescent populations deserves consideration in randomized trials.

STUDY OBJECTIVES: By March 2020, COVID-19 forced much of the world to stay at home to reduce the spread of the disease. Whereas some health care workers transitioned to working from home, many continued to report to work in person as essential employees. We sought to explore changes in sleep, health, work, and mood in health care workers during the stay-at-home orders. METHODS: We developed a cross-sectional online survey administered to health care workers. The survey assessed changes in sleep, work, screen time, media exposure, diet, exercise, substance use, and mood. The survey data were collected between March 28, 2020, and April 29, 2020. RESULTS: A total of 834 of 936 individuals completed the entire survey. Respondents were from 41 US states. Mood after the stay-at-home orders worsened, and screen time and substance use increased. Total sleep time shortened in those continuing to work in person (P < .001), whereas it was unchanged in those working from home (P = .73). Those working from home went to bed later, woke up later, and worked fewer hours. Reduced total sleep time and increased screen time before bed were associated with worse mood and screen time. Longer sleep time was associated with better mood. CONCLUSIONS: Health care workers’ mood worsened regardless of whether work was in person or remote, although total sleep time was shorter for those working in person. Those working from home may have shifted their sleep time to be more in line with their endogenous circadian phase. Peer or other support services may be indicated to address sleep, mood, and health behaviors among health care workers during these unprecedented times. CITATION: Conroy DA, Hadler NL, Cho E, et al. The effects of COVID-19 stay-at-home order on sleep, health, and working patterns: a survey study of US health workers. J Clin Sleep Med. 2021;17(2):185–191.

Study Objectives In a randomized controlled noninferiority trial, we compared face-to-face and telemedicine delivery (via the AASM SleepTM platform) of cognitive-behavioral therapy (CBT) for insomnia for improving insomnia/sleep and daytime functioning at posttreatment and 3-month follow-up. A secondary objective compared the modalities on treatment credibility, satisfaction, and therapeutic alliance. Methods A total of 65 adults with chronic insomnia (46 women, 47.2 ± 16.3 years of age) were randomized to 6 sessions of CBT for insomnia delivered individually via AASM SleepTM (n = 33, CBT-TM) or face-to-face (n = 32, CBT-F2F). Participants completed sleep diaries, the Insomnia Severity Index (ISI), and daytime functioning measures at pretreatment, posttreatment, and 3-month follow-up. Treatment credibility, satisfaction, and therapeutic alliance were compared between treatment modalities. The ISI was the primary noninferiority outcome. Results Based on a noninferiority margin of four points on the ISI and, after adjusting for confounders, CBT-TM was noninferior to CBT-F2F at posttreatment (β = 0.54, SE = 1.10, 95% CI = 1.64 to 2.72) and follow-up (β = 0.34, SE = 1.10, 95% CI = 1.83 to 2.53). Daytime functioning measures, except the physical composite scale of the SF-12, were significantly improved at posttreatment and follow-up, with no difference between treatment formats. CBT-TM sessions were, on average, nearly 10 min shorter, yet participant ratings of therapeutic alliance were similar to CBT-F2F. Conclusions Telemedicine delivery of CBT for insomnia is not inferior to face-to-face for insomnia severity and yields similar improvements on other sleep and daytime functioning outcomes. Further, telemedicine allows for more efficient treatment delivery while not compromising therapeutic alliance. Clinical Trial Registration Number NCT03293745

Objectives We examined the feasibility and acceptability of a portable bright light intervention and its impact on sleep disturbance and depressive symptoms in older adults. Methods One-arm prevention intervention pilot study of the Re-Timer (Re-Timer Pty Ltd, Adelaide, Australia) bright light device (worn 30 minutes daily for 2 weeks) in 1 older adults (age 65 + years) with subsyndromal symptoms of depression and poor sleep quality. Participants were assessed on intervention acceptability and adherence, depressive symptoms (Patient Health Questionnaire- 9), and sleep (Pittsburgh Sleep Quality Index, Insomnia Severity Index, actigraphy and daily diary reports). Results The Re-Timer device was rated positively by participants, and, on average, participants only missed 1 day of utilization. Although depressive symptoms declined and self-reported sleep improved, improvement was seen largely before the start of intervention. Conclusions An effective preventive intervention that is targeted towards a high risk group of older adults has the potential to reduce distress and costly health service use.

