Objective

The objective was to investigate relationships between adolescent sleep disturbance and various worry themes.

Methods

Questionnaire data from 8 cross-sectional collections between 1988 and 2011 were used. The sample included more than 20,000 adolescents aged 15-16. Binary logistic regressions were used for the analyses.

Results

Sleep disturbance and female sex increased the odds of worrying about all themes. Sleep disturbance shared stronger associations with worry about financial security, accidents/illness, being bullied, and terrorist attacks (odds ratios, 2.65-3.35) compared with worry about environmental destruction or nuclear war (odds ratios, 1.73-2.11). No interactions between sleep and year of investigation were found.

Conclusions

Little is known about the association between adolescent worry and sleep, and about sleep disturbance and specific worry content. This study shows that the strength in the relationship between adolescent worry and sleep varies with worry themes. Knowledge of the worry content related to sleep may aid in targeting preventions and interventions.

The Minimal Insomnia Symptom Scale (MISS) is a three-item screening instrument that has been found to be psychometrically sound and capable of screening for insomnia among adults and older people. This study aimed to test the measurement properties of the MISS together with an additional item focusing on daytime functioning among adolescents using the Rasch measurement model.

Purpose: Insomnia affects up to one in four adolescents and has been shown to have a negative impact on their mental and physical health. This study aimed to investigate the association between insomnia, academic performance, self-reported health, physical activity, school start time, and substance use among adolescents. Methods: A survey with a cross-sectional design was completed by adolescents (15-17 years old; n = 1504) in southern Sweden. The Minimal Insomnia Symptoms Scale (MISS) was used to operationalize insomnia. A multiple logistic regression analysis was used to analyze the relationship between insomnia and self-reported health, failed school courses, substance use, school start time, family financial situation, screen time, and gender. Results: Insomnia (MISS >= 6) was associated with poor self-reported health (OR: 4.35), failed school courses (OR: 1.47), and use of alcohol and/or cigarettes (OR: 1.43). When the combined effect of self-reported health and physical activity were investigated, a combination of low physical activity (<= 1 time/week) and poor self-reported health was strongly associated with insomnia (OR: 18.87). Conclusions: Insomnia was associated with other problems that in themselves are risk factors for poor health. This highlights the need for a holistic health-promoting approach to prevent insomnia, such as efforts to promote physical activity, school success, and the reduction of alcohol/cigarette use.

Background Sleep deprivation among adolescents is a major public health issue. Although previous studies have described their sleep habits and the consequences thereof, the voices of adolescents themselves are rarely heard. The aim of this study was to investigate adolescents' experiences regarding what they perceived as facilitators and barriers for a good night's sleep. Methods A qualitative focus group study with Swedish adolescents (n = 45) aged 16-18 years was performed with seven focus groups and analyzed using qualitative content analysis. Results Three categories were identified in the analysis regarding facilitators and barriers for achieving a good night's sleep: (1) Striving for a sense of well-being, (2) Tiring yourself out, and (3) Regulating electronic media availability. The adolescents thought that sleep was important in order to be able to cope with everyday life and to allow physical recovery. Overall, the adolescents were knowledgeable regarding commonly recommended strategies for improving sleep, but they had trouble finding a balance between sleep and other activities. Electronic media was used to obtain a sense of belonging and to communicate with others, which in itself was described as important for the adolescents' well-being. However, communicating with friends and family during the night conflicted with achieving a good night's sleep. Parental behaviors (late work habits, internet rules) were also perceived as important for adolescents' sleep habits. Conclusions An understanding of the dilemma of finding a balance between sleep and other activities may aid future sleep-promoting interventions for adolescents, incorporating the impact from social factors' on the adolescents' sleep.

ObjectivesInsufficient sleep is a public health problem that impacts the mental and physical health of children and adolescents. Complaints of insomnia are particularly pervasive among adolescents. This longitudinal study investigates factors that contribute to teen insomnia symptoms. DesignFive-year prospective follow-up study. SettingSchool-based. ParticipantsA total of 522 children (49.8% girls) aged 9.4 +/- 1.3 years at baseline; 14.4 +/- 0.7 years at follow-up. MeasurementsThe dependent variable of insomnia symptoms at follow-up was assessed with the Minimal Insomnia Symptom Scale-Revised. The independent variables at baseline were the perceived family financial situation, tiredness at school, problems waking up, short sleep duration, sleeping difficulties, having a bedroom Television (TV), and time spent with a TV/computer. Multivariate binary logistic regression analyses were used to examine whether the independent variables at baseline predicted insomnia symptoms at follow-up. ResultsPerceived quite bad/very bad family financial situation (OR 3.1; CI 1.4-6.7) and short sleep duration (<10 h) (OR 2.3; CI 1.0-5.3) among girls at baseline were associated with insomnia symptoms at follow-up. Having problems waking up among boys at baseline was associated with insomnia symptoms at follow-up (OR 4.9; CI 1.6-14.4). ConclusionShort sleep duration, problems waking up, and perceived bad family financial situation during childhood were linked with adolescent insomnia symptoms. The sex-based differences in these associations warrant further investigation to effectively mitigate adolescent insomnia.

