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Background: Insomnia is common in primary care medical practices. Although behavioral treatments for insomnia are safe, efficacious, and recommended in practice guidelines, they are not widely-available, and their effects on comorbid medical conditions remain uncertain. We are conducting a pragmatic clinical trial to test the efficacy of two cognitive behavioral treatments for insomnia (Brief Behavioral Treatment for Insomnia (BBTI) and Sleep Healthy Using the Internet (SHUTi)) versus an enhanced usual care condition (EUC)., Methods/design: The study is a three-arm, parallel group, randomized controlled trial. Participants include 625 adults with hypertension and insomnia, recruited via electronic health records from primary care practices affiliated with a large academic medical center. After screening and baseline assessments, participants are randomized to treatment. BBTI is delivered individually with a live therapist via web-interface/telehealth sessions, while SHUTi is a self-guided, automated, interactive, web-based form of cognitive behavioral therapy for insomnia. Participants in EUC receive an individualized sleep report, educational resources, and an online educational video. Treatment outcomes are measured at 9 weeks, 6 months, and 12 months. The primary outcome is patient-reported sleep disturbances. Secondary outcomes include other self-reported sleep measures, home blood pressure, body mass index, quality of life, health functioning, healthcare utilization, and side effects., Discussion: This randomized clinical trial compares two efficacious insomnia interventions to EUC, and provides a cost-effective and efficient examination of their similarities and differences. The pragmatic orientation of this trial may impact sleep treatment delivery in real world clinical settings and advance the dissemination and implementation of behavioral sleep interventions., Trial Registration: ClinicalTrials.gov (Identifier: NCT02508129 ; Date Registered: July 21, 2015).

Background: Sleep disturbances are a prominent feature of bipolar disorder (BP). However, it remains unclear how sleep phenotypes may evolve among at-risk youth, and their relevance to BP onset., Methods: Pittsburgh Bipolar Offspring Study (BIOS) offspring (ages 10-18) and their parents completed assessments approximately every two years pertaining to current psychopathology and offspring sleep habits. A latent transition analysis (LTA) identified latent sleep groups within offspring based on their ratings of six sleep domains using the School Sleep Habits Survey. Demographic and clinical characteristics were compared between sleep groups. Logistic regression tested links between sleep group and BP onset at the subsequent assessment., Results: The LTA model identified latent groups of good, poor, and variable sleepers. We observed an overall trend of good sleep becoming variable, and then poor, as youth age. Offspring in the poor sleep group were more likely to have psychopathology. Adjusting for age and depression, poor sleepers had nearly twice the odds of developing BP relative to good (OR=1.99, CI=0.45-8.91) or variable (OR=2.03, CI=0.72-5.72) sleepers., Limitations: Limitations include the use of proximal sleep phenotypes to predict BP onset, and a self-report measure of sleep CONCLUSIONS: We found three non-overlapping sleep phenotype groups in a large sample of offspring of bipolar probands and offspring of demographically-matched community control parents. Clinicians should consider that youth will likely experience variable and/or poor sleep as they age, and that at-risk youth with poor sleep may be at increased risk of developing MDD and BP at their next assessment., (Copyright © 2017. Published by Elsevier B.V.)

Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. The aims of this report are (1) to summarize current knowledge on the pathophysiology of insomnia and (2) to present a model of the pathophysiology of insomnia that considers evidence from various domains of research. Working within several models of insomnia, evidence for the pathophysiology of the disorder is presented across levels of analysis, from genetic to molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and self-report. We discuss the role of hyperarousal as an overarching theme that guides our conceptualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that integrates the various types of evidence presented.

Study Objective: Establishing quantitative criteria to distinguish individuals with and without insomnia is important for clinical and research applications, but consensus has not yet been reached for specific values. The purpose of this study was to identify the optimal quantitative thresholds for actigraphy and sleep diary that differentiate older adults (> 60 years) with insomnia from good sleeper controls., Methods: A total of 119 participants (79 insomnia [35% male], 40 control [31.7% male]; mean age = 71.7 [7.2] years) completed at least 7 nights of sleep diary and actigraphy. Receiver operating characteristic curve analyses and the Youden index were used to identify optimal threshold values. Outcomes for each measurement method included sleep onset latency (SOL), wake time after sleep onset (WASO), sleep efficiency (SE), and total sleep time (TST)., Results: Sleep diary measures produced areas under the curves (AUC) in the high range (0.84-0.97), whereas actigraphy performed poorly at discriminating the two groups (AUC 0.58-0.61). The Youden index identified SOL = 18 minutes, WASO = 21 minutes, SE = 92%, and TST = 388 minutes as the sleep diary measures that yielded the highest sensitivity and specificity values for insomnia-control discrimination. Accounting for hypnotic medication and sleep apnea use did not change the findings., Conclusion: Sleep diary parameters discriminated individuals with insomnia from good sleepers more accurately than actigraphy. These quantitative criteria are similar to those reported by other investigators using different methods and samples, including younger adults. The results suggest that the sleep diary, an inexpensive self-report sleep measure, may be used in clinical and research settings to help distinguish older adults with and without insomnia.