Little is known about motives for cannabis use among the population of adults using cannabis medically. Therefore, we evaluated the performance of the 12 factor, 36-item Comprehensive Marijuana Motives Questionnaire (CMMQ) among a sample of medical cannabis patients.Study participants were adults ages 21years or older with scheduled appointments to obtain new or renewed medical cannabis certification from clinics in one Midwestern state (n=1116). Confirmatory factor analysis was used to evaluate properties of the CMMQ. Multiple regressions were used to estimate associations between motives and cannabis use, physical health functioning, and mental health functioning.Fit indices were acceptable, and factor loadings ranged from 0.57 to 0.94. Based on regression analyses, motives accounted for 7% of the variance in recent cannabis use, and independent of cannabis use, accounted for 5% and 19% of physical and mental health functioning, respectively. Regression analyses also revealed that distinct motives were associated with cannabis use and physical and mental health functioning.Among adults seeking medical cannabis certification, the factor structure of the CMMQ was supported, and consistent with prior studies of adolescents and young adults using cannabis recreationally. Thus, individuals who use cannabis medically may have diverse reasons for use that extend beyond the management of medical symptoms. In addition, coping and sleep-related motives may be particularly salient for this population. Findings support the utility of the CMMQ in future research on medical cannabis use; however, expansion of the scale may be needed to address medical motives for use.

Objective/Background: The purpose of the study was to pilot a five-week insomnia treatment in adolescents with major depressive disorder (MDD) and insomnia. This was an open-label trial of a modified-group cognitive behavioral therapy for insomnia (CBTI). Participants: Adolescents with MDD (n = 16; mean age = 17.3 +/- 1.7), characterized by the Children's Depression Rating Scale-Revised T-score ≥ 55 and insomnia, characterized by > 30 min to fall or return to sleep and an Insomnia Severity Index (ISI) score of ≥ 7 participated. Methods: Sleep diaries, actigraphy, weekly ISI, Quick Inventory of Depressive Symptomatology (QIDS), and Multidimensional Fatigue Inventory (MFI) were completed. Results: Paired t-tests comparing pre- and posttreatment revealed a decrease in sleep onset latency from 41 min +/- 14 min to 18 min +/- 8.9 min (t = 5.9, p = .004). Linear mixed modeling across sessions revealed that ISI (B = 11.0, SE = 0.94, p < .001), QIDS (B = 11.3, SE = 0.96, p < .001), and MFI (B = 30.0, SE = 4.4, p < .001) improved across treatment. Daily sleep diaries showed decreased wake during the night (B = 22.8, SE = 7.19, p = .008), increased sleep time (B = 382.4, SE = 71.89, p < .001), and increased quality of sleep (B = 3.7, SE = 0.37, p < .001). When asked whether group members would recommend this group, 27% responded "yes" and 73% responded "definitely yes." Conclusions: Additional controlled studies utilizing sleep-focused therapy in depressed adolescents with insomnia are warranted.

Introduction CBT for insomnia (CBTI) is effective but a barrier to its widespread use is the lack of evidence-based delivery modalities other than face-to-face. The perception and acceptability of telemedicine for the delivery of CBTI is unknown. We conducted a randomized controlled non-inferiority trial comparing face-to-face (F2F) and telemedicine (via AASM SleepTM) delivery of CBTI. We compared measures of patient satisfaction with treatment and the perception of the therapist’s warmth and skills between F2F and SleepTM. Methods Adults with insomnia were recruited from insomnia clinics and the community and screened for sleep, medical, and mental health disorders. Eligible participants were randomized to receive CBTI either via AASM SleepTM or F2F in 6 weekly sessions of 45-60 minutes each. Participants completed the Client Satisfaction Questionnaire (CSQ-8) and The Therapy Evaluation Questionnaire (TEQ) after completing treatment. The CSQ-8 score ranges from 8-32 with high scores indicating greater satisfaction. We also analyzed the two items on the TEQ that assess participants’ perception of therapist’s warmth and skills. Item scores ranged from 1-7, with higher scores indicating greater warmth and skills. Results Sixty-five adults with chronic insomnia were recruited primarily from insomnia clinics. Sixty-two participants (41 women, mean age 48.9 ± 15.4 years) completed all 6 sessions of CBTI via F2F (n=32) or via AASM SleepTM (n=30). Independent samples t-tests revealed no significant differences between conditions on patient satisfaction (SleepTM, 28.5 +/-4.2 vs F2F 29.9 +/-2.4, t(-1.5), p=.14), therapist warmth (SleepTM, 6.0 ±1.1 vs F2F, 6.4±0.95, t(-1.4), p=.16), or therapist skills (Sleep TM 6.4 ±1.0 vs F2F, 6.7±0.59, t(-1.5), p=.15). Conclusion Our findings suggest no differences in patient satisfaction, perception of therapist’s warmth, or confidence in therapist’s skills between telemedicine (via the AASM SleepTM) and F2F delivery of CBTI. Telemedicine-delivered CBTI should be implemented more widely. Support Research supported by American Sleep Medicine Foundation Grant # 168-SR-17 (JT Arnedt)