Paradoxical intention (PI) has been considered an evidence-based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta-analysis. The present study aimed to conduct the first systematic review and meta-analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory-derived processes. A systematic review and meta-analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge's g at post-treatment. Test for heterogeneity was performed, fail-safe N was calculated, and study quality was assessed. The study was pre-registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep-related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.

The purpose of this longitudinal investigation was to examine the association between emotion regulation and future insomnia (incidence and persistence). DesignA longitudinal study in the general population. MethodsA survey was sent out to 5,000 individuals in the community. To those who returned the baseline questionnaire (n=2,333), two follow-up surveys, 6 and 18months later, were sent out and then completed by 1,887 and 1,795 individuals, respectively. The survey contained information about demographic factors, insomnia symptomatology, the Difficulties in Emotion Regulation Scale, anxiety, and depression. ResultsThe findings suggested that emotion regulation at baseline was not associated with the incidence or persistence of insomnia. Overall, the effect sizes were very small to medium. When examining changes in emotion regulation over time, a different pattern emerged. Partial support was established for the notion that decreases in emotion regulation were related to incident and persistent insomnia, as a decrease in emotion regulation was associated with a higher likelihood of future insomnia. Yet, the effect sizes were very small to small. ConclusionThis study does partly point towards a longitudinal association between emotion dysregulation and insomnia. This might have implications for the conceptualization and management of insomnia as well as for future research.

The aim of this study was to examine the psychometric properties of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), with a focus on factorial validity and internal consistency as well as discriminative, convergent, and association with sleep parameters and daytime impairment. Among a randomly selected sample from the general population (N = 5,000), 2,333 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1800 participants who did not fulfill criteria for another sleep disorder than insomnia. A two-factor solution, accounting for 70.7% of the variance, was extracted from the 10 APSQ items. One six-item factor determined worries about the consequences of poor sleep (a = .91); the second factor, with four items, assessed worries about the uncontrollability of sleep (a = .86). The two factors were significantly intercorrelated (ρ = .65) and significantly associated with the total APSQ (ρs = .97 and .76, respectively). The APSQ and the two subscales showed discriminant validity between three sleep status groups (normal sleep, poor sleep, and insomnia disorder; R² = .33-.41). The APSQ and the subscales demonstrated convergent validity with measures on cognitive arousal, sleep-related beliefs, anxiety, and depression. They also were significantly correlated with sleep parameters and daytime impairment. The findings suggest that the APSQ is a psychometrically sound instrument for assessing worry in insomnia.

Objectives: Cognitive models of insomnia underscore cognitive mechanisms as important in the maintenance of insomnia. The aim of this study was to examine psychological factors in insomnia and the association between psychological mechanisms with night-time and daytime symptoms.

Methods: In a cross-sectional examination, participants (n = 2327) from a randomly selected sample of the general population completed a survey on demographic parameters, night-time symptoms, daytime impairment, health outcomes, and psychological factors intended to index five cognitive processes (Harvey, 2002). Excluding those with a sleep disorder other than insomnia, the study sample consisted of 1890 participants.  

Results: Relative to poor and normal sleepers, the insomnia group scored higher on worry, beliefs, physiologic arousal, monitoring/attentional bias, and safety behaviours relative to the other two groups, and the poor sleepers exhibited a similar pattern relative to the normal sleepers. High total wake time was associated with more worry, physiologic arousal, and safety behaviours (26.3% variance), low sleep restoration with more worry, unhelpful beliefs, and monitoring/attentional bias (28.2% variance), and low sleep quality with higher scores on all the psychological mechanisms (35.8% variance). Elevated daytime symptoms were related to more unhelpful beliefs and monitoring/attentional bias (44.3% variance).

Conclusion: The findings show that psychological factors discriminate those with insomnia from those with poor or normal sleep. The results also indicate that psychological factors are linked to insomnia-specific night-time and daytime symptomatology.

Purpose: The aim of this study was to examine psychological factors in insomnia and the association between psychological mechanisms and nighttime and daytime symptoms.

Methods: A cross-sectional examination in the general population was used. The study sample consisted of 1890 participants from the general population. The participants completed a survey on nighttime and daytime symptoms, health outcomes, and psychological factors.

Results: Relative to poor and normal sleepers, the insomnia group had higher scores on worry, beliefs, physiologic arousal, monitoring/attentional bias, and safety behaviors than the other two groups, and the poor sleepers exhibited a similar pattern relative to the normal sleepers. High total wake time was associated with more worry, physiologic arousal, and safety behaviors (26.3% variance), low sleep restoration with more worry, unhelpful beliefs, and monitoring/attentional bias (28.2% variance), and low sleep quality with higher scores on all the psychological mechanisms (35.8% variance). Elevated daytime symptoms were related to more unhelpful beliefs and monitoring/attentional bias (44.3% variance).

Conclusion: The findings indicate that psychological factors are linked to nighttime and daytime symptomatology in insomnia.

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.

