sleep initiation and maintenance disorders

When a child does not sleep well, the entire family feels the impact. Sleep supports growth and development and prevents other illnesses. Poor sleep can lead to daytime irritability, trouble focusing, behavioral issues, and learning difficulties. Poor sleep is also associated with long-term problems, such as obesity, breathing problems, and heart problems.

Childhood sleep problems fall into 4 main categories. The most common is behavioral insomnia. This happens when a child has trouble falling or staying asleep, often because they need a specific habit or aid (like rocking or feeding) to settle. Without this help, they struggle to soothe themselves to sleep.

A second category is parasomnias, which are sleep disturbances like night terrors, sleepwalking, and teeth grinding. Night terrors are sudden episodes in which a child screams or appears panicked early in the night. While frightening to witness, the child is unaware of the episode and will have no memory of it. These are usually harmless and temporary.

A third category is bed-wetting, which is also common up to around age 7 years and is usually normal. If it continues regularly after that, discuss with a health care professional to rule out underlying issues or find strategies to help.

Sleep apnea is the final category and is a more serious condition involving repeated pauses in breathing during sleep. Sleep apnea can be caused by enlarged tonsils or excess weight. Children may snore loudly, gasp, or appear restless at night. This disrupted sleep can affect their mood, behavior, and ability to learn. Some children may need overnight sleep studies to diagnose sleep apnea and provide interventions to decrease lifetime illness.

Speak to your child’s pediatrician if you have concerns. Note if your child snores loudly 3 or more nights per week, especially if they gasp or choke during sleep. Excessive daytime sleepiness, frequent headaches or stomachaches, or sleep consistently lasting less than the recommended amount (less than 9 hours for school-aged children) are also signs that your child may have a more serious sleep condition.

All sleep problems need attention. The best way to support better sleep is to create consistent routines that support sleep, known as good sleep hygiene. Keep the same bedtime and waking time every day, including weekends. Establish a calm wind-down routine (like a bath or quiet reading) for 20 to 45 minutes before bed. Turn off all screens and end exciting activities at least 1 hour before bedtime, and make sure the bedroom is cool, dark, and quiet without televisions and screens. Pay attention to both nighttime signs (like snoring or waking) and daytime behaviors (like crankiness, trouble concentrating