Introduction Telemedicine is increasingly an option for delivery of healthcare services, but its efficacy and acceptability for delivering CBT for insomnia has not been adequately tested. In a randomized controlled non-inferiority trial, we compared face-to-face and telemedicine delivery (via the AASM SleepTM platform) of CBT for insomnia for improving sleep and daytime functioning at post-treatment and 12-week follow-up. Methods Sixty-five adults with chronic insomnia (46 women, mean age 47.2 ± 16.3 years) were recruited primarily from insomnia clinics and screened for disqualifying sleep, medical, and mental health disorders. Eligible participants were randomized to 6 sessions of CBT for insomnia delivered face-to-face (n=32) or via AASM SleepTM (n=33). Participants completed self-report measures of insomnia (Insomnia Severity Index, ISI) and daytime functioning (fatigue, depression, anxiety, and overall functioning) at pre-treatment, post-treatment, and 12-week follow-up. The ISI was the primary non-inferiority outcome. Results Telemedicine was non-inferior to face-to-face delivery of CBT for insomnia, based on a non-inferiority margin of 4 points on the ISI (β = -0.07, 95% CI -2.28 to 2.14). Compared to pre-treatment, ISI scores improved significantly at post-treatment (β = -9.02, 95% CI -10.56 to -7.47) and at 12-week follow-up (β = -9.34, 95% CI -10.89 to -7.79). Similarly, daytime functioning measures improved from pre- to post-treatment, with sustained improvements at 12-week follow-up. Scores on the fatigue scale were lower in the telemedicine group at both post-treatment (F=4.64, df=1,119, p Conclusion Insomnia and daytime functioning improve similarly whether CBT for insomnia is delivered via telemedicine or face-to-face. Telemedicine delivery of CBT for insomnia should be implemented more systematically to improve access to this evidence-based treatment. Support American Sleep Medicine Foundation Grant # 168-SR-17 (JT Arnedt, PhD)

OBJECTIVE Prescriptions for sedative hypnotics are routinely initiated and renewed to treat insomnia, despite evidence supporting nonpharmacologic treatments as comparable and more favorable over time. We used national Veterans Health Administration data to assess patient characteristics associated with high-dose and long-term zolpidem use. METHOD The study included outpatients with new zolpidem prescriptions (January 1, 2013, to June 3, 2014). We defined high-dose use as use of doses above those recommended in the 2013 FDA safety warning (> 5 mg for women, > 10 mg for men) and defined long-term use as at least 180 days of continued supply. We fit separate logistic regression models by sex to evaluate how patient factors, adjusting for facilities, predicted high-dose and long-term use. RESULTS Of 139,525 new zolpidem users, < 1% of men and 41% of women used high doses within 180 days of initiation, and 20% continued to use zolpidem long-term. Prior-year use of other sleep medications was associated with both high-dose and long-term use. Substance abuse/dependence was associated with high-dose use in women (odds ratio = 1.20, P < .001). Although long-term use was less likely in those over the age of 85 years, about 1 in 5 users aged 65 to 85 continued long-term. In both sexes, individuals of Hispanic ethnicity and nonwhite races were less likely to use long-term, whereas those with ICD-9-CM-defined psychiatric and sleep disorder diagnoses were more likely to use long-term. CONCLUSIONS Zolpidem use at a higher-than-recommended dose was common in women who were new zolpidem users. In both sexes, 1 in 5 users continued to use zolpidem for at least 180 days. Efforts to improve access to effective nonpharmacologic treatment alternatives may benefit from attention to subpopulations with higher risk of high-dose and long-term use.