Stimulus control (SC) is commonly viewed as an evidence-based treatment for insomnia, but it has not been evaluated comprehensively with modern review and meta-analytic techniques. The aim of the current study was thus to perform a systematic review and meta-analysis of trials that examine the efficacy of stimulus control for insomnia. A systematic search for eligible articles and dissertations was conducted in six online bibliographic databases. The 11 included studies, with the majority published between 1978 and 1998, were randomised controlled and experimental studies in adults, comparing stimulus control for insomnia with passive and active comparators and assessing insomnia symptoms as outcomes. A random effects model was used to determine the standardised mean difference Hedge's g at post-treatment and follow-up for three sleep diary measures: the number of awakenings, sleep onset latency, and total sleep time. A test for heterogeneity was conducted, forest plots were produced, the risk of publication bias was estimated, and the study quality was assessed. In the trials identified, stimulus control resulted in small to large improvements on sleep onset latency and total sleep time, relative to passive comparators (g = 0.38-0.85). Compared with active comparators, the improvements following stimulus control were negligible (g = 0.06-0.30). Although methodological uncertainties were observed in the included trials, stimulus control appears to be an efficacious treatment for insomnia when compared with passive comparators and with similar effects to active comparators. More robust studies are, however, warranted before stronger conclusions are possible to infer.

Insomnia means difficulties in initiating or maintaining sleep and is commonly comorbid with psychiatric disorders. From being considered secondary to primary psychiatric disorders, comorbid insomnia is now considered an independent health issue that warrants treatment in its own right. Cognitive behavioural therapy for insomnia (CBT-I) is an evidence-based treatment for insomnia. The effects from CBT-I on comorbid psychiatric conditions have received increasing interest as insomnia comorbid with psychiatric disorders has been associated with more severe psychiatric symptomologies, and there are studies that indicate effects from CBT-I on both insomnia and psychiatric symptomology. During recent years, the literature on CBT-I for comorbid psychiatric groups has expanded and has advanced methodologically. This article reviews recent studies on the effects from CBT-I on sleep, daytime symptoms and function and psychiatric comorbidities for people with anxiety, depression, bipolar disorder, psychotic disorders and post-traumatic stress disorder. Future strategies for research are suggested.

Objective: The purpose was to examine the psychometric properties of the Pre-Sleep Arousal Scale.

Methods: From a randomly selected sample of the general population (N = 5000), 2327 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1890 participants who did not fulfill criteria for a sleep disorder other than insomnia.

Results: Findings indicated that the PSAS did not produce an adequate factorial solution. When three problematic items were removed, the solution, accounting for 48.5% of the variance, improved (PSAS-13). One subscale, cognitive arousal (alpha = .88), consisted of five items (37.1%), and one subscale, somatic arousal (alpha = .72), of eight items (11.4%). The two factors were significantly inter-correlated (rho = .51) and associated with the PSAS-13 (rho = .91, rho = .80). Among those with insomnia, a shortened PSAS (PSAS-14) was established, which consisted of a cognitive and a somatic subscale (48.6% of the variance). The PSAS-13 and the two subscales showed discriminant validity between three sleep groups (normal sleep, poor sleep, and insomnia disorder) (R-2 = .24-.34). The PSAS-13 and the subscales demonstrated convergent validity with measures on sleep-related worry, sleep-related beliefs, anxiety, and depression. The PSAS-13 and the two subscales were significantly correlated with sleep parameters and daytime impairment.

Conclusion: Though acceptable psychometric properties were established for the PSAS, the cognitive sub-scale's focus upon general pre-sleep arousal and the relatively low variance accounted for calls for further work on and a possible re-conceptualization of the PSAS.

Since the beginning of the twenty-first century, there has been an increased focus on developing and testing cognitive components and therapies for insomnia disorder. The aim of the current review was thus to describe and review the efficacy of cognitive components and therapies for insomnia. A systematic review was conducted on 32 studies (N = 1455 subjects) identified through database searches. Criteria for inclusion required that each study constituted a report of outcome from a cognitive component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is concluded that there is support for paradoxical intention and cognitive therapy. There are also other cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments. For most interventions, the study quality was rated as low to moderate. We conclude that several cognitive treatment components and therapies can be viewed as efficacious or promising interventions for patients with insomnia disorder. Methodologically stronger studies are, however, warranted.

ObjectiveThe objective was to investigate the role of psychiatric and somatic conditions in incident and persistent insomnia.DesignThis was a prospective study with 3 measurement points over 1.5 years.SettingThe participants were sent a survey to their home addresses.ParticipantsA survey was sent out to 5000 random individuals (18-70 years) in 2 Swedish counties. To those who returned the baseline questionnaire (n = 2333), 2 follow-up surveys (6 and 18 months later) were sent out and completed by 1887 and 1795 individuals, respectively.MeasurementsThe survey contained questions about sociodemographic factors and insomnia symptomatology, the Hospital Anxiety and Depression Scale, and items assessing 12 forms of somatic conditions (eg, heart disease and headache).ResultsBaseline depression, headache, and number of psychiatric and somatic conditions were found to be independent risk factors for incident insomnia. Also, deterioration in depression and heart disease status and increased number of conditions over time increased the risk for insomnia incidence. Anxiety; depression; pain in neck, back, or shoulders; and headache at baseline were found to significantly discriminate between those with persistent insomnia and those with persistent normal sleep. Those with persistent insomnia also reported a higher number of conditions relative to those with persistent normal sleep. None of the psychiatric or somatic conditions were found to be associated with persistence of insomnia relative to remission of insomnia.ConclusionThe current study suggests that both psychiatric and somatic conditions are involved in the incidence but not in the persistence of insomnia. Clinical and theoretical implications of the results are discussed.