Children of alcoholic parents are at greater risk for developing substance use problems. Having a parent with any mental illness increases the risk for sleep disorders in children. Using actigraphy, this study characterized sleep in children of alcoholics and community controls over a period of 1 week. This study further examined whether sleep characteristics of the children mediated the relationship between self-regulation indices (i.e. undercontrol and resiliency) and outcome measures of function (e.g. problem behaviours and perceived conflict at home). Eighty-two children (53 boys, 29 girls, 7.2-13.0 years old) were recruited from the ongoing Michigan Longitudinal Study. Seventeen participants had no parental history of alcohol abuse or dependence family history negative (FH-), 43 had at least one parent who was a recovered alcoholic, and 22 had at least one parent who met diagnostic criteria within the past 3 years. Sleep was assessed with actigraphy and sleep diaries for 1 week, and combined with secondary analysis of data collected for the longitudinal study. FH- children had more objectively measured total sleep time. More total sleep time was associated with greater resiliency and behavioural control, fewer teacher-reported behavioural problems, and less child-reported conflict at home. Further, total sleep time partially mediated the relationship between resiliency and perceived conflict, and between resiliency and externalizing problems. These findings suggest that in high-risk homes, the opportunity to obtain sufficient sleep is reduced, and that insufficient sleep further exacerbates the effects of impaired dispositional self-regulatory capacity on behavioural and emotional regulation.

Study ObjectivesWhile disruptions in sleep are common after mild traumatic brain injury (TBI), the longitudinal relationships between sleep problems and global functioning after injury are poorly understood. Here, we prospectively investigate risk for functional impairment during the first 6 months of TBI recovery based on sleep onset insomnia symptoms and short sleep.MethodsPatients presenting to the Emergency Department (ED) at Johns Hopkins Hospital within 24 hours of head injury and evaluated for TBI were eligible for our study. Demographic and injury-related information were collected in the ED. Patients then completed in-person surveys and phone interviews to provide follow-up data on global functioning, sleep, and depressive symptoms at 1, 3, and 6 months post-injury. A total of 238 patients provided sufficient data for analysis, and hypotheses were tested using mixed effects modeling.ResultsSleep quality and global functioning improved over the 6 months of TBI recovery, but patients were at increased risk for functional impairment when sleeping poorly (odds ratio [OR] = 7.69, p < .001). Sleep onset insomnia symptoms and short sleep both independently corresponded to poor global functioning. Functional impairment was highest among those with both insomnia and short sleep (43%–79%) compared to good sleepers (15%–25%) and those with short sleep (29%–33%) or insomnia alone (33%–64%). A bidirectional relationship between sleep quality and functioning was observed.ConclusionsFunctionally impaired patients diagnosed predominantly with mild TBI exhibit high rates of insomnia and short sleep, which may impede TBI recovery. Monitoring sleep after head injury may identify patients with poor prognoses and allow for early intervention to improve functional outcomes.

Sedative hypnotic medications are routinely prescribed for insomnia treatment, but have been associated with significant risks of morning-after impairment. We evaluated responsiveness in the Veterans Health Administration (VHA) facilities to two drug safety warnings recommending against high-dose zolpidem use-a 2007 Veterans Administration Pharmacy Benefits Management Service warning and a 2013 Food and Drug Administration (FDA) warning.We used interrupted time-series design to assess how the two warnings influenced prescribing within the VHA in outpatients from 2005 to 2014. We assessed two outcomes: monthly outpatient use of (1) higher-than-recommended dose of zolpidem among zolpidem users and (2) any-dose zolpidem among all VHA users. In sensitivity analyses, we compared zolpidem prescribing to prescribing other sleep medications not subject to safety warnings.After the 2007 VHA warning, high-dose zolpidem use decreased significantly among both sexes from approximately 10% to 2%. Following the 2013 FDA warning, high-dose zolpidem use declined again; however, approximately half of women Veterans remained on high doses. Overall zolpidem use nearly quadrupled between the 2007 VHA and 2013 FDA warnings, but the overall use declined after the 2013 FDA warning. Increase in sedating antidepressant use was seen after the FDA warning, suggesting potential substitution.Higher than recommended dose use within the VHA decreased after each zolpidem high dose warning. Although overall use also decreased after the FDA warning, almost 50% of high-dose use among women Veterans is concerning. Different strategies to communicate the warnings should be examined.A commentary on this article appears in this issue on page 1093.

Background and Objectives Marijuana (MJ) is a widely used substance that has been shown to impair cognition in laboratory settings. There is a growing number of medical MJ dispensaries and state policies permitting the use of MJ in the United States. This study is a naturalistic study that explores the association of same day MJ use on self-rated cognition in young adult men and women. Methods Forty-eight (n = 48) young adults (22 F; mean age = 22.3) participated. After a baseline assessment, participants made daily phone calls to study staff over the next 3 weeks. Cumulative minutes of MJ use in the last 24-hours were assessed. Demographic information collected and self-ratings of cognitive impairment were assessed using six questions about areas of difficulty thinking each day. Results There was a significant relationship between greater number of minutes of MJ use and higher levels of self-rated cognitive difficulties (b = .004; SE = .001; p

Purpose To examine the prevalence and correlates of sleep problems in a sample of medical cannabis patients. Procedures Adults ages 21 and older (N = 801, M age = 45.8) who were seeking medical cannabis certification (either for the first time or as a renewal) for chronic pain at medical cannabis clinics in southern Michigan completed baseline measures of cannabis use, sleep, pain, and other related constructs. Findings Over half of the sample (59%) met criteria for past 1-month sleep disturbance, defined as at least one sleep problem occurring on 15 or more nights in the past month. Most participants (86%) reported that sleep problems were due to their current pain. Approximately 80% of participants reported using cannabis in the past 6 months to improve sleep and, among these participants, cannabis was rated as helpful for improving sleep. Sleep-related cannabis side effects were rare (35%), but sleep-related cannabis withdrawal symptoms were relatively common (65%). Statistically significant correlates of past 1-month sleep disturbance included a) being female, b) being white, c) being on disability, d) not having a medical cannabis card, and e) frequency of using cannabis to help sleep. Conclusions Sleep problems are highly prevalent and frequent in medical cannabis patients and are closely tied to pain. Sleep-related cannabis withdrawal symptoms are relatively common but their clinical relevance is unknown. The association between frequency of cannabis use to help sleep with higher odds of sleep problems will need to be clarified by longitudinal studies.

BACKGROUND: Past research has indicated that both sleep difficulties (Gregory and Sadeh, 2012) and a parental history of alcoholism (Zucker, 2006) increase the risk of behavioral problems. But it is not known whether sleep difficulties differentially increase the risk of problem behaviors among children of alcoholics and controls. We compared multiple measures of sleep and the relationships between sleep and behavioral problems in these two groups of children. METHODS: One hundred and fifteen children aged 8–12 (67% children of alcoholics or COAs; 56% girls; M(age)=10.85, SD(age)=1.51) participated in this study. Data presented here were taken from Time 1 of a larger prospective study designed to understand the relationship between sleep and alcohol use. All participants were naïve to alcohol and other illicit drugs. Participants were asked to wear an actigraph watch on their non-dominant wrists for one week. Parents completed the Pediatric Sleep Questionnaire and the Achenbach Child Behavioral Checklist. RESULTS: Parents of COAs were more likely to rate their children as overtired compared with parents of non-COAs. SEM analyses focusing on overall internalizing and externalizing problems did not reveal any group differences on the relationships between sleep measures and behavioral problems. Regression analyses focusing on specific behavioral problems showed that longer TST, parental ratings of “sleep more” and “sleep less” than other children interacted with COA status to predict specific behavioral problems. CONCLUSIONS: Sleep difficulties and duration appear to be a general risk factor for behavioral problems in both COAs and non-COAs, yet the relationships between specific sleep parameters and behavioral problems appear to be different between the two groups.