Introduction: Some therapies described within alternative and complementary medicine are advertised as sleep-promoting, including flotation-REST (Restricted Environmental Stimulation Technique). Flotation-REST induces deep relaxation through sensory isolation in a water-filled tank and is plausibly reported to mitigate insomnia problems, which have consistently been associated with stress, worry and arousal. However, the effects of flotation-REST have not been previously summarised. The aim of this systematic review was to investigate the efficacy of flotation-REST on sleep in clinical and non-clinical samples. Methods: A systematic search for studies on flotation-REST, involving at least one sleep-related variable, was conducted in the databases PubMed, Google Scholar, Web of Science and PsychINFO. Thirteen full-text articles met the inclusion criteria and were considered for eligibility. Nine were included in the current review. The methodological quality of the studies was assessed using a structured checklist, and a standard data extraction sheet was used to summarize the ratings. Results: In all included studies, flotation-REST demonstrated beneficial effects on sleep, both in clinical and nonclinical samples. In two studies, the effects were maintained 4 or 6 months post-treatment. The quality of the sleep outcome measures were, however, low in most studies, particularly regarding the participants' nightly sleep habits, self-reported sleep problems and insomnia diagnosis. Conclusions: Flotation-REST may be a promising treatment for insomnia symptoms, but more controlled studies with established sleep measures, and on populations with clinically verified insomnia, are needed.

Background Sleep is essential for health and recovery. Hospital stays may affect adolescents' sleep quality negatively as routines in the ward are not adapted for adolescents' developmental status or sleep habits. The aims with this study were to (a) explore and describe how adolescents experience sleep in the family-centered pediatric ward, (b) explore and describe how adolescents experience the presence or absence of a parent during the hospital stay, and (c) identify circumstances that the adolescents describe as influential of their sleep in the pediatric wards. Methods This is a qualitative interview study employing thematic analysis with an inductive and exploratory approach. Sixteen adolescents aged between 13 and 17 years participated in the study. Results Three themes were found: the importance of good sleep, safety as a prerequisite for sleep in hospital, and circumstances influencing adolescents' sleep in hospital. Conclusion The adolescents described their sleep at the pediatric ward positively, but mentioned disturbing factors associated with pain, nightly check-ups, noises, and inactivity. Parental presence was perceived as very positive both during the night and the day.

Insomnia is a common health complaint that often becomes a persistent problem. The theoretical frameworks for understanding and treating insomnia have mostly been behavioural, yet the importance of cognitive processes has received greater attention over the years. The overall aim of this dissertation was to expand the knowledge on the processes from the Cognitive Model of Insomnia by investigating them in novel contexts. Study I examined the outcomes from cognitive therapy for insomnia on adolescents. Study II explored the relationship between cognitive processes and the association with remission and persistence of insomnia in the general population. Lastly, Study III investigated if cognitive processes mediated between cognitive behavioural therapy for insomnia (CBT-I) and outcomes of insomnia and depressive severity in a sample of people with insomnia comorbid with depressive problems.

The findings show that cognitive therapy for insomnia affected sleep for adolescents, thus this is a promising treatment option for this age group. Further, it was found that cognitive processes distinguished between adults with normal sleep and persistent insomnia. For people with insomnia, elevated sleep-related worry at baseline increased the risk of reporting persistent insomnia later on, whereas a lowering of selective attention and monitoring, and safety behaviours over time increased the likelihood of remission from insomnia. This has clinical implications for insomnia assessment and treatment, as well as theoretical implications, and warrants further research. CBT-I was associated with greater reductions in dysfunctional beliefs and sleep-related safety behaviours compared to control treatment. Dysfunctional beliefs mediated between CBT-I and insomnia severity and depressive severity respectively. This supports the importance of negative thought content in both insomnia and depression.

Aims: The aim was to investigate changes in child and adolescent sleep habits in Sweden over time. This had not been done previously. Methods: Cross-sectional questionnaire data over three decades of investigations of the Health Behaviours of School Children study (1985/1986, 2005/2006 and 2013/2014) were used. The sample included 18,682 children and adolescents, aged 11, 13 and 15. Empirically based age-specific sleep duration recommendations were used to operationalise sleep duration. Results: The results showed that, over time, fewer go to bed early and more go to bed late. Regarding sleep duration, there have been decreases in the proportion of children and adolescents that sleep as much as is recommended for their age. Sleep onset difficulties have increased for all ages and increase the odds of sleeping less than recommended as well as having late bedtimes. Boys were more likely than girls to have later bedtimes and to sleep less than recommended. A vocational educational track, not planning to study further or being unsure of which track to choose increased the odds for 15 year olds to have late bedtimes and to sleep less than recommended compared with a college preparatory track. Conclusions: The results indicate that over time, fewer children and adolescents attain sufficient sleep duration. This may have implications for study results, mental health and cognitive abilities.

Purpose: To investigate the association between sleep duration, sleep initiation difficulties and psychological and somatic complaints. Methods: We used three cohorts of cross-sectional Swedish questionnaire data, from the Health Behaviours of School aged Children (1985/1986, 2005/2006, 2013/2014, n=>18 000, aged 11–15). Specific complaints (e.g. pain) and total complaint load were used as outcomes of sleep duration, sleep initiation difficulties and the combination of them both. Results: Sleeping less than recommended and sleep initiation difficulties were associated with increased odds of specific complaints and belonging to the group with the greatest complaint load. The combination of short sleep duration and sleep initiation difficulties were associated with higher odds than either sleep issue alone. No interaction effects between time and sleep variables were found regarding complaints. Conclusions: The findings support recent sleep duration recommendations. Further, sleep issues warrant a broad health assessment as they indicate a high likelihood of other complaints.

Aim: The aim was to investigate the association between psychosomatic problems and lifestyle patterns of alcohol use and physical exercise in adolescence. Subject and Methods: Cross-sectional questionnaire data from 8 years of investigations (1988–2011) were used. The sample included over 20,000 adolescents (50 % girls), aged 15–16. Adolescents were divided into three groups depending on psychosomatic problem load: 10th, 11th–89th and 90th percentiles on the psychosomatic problems scale (PSP). A composite measure of alcohol use (frequent/rarely/never) and physical exercise (regular/little/never) was created, resulting in nine combinations of health-related behaviours, and used as dependent variable. Results: Multinomial regression analysis showed that those over the 90th percentile of the PSP had nearly 12 times higher odds of regular alcohol use combined with no exercise compared with those who had the least symptoms. The former subgroup also had higher odds of belonging to all suboptimal lifestyle categories. Those in the 11th–89th percentiles had increased, albeit smaller, odds of belonging to all lifestyle categories. Descriptive data analysis indicated gender differences and changes over time in the strength of the association between psychosomatic problems and health-related behaviours but the regression analysis did not show any statistically significant interactions. The proportion of adolescents engaging in the unhealthiest lifestyle had decreased over time while reports of psychosomatic problems had increased. Conclusion: Adolescents with the greatest psychosomatic symptom load were the most likely to engage in unhealthy lifestyles. This may mean multiplied risks of future psychopathology and warrants longitudinal investigations

Aim: According to the Cognitive Model of Insomnia, engaging in sleep-related cognitive processes may lead to sleep problems over time. The aim was to examine associations between five sleep-related cognitive processes and the incidence of insomnia, and to investigate if baseline anxiety and depression influence the associations. Methods: Two thousand three hundred and thirty-three participants completed surveys on nighttime and daytime symptoms, depression, anxiety, and cognitive processes at baseline and 6 months after the first assessment. Only those without insomnia at baseline were studied. Participants were categorized as having or not having incident insomnia at the next time point. Baseline anxiety and depression were tested as moderators. Results: Three cognitive processes predicted incident insomnia later on. Specifically, more safety behaviors and somatic arousal at Time 1 increased the risk of developing insomnia. When investigating changes in the cognitive processes over time, reporting an increase of worry and safety behaviors also predicted incident insomnia. Depressive symptoms moderated the association between changes in worry and incident insomnia. Conclusion: These findings provide partial support for the hypothesis that cognitive processes are associated with incident insomnia. In particular, safety behaviors, somatic arousal, and worry increase the risk for incident insomnia. Preventative interventions and future research are discussed.

Aim: Insomnia is a common health problem that affects about 10% of the population. The purpose of this investigation was to examine the association between cognitive processes and the persistence and remission from insomnia in the general population. Methods: In a longitudinal design, 2333 participants completed a survey on night time and daytime symptoms, and cognitive processes. Follow-up surveys were sent out six months and 18 months after the first assessment. Participants were categorised as having persistent insomnia, being in remission from insomnia or being a normal sleeper. Results: Cognitive processes distinguished between people with persistent insomnia and normal sleepers. Specifically, worry, dysfunctional beliefs, somatic arousal, selective attention and monitoring, and safety behaviours increased the likelihood of reporting persistent insomnia rather than normal sleep. For people with insomnia, more worry about sleep at baseline predicted persistent insomnia but not remission later on. Lower selective attention and monitoring, and use of safety behaviours over time increased the likelihood of remission from insomnia. In general, these results remained, when psychiatric symptoms and medical complaints were added to the models. Conclusions: The findings support that certain cognitive processes may be associated with persistence and remission of insomnia. Clinical implications are discussed.

AIM: To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up.

METHODS: 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment.

RESULTS: CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time.

CONCLUSION: Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms.