Insomnia is a highly prevalent condition that constitutes a major public health and economic burden. However, little is known about the developmental etiology of adulthood insomnia.We examined whether indicators of psychological vulnerability across multiple developmental periods (psychiatric diagnoses in young adulthood and adolescence, childhood behavioral problems, and familial psychiatric history) predicted subsequent insomnia in adulthood.We used data from the ongoing Dunedin Multidisciplinary Health and Development Study, a population-representative birth cohort study of 1,037 children in New Zealand who were followed prospectively from birth (1972-1973) through their fourth decade of life with a 95% retention rate.Insomnia was diagnosed at age 38 according to DSM-IV criteria. Psychiatric diagnoses, behavioral problems, and family psychiatric histories were assessed between ages 5 and 38.In cross-sectional analyses, insomnia was highly comorbid with multiple psychiatric disorders. After controlling for this concurrent comorbidity, our results showed that individuals who have family histories of depression or anxiety, and who manifest lifelong depression and anxiety beginning in childhood, are at uniquely high risk for age-38 insomnia. Other disorders did not predict adulthood insomnia.The link between lifelong depression and anxiety symptoms and adulthood insomnia calls for further studies to clarify the neurophysiological systems or behavioral conditioning processes that may underlie this association.

Objectives: To determine correlates of sleep problems among adolescents. Specifically, to assess the relative strength of associations between sleep problems and dating victimization, reasons for emergency department (ED) visit, depression, unhealthy alcohol use, and other drug use (marijuana, nonmedical use of prescription opioids, stimulants, and tranquilizers). Methods: A total of 1852 adolescents aged 14 to 20 years presenting for care to the University of Michigan Emergency Department, Ann Arbor, Michigan, during 2011–2012, self-administered a computerized health survey. Sleep problems were identified if any of the 4 items on the Sleep Problems Questionnaire were rated by a patient as greater than 3 on a 0 to 5 scale. Adolescents who were too sick to be screened in the ED were eligible to participate in the study during their inpatient stay. Exclusion criteria for baseline included insufficient cognitive orientation precluding informed consent, not having parent/guardian present if younger than 18 years, medical severity precluding participation, active suicidal/homicidal ideation, non-English-speaking, deaf/visually impaired, or already participated in this study on a prior visit. Results: 23.5% of adolescents reported clinically significant sleep problems. Female gender, depression, dating victimization, tobacco use, nonmedical use of prescription medication, and an ED visit for medical reasons were each associated with sleep problems among adolescents, even while controlling for age, other types of drug use, receiving public assistance, and dropping out of school. Conclusions: These exploratory findings indicate that ED-based screening and brief intervention approaches addressing substance use and/or dating victimization may need to account for previously undiagnosed sleep problems.

Marijuana is the most commonly used recreational drug in the United States. Research on the relationship between marijuana and sleep is still in its infancy. The study examined differences in sleep characteristics between a community sample of daily users, non-daily marijuana users, and non-users. A total of 98 subjects (45 M; 53 F) participated. The mean age was 22.3 (standard deviation = 3.0). There were 53 females and 55% of the sample was Caucasian. Recruitment was done online and via print advertisements in the community. Groups were categorized as non-daily users (n = 29), daily users (n = 49), and non-user controls (n = 20). Sleep was characterized by the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, and the Morningness Eveningness Questionnaire. A standard cut off score of >10 for the Insomnia Severity Index was found in 38.8% of daily users, 10.3% of non-daily users, and 20% of non-users. Pittsburgh Sleep Quality Index scores in daily users (7.0+/-3.8) were higher than non-daily (4.9+/-3.2) and non-user controls (5.0+/-3.7), p = .02. Insomnia Severity Index scores in daily users (7.9+/-6.1) were higher than non-daily (5.1+/-4.3) and non-user controls (4.3+/-4.8), p = .01. Covariate adjusted regression analyses revealed mean Pittsburgh Sleep Quality Index and Insomnia Severity Index scores were significantly lower for non-daily users and controls relative to the daily users. When adjusting for depression and anxiety, these unique associations were not significant. There were no differences in the Epworth Sleepiness Scale or Morningness Eveningness Questionnaire. Daily marijuana users endorsed more sleep disturbance than non-daily users. Future studies should consider mood in the relationship between marijuana use and sleep.