Objectives: Flotation-REST is a treatment for deep relaxation, where a person is contained in a stimuli-restricted environment and floats in water with high salt content. The aim was to investigate the effects from flotation-REST on people with insomnia diagnosis, as previous studies of flotation-REST have demonstrated some effects on sleep but have limitations regarding sample selections and sleep measures. Material and Methods: Six participants were recruited through an outpatient psychiatry clinic and posters on a university campus. All participants fulfilled criteria for insomnia diagnosis and four fulfilled criteria for major depressive disorder. Using a single case experimental design, daily changes were investigated on sleep logs regarding sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency over the course of 12 sessions consisting of 45 min of flotation-REST. No other treatments were offered simultaneously. Questionnaire data on insomnia severity (the ISI) and depressive severity (the MADRS) were also collected. Results: Three participants improved on their most salient insomnia symptom (long SOL or WASO), and two improved on sleep efficiency. The improvements were maintained 2 months after treatment. Insomnia severity decreased for three patients, whereas depressive severity decreased for five. No changes in TST were found and two patients did not improve on any sleep measure. The two participants who benefitted the most were students in their 20s. Discussion: The results were mixed. Flotation-REST may be beneficial for young adults with sleep-onset insomnia but more research is warranted.

Background: Sleeping difficulties are an increasing problem for youths, but there is a lack of treatment research for this age group. Aim: The aim of this study was to investigate the effects of Cognitive Therapy for Insomnia (CT-I) on youths with primary insomnia; this treatment has never been tested on youths before. Method: The study was conducted according to an AB single-case experimental phase design, with pre-tests and post-tests. After 7–10 days of baseline assessment, three youths aged 16–18 (2 male) with primary insomnia participated in a 7-week long treatment. A sleep diary was used throughout the treatment. A followup assessment including one week with a sleep diary was conducted 3 months later. Visual inspection was used to analyze outcome. Results: Insomnia severity was greatly reduced for all participants after treatment. Daily measures showed that sleep onset latency was reduced for two participants but no change in total sleep time was confirmed. Daytime symptoms fluctuated for the participants. The insomnia-specific psychological processes were reduced to varying extents. These results were maintained at the follow-up measure. Conclusions: CT-I may be a promising treatment for youths with insomnia and the treatment should be tested further in randomized controlled studies.

Background: Recent treatment studies with cognitive behavioural therapy for insomnia (CBT-I) have demonstrated effects on both sleep problems and depression. Two previous studies have indicated that the beneficial effect from CBT-I on depression may come through improved sleep, although insomnia severity during treatment had not previously been investigated as a mediator. Aims: Our aim was to investigate if insomnia severity during treatment mediated between CBT-I and depression severity after treatment, in a sample with co-morbid insomnia and depressive symptomology. We also examined whether depressive severity during treatment mediated between CBT-I and insomnia after treatment. Method: The participants were recruited from advertisements and fulfilled criteria for insomnia diagnosis, and had depressive symptomatology (Beck Depression Inventory-second edition: BDI-II > 13). Two-thirds of the participants were diagnosed with major depressive disorder. The participants received four biweekly group sessions of CBT-I or relaxation training (active control). Insomnia severity (Insomnia Severity Index) and depressive severity (BDI-II) were measured at baseline, mid-treatment, post-treatment and 6-month follow-up. The mid-treatment measures were used as mediators. Results: Mediational analyses demonstrated a significant reciprocal relationship between insomnia severity and depressive severity throughout CBT-I, although mid-treatment insomnia had a stronger effect on depression than mid-treatment depression had on insomnia. The results were similar for both post-treatment and follow-up. Discussion: Some improvement in depressive severity after CBT-I is explained by improved sleep. The findings emphasize the importance of making comorbid insomnia a treatment focus in its own right.

The aim of this study was to gain a greater understanding of the five cognitive processes from the cognitive model of insomnia, negative automatic thoughts, and time in bed as outcomes and potential mediators of cognitive behavioral therapy for insomnia (CBT-I), in a sample with insomnia and depressive symptomatology. Sixty-four participants were randomized to receive either CBT-I or an active control (relaxation training: RT) in groups during four biweekly sessions. Insomnia, depressive severity, and the potential processes of change were measured pre-, mid-, and post-treatment. CBT-I was associated with greater reductions of dysfunctional beliefs about sleep, sleep-related safety behaviors, and time in bed compared to RT. Mid-treatment dysfunctional beliefs about sleep was the only process that mediated between CBT-I and outcomes on insomnia and depressive severity, respectively. The relationships were reciprocal. Dysfunctional beliefs about sleep may be a transdiagnostic process of both insomnia and depression.

Clinical trials have shown that cognitive behavioural therapy for insomnia (CBT-I) may have an effect on both insomnia and depression in comorbid samples, but there is a gap in the knowledge on why CBT-I has an impact on depression. Neuropsychological theories suggest that disturbed sleep may work as a transdiagnostic process that maintains psychopathology. The aim was to test whether CBT-I impacts depressive symptoms through improved sleep, in a sample with insomnia comorbid with major depression and subthreshold depressive symptoms. 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four bi-weekly sessions. Insomnia (ISI) and depressive severity (BDI-II) were measured pre-, mid- and post-treatment. Mediational analyses were conducted. Insomnia and depressive severity lowered over the course of treatments. CBT-I was superior in reducing insomnia. The main treatment outcomes have been published elsewhere (Norell-Clarke et al, 2015). The relationship between CBT-I and post-treatment depressive severity was mediated by mid-treatment insomnia severity, which indicates that the effect of CBT-I on depression goes through improved sleep (b = -4.87, BCa CI = -9.21, -1.97). The results were maintained when pre-treatment insomnia and depressive severity were controlled for (b = -3.36, BCa CI = -8.86, -0.45). Testing for reciprocity, we found that mid-treatment depressive severity did not mediate between CBT-I and post-treatment insomnia severity. The results support the perpetuating role of insomnia in depression. This may have implications for other psychiatric patient groups with comorbid insomnia. Also, the results indicate that CBT for comorbid patient groups may need to target sleep specifically.

The impact factor is used to rank the quality of scientific journals but has been criticised for a number of reasons. The aim of the study was to investigate sleep researchers' perceptions of sleep journals to determine whether subjective rankings of journals were in line with the journals' impact factors. Clarivate's Journal Citation Reports website was used to identify journals containing the words 'sleep' or 'dream' in the titles with an impact factor since 2018, resulting in 12 journals. A survey including questions about how the respondent would rank these journals (e.g., three most prestigious journals) was developed. A total of 122 sleep researchers completed the survey. Sleep, Sleep Medicine Reviews and Journal of Sleep Research were ranked as the three most prestigious sleep journals, in line with the impact factors of the journals. For the rest of the journals, the subjective rankings and impact factors did not correspond as much.

Introduction: The study aimed to explore characteristics of responders to a sleep robot intervention for adults with insomnia, and the likelihood that participants responded to the intervention. Methods: Data from the intervention and the control group in a randomized waitlist-controlled trial (n = 44) were pooled together after both had undergone the intervention. A repeated measures ANOVA and Friedman tests were used to explore changes over time. Differences in baseline characteristics between responders (n = 13), defined as a reduction of -5 on the Insomnia Severity Index from pre- to post-intervention, and non-responders (n = 31) were analyzed with t-tests and chi-square tests. Finally, logistic regression models were estimated.Results: Baseline anxiety was the only statistically significant difference between responders and non-responders (p = 0.03). A logistic regression model with anxiety and sleep quality as predictors was statistically significant, correctly classifying 83.3% of cases. Discussion: The results imply that people with lower anxiety and higher sleep quality at baseline are more likely to report clinically significant improvements in insomnia from the sleep robot intervention.

The study objective was to assess if a 3-week intervention with the Somnox sleep robot had effects on symptoms of insomnia, somatic arousal, and/or concurrent symptoms of depression and anxiety in adults with insomnia, compared with a waitlist-control group. The participants (n = 44) were randomized to a 3-week intervention with the sleep robot (n = 22), or to a waitlist-control group (n = 22). The primary outcome measure was the Insomnia Severity Index administered at baseline, mid-intervention, post-intervention and at 1-month follow-up. Secondary outcome measures were the Pre-Sleep Arousal Scale, and the Hospital Anxiety and Depression Scale. Additionally, sleep-onset latency, wake time after sleep onset, total sleep time and sleep efficiency were measured the week prior to and the last week of the intervention, both subjectively with the Consensus Sleep Diary and objectively with wrist actigraphy. Mixed-effects models were used to analyse data. The effect of the sleep robot on the participants' insomnia severity was not statistically significant. The differences between the intervention group and the control group on the measures of arousal, anxiety and depression were also not statistically significant, and neither were the sleep diary and actigraphy variables. In conclusion, a 3-week intervention with daily at-home use of the robot was not found to be an effective method to relieve the symptom burden in adults with insomnia.

Insomnia is a common sleep disorder characterized by difficulties initiating sleep, maintaining sleep and/or early-morning awakenings. Hyperarousal is a common causal and maintaining factor in insomnia models. Different techniques to decrease arousal have shown to be effective. Calm breathing can be one approach to enhance sleep. The Somnox sleep robot looks like a bean-shaped cushion to hug, and it gives physical and auditive guidance to calm down the users' breathing. There is currently no impartial empirical evidence of the sleep robot's effects on insomnia. This study is a randomized waitlist-controlled trial with a recruitment target of a minimum of 44 adults with insomnia and sleep disturbing arousal. Participants will complete pre-, mid- and post-intervention assessments, in addition to a 1-month follow-up. The primary outcome measure is the Insomnia Severity Index. Secondary sleep outcome measures are the Pre-Sleep Arousal Scale, a sleep diary and actigraphy. A secondary comorbid symptoms outcome measure is the Hospital Anxiety and Depression Scale. The main research question is whether treated participants have greater improvements regarding symptoms of insomnia post-intervention, compared with the waitlist control group. The analytic approach will be mixed-effects models. The current study will increase the knowledge on breath guidance as a way to reduce hyperarousal and enhance sleep. The sleep robot is a novel method and a potential treatment option for people with insomnia, when the recommended first-line treatments of Cognitive Behavioral Therapy and pharmaceuticals are inaccessible or undesirable. The ethics of healthcare robotics is discussed.