Heavy drinking patterns among adults are common in Ukraine (Webb et al. in Alcohol Alcohol 40(4):327, 2005). According to the WHO Global Information System on Alcohol and Health, the total recorded and unrecorded alcohol per capita consumption among adults (15+) in Ukraine was 14.3 (in liters of pure alcohol) in 2003–2005 which decreased to 13.9 in 2008–2010, with spirits being the main beverage group (48 % of all the alcohol) followed by beer (40 %) and wine (9 %). The 12-month prevalence of alcohol use disorders (including alcohol dependence and harmful use of alcohol) and alcohol dependence estimates (15+) among males were 9.3 and 4.2 % and females 1.1 and 0.5 %, respectively (WHO 2014). The same report found that the highest patterns of drinking score, i.e., the most risky patters of drinking, have been found in Russia and Ukraine.

Nonpharmacological treatments for insomnia in adolescents with depression are lacking. This qualitative study was a thematic analysis of the unique characteristics of and preferences for an insomnia treatment in a group of depressed adolescents. Fourteen adolescents with insomnia (age range = 14-19, mean = 17, SD ± 1.7; 71% female) and depression completed a 90-min focus group. Information was elicited about sleep disruptions, insomnia's impact on mood, and preferences for insomnia treatments. Themes included poor daytime functioning affecting sleep, lack of benefit from sleep medication, and bedtime rumination. Most identified sleep diaries as a barrier to treatment regardless of mode of delivery. Participants also preferred an in-person therapy. Insomnia therapy in adolescents should consider the unique characteristics of depression. Larger studies are warranted.

In a randomized controlled trial, we evaluated the efficacy of cognitive-behavioral treatment for insomnia to improve sleep and daytime symptoms, and to reduce relapse in recovering alcohol dependent (AD) participants. Seventeen abstinent AD patients with insomnia (6 women, mean age 46.2 ± 10.1 years) were randomized to 8 sessions of cognitive-behavioral treatment for insomnia for AD (CBTI-AD, n=9) or to a behavioral placebo treatment (BPT, n=8). Subjective measures of sleep, daytime consequences of insomnia and AD, alcohol use, and treatment fidelity were collected at baseline and post-treatment. Diary-rated sleep efficiency and wake after sleep onset, and daytime ratings of General Fatigue on the Multidimensional Fatigue Inventory improved more in the CBTI-AD compared to the BPT group. In addition, more subjects were classified as treatment responders following CBTI-AD. No group differences were found in the number of participants who relapsed to any drinking or who relapsed to heavy drinking. The findings suggest that cognitive-behavioral insomnia therapy benefits subjective sleep and daytime symptoms in recovering AD participants with insomnia more than placebo. The benefits of treating insomnia on drinking outcomes are less apparent.

Background: Subjective and objective measures of poor sleep in alcoholic insomniacs predict relapse to drinking. Nonalcoholic insomniacs underestimate their total sleep time (TST) and overestimate their sleep onset latency (SOL) and wake time after sleep onset (WASO) compared with polysomnography (PSG). This study evaluated 3 hypotheses: (1) subjective SOL would predict frequency of future drinking; (2) participants would overestimate SOL and WASO and underestimate TST; and (3) higher amounts of over- and underestimates of sleep at baseline would predict worse drinking outcomes prospectively. Methods: Participants (N 5 18), mean age 44.6 years (13.2), underwent an adaptation night and then 2 nights of PSG 3 weeks apart. They also provided morning estimates of SOL, WASO, TST, and sleep efficiency (SE). Following the baseline PSG, participants were followed over 12 weeks. A 2-way ANOVA (nightmethod of measuring sleep) compared results and regression analyses predicted drinking. Drinking outcomes were defined as number of days drinking (DD) and number of heavydrinking days (HDD) during 2 consecutive 6-week follow-up periods. Results: Most participants (72%) overestimated SOL by a mean of 21.3 (36) minutes compared with PSG [F(1, 14) 5 7.1, po0.03]. Unexpectedly, 89% underestimated WASO by a mean difference of 48.7 (49) minutes [F(1, 14) 5 15.6, po0.01]. Drinking during the first 6-week study period was predicted by both subjective estimates of WASO and their accuracy, whereas drinking during the second 6-week period was predicted by both subjective estimations of sleep and rapid eye movement sleep latency. Conclusion: Greater subjective accuracy of wakefulness at night provided by the patient predicted drinking during the study. Unlike nonalcoholic insomniacs, this alcoholic sample significantly underestimated WASO compared with PSG values. The predictive ability of sleep parameters depended on the selected measure of drinking outcomes and when outcomes were measured. Subjective sleep

Substance use disorders (SUD) are common and individuals who suffer from them are prone to relapse. One of the most common consequences of the use of and withdrawal from substances of abuse is sleep disturbance. Substances of abuse affect sleep physiology, including the neurotransmitter systems that regulate the sleep-wake system. Emerging research now highlights an interactive effect between sleep disorders and substance use. New findings in alcohol and sleep research have utilized sophisticated research designs and expanded the scope of EEG and circadian rhythm analyses. Research on marijuana and sleep has progressed with findings on the effects of marijuana withdrawal on objective and subjective measures of sleep. Treatment studies have focused primarily on sleep in alcohol use disorders. Therapies for insomnia in cannabis disorders are needed. Future research is poised to further address mechanisms of sleep disturbance in alcoholics and the effect of medical marijuana on sleep and daytime functioning.

Objective: Sleep undergoes dramatic changes during the adolescent years due to biological, circadian, and psychosocial influences. It is now known that sleep loss, both acute and chronic, can affect emotion regulation and can increase the likelihood of developing depression and risky behaviors. Method: The authors carried out a systematic review utilizing the PubMed database by using the search terms including: “adolescence, depression, sleep, and insomnia.” The present review covers manuscripts accepted up to the year 2013. The following review discusses findings on the bidirectional relationship between insomnia and depression and will cover current evaluation and treatment options. Results: Depression can be present in up to 20 percent of adolescents and most of these children will have some form of sleep disturbance. The etiology of sleep disturbances may reflect insomnia, circadian rhythm sleep disorder, sleep apnea, or other factors. Pharmacological and cognitive behavioral therapy approaches are common, but may result in limited gains due to persistent insomnia. Antidepressant medications may be lessened and relapse may be higher in those with insomnia. Treatment monitoring may be helped by motivational interviewing techniques and examining the teen’s self-report over parental sleep reports. Conclusion: Sleep disturbances that are identified, addressed, and appropriately monitored may result in improved sleep and mood. Active involvement of the teen in the therapy process may improve outcomes. Further research is needed to develop non-pharmacological strategies that are acceptable and sustainable for adolescents

Deirdre A Conroy, Anameti Usoro, Robert F Hoffmann, Kirk J Brower, Roseanne ArmitageUniversity of Michigan, Department of Psychiatry, Ann Arbor, MI, USAPurpose: Sleep disturbances can lead to the onset and relapse of psychiatric disorders. However, the age at which this relationship begins and the role of sleep disturbances in the trajectory to the onset of a psychiatric disorder are still not fully understood. The purpose of this study was to explore, based on self- and parental-reports of mood symptoms, subjective and objective sleep in young children who are at risk of developing a psychiatric disorder but who have not yet met diagnostic criteria.Patients and methods: Twenty-one children (eleven girls) between the ages of 8 and 11 (mean age = 9.7 years, standard deviation = 1.1 years) were dichotomized into low mood (LM) and not low mood (NLM) groups based on scoring below or above the median threshold score on at least two of the following questionnaires: the Child Depressive Rating Scale (CDRS), Weinberg Screening Affective Scale (WSAS), and Quick Inventory of Depressive Symptomatology (QIDS). The children completed sleep diaries and underwent two nights (for adaptation and baseline) of polysomnography. Sleep stages and sleep microarchitecture (alpha, sigma, beta, and delta) in the first half of the night, were analyzed.Results: Self-reported sleep disturbance accounted for 72% of the variance (F[3, 20] = 15, P < 0.005) of the Weinberg Screening Affective Scale in LM children. LM children had fewer arousals at night, but awakened earlier than NLM children. Regardless of mood, girls had more sleep disturbance, as well as lower alpha, beta, and delta power in the first half of the night, compared to boys. Girls with LM had shorter sleep times and a lower percentage of rapid eye movement sleep.Conclusions: Girls with and without LM, and without a clinical diagnosis of depression, showed more sleep disturbances than boys of the same age. Sleep disturbances evident early in life and in LM girls may reflect greater risk for future sleep or psychiatric disorders.Keywords: depression, insomnia, EEG, pediatrics