The Somnox sleep robot is promoted as sleep enhancing. The currentstudy investigated individual effects, the acceptability and the safety of, andexperiences with, a 3-week intervention in adults with insomnia. A repeatedABA single-case design (n = 4) was used to evaluate the effects of the sleeprobot compared with baseline, as measured with a sleep diary and actigraphy.Pre-, post-, and 1-month follow-up assessments were conducted, measuringsymptoms of insomnia, level of somatic arousal, and symptoms of depressionand anxiety. Questions about adherence were included in the sleep diary.Individual interviews were conducted post intervention to explore theparticipants’ experiences with the sleep robot. The sleep diary and actigraphydata showed marginal differences, and if something, often a slight deteriorationin the intervention phase. Three participants reported improvements regardingtheir sleep in the interviews compared with baseline, which mirrored theresults on the questionnaires (insomnia and arousal) for two of the participants.The same three participants adhered to the intervention. Stable or improvedself-assessed symptoms of depression and anxiety, and information fromthe individual interviews, suggest that the intervention is safe for adults withinsomnia. The results regarding the effects of the sleep robot were mixed, andought to be scrutinized in larger studies before confident recommendationscan be made. However, the study supports the acceptability and safety of theintervention in adults with insomnia.

Objectives: An increasing number of children and adolescents divide their time between their separated parents' homes. Although marital conflict is disadvantageous for children's sleep, little is known about how children of separated parents sleep. The objective was to investigate the association between children's cus-tody arrangements and sleep habits and sleep initiation difficulties. Design: Cross sectional nationally representative samples of adolescents from the WHO study Health Behav-iour in School-aged Children (HBSC) (n = 11,802). Setting: Sweden in 2013/2014 and 2017/2018. Participants: Adolescents in grades 5, 7, and 9 from Swedish compulsory comprehensive school. Measurements: The survey included questions on sleep behaviors including bedtime, wake-up time and fre-quency of sleep onset problems. The analysis methods used were ordinary least squares and logistic regression. Results: The results show differences by custody arrangement, but they are not uniform across the dependent variables. Children and adolescents in sole maternal custody were less likely to sleep as much as recommended (P < .001), more likely to have late bedtimes (P < .001), report sleep initiation difficulties (P < .01) and to report social jetlag between school mornings and weekends (P < .05) compared to those in 2-parent families. Shared physical custody was associated with a higher likelihood of late bedtimes (P < .05) and sleep initiation difficulties (P < .05) compared to those in 2-parent families, but not of sleeping less than recommended or reporting social jetlag. Less-than-equal sharing was generally associated with worse sleep than in 2-parent families. Conclusions: As custody arrangements seem to be associated with sleep, it is important to understand the mechanisms behind the findings.

IntroductionRepetitive negative thinking (RNT) has been described as a maintaining transdiagnostic factor for psychopathology within the areas of depression, anxiety and insomnia. We investigated the effects of rumination-focused cognitive-behaviour therapy (RF-CBT) in a group format at a primary health care centre on symptoms of depression, anxiety, insomnia, RNT, and quality of life. The participants presented clinical symptom levels of worry and at least two disorders among anxiety disorders, major depressive disorder, and insomnia disorder.MethodsA randomised controlled superiority parallel arm trial was used. 73 participants were included and randomised in pairs to either group-administered RF-CBT or a waiting list condition. The primary outcomes were self-rated worry and transdiagnostic symptoms (depression, anxiety, and insomnia). Intention-to-treat analyses of group differences were conducted using linear mixed models. Adverse side effects and incidents were presented descriptively.ResultsGroup RF-CBT significantly reduced self-reported insomnia at post-treatment and self-reported insomnia and depression at the 2 month-follow-up, relative to the wait-list control group. There was no significant difference in change in RNT, anxiety, or quality of life.DiscussionThe current study suggests that group-administered RF-CBT may be effective for insomnia and potentially effective for depression symptomatology. However, the study was underpowered to detect small and moderate effects and the results should therefore be interpreted with caution.

Background: Although insomnia disorder and social anxiety disorder are among the most prevalent psychiatric disorders, no studies have yet evaluated the use of sequential evidence-based treatment protocols in the population with co-morbid social anxiety disorder and insomnia disorder. Aims: This study aimed to investigate the effects of sequential treatments on co-morbid insomnia disorder and social anxiety disorder. As depression is a common co-morbid syndrome for both insomnia and social anxiety, a secondary aim was to examine depressive symptoms. Method: A single-case repeated crossover AB design was used. Ten participants between 18 and 59 years of age with co-morbid DSM-5 diagnoses of insomnia disorder and social anxiety disorder received sequential treatments with cognitive behavioural therapy (CBT). Seven participants completed the treatment course. The primary outcomes were symptoms of insomnia and social anxiety, and the secondary outcome was symptoms of depression. Results: The effects of CBT on people with co-morbid social anxiety disorder and insomnia disorder were mixed. The majority of participants improved their sleep quality and lessened symptoms of social anxiety and depression. However, participants differed in their degree of improvement concerning all three disorders. Conclusions: Sequential CBT treatments are potentially effective at decreasing symptoms of social anxiety and insomnia for people with co-morbid social anxiety disorder and insomnia disorder. The variation in outcome across participants makes firm conclusions about the treatment efficacy difficult to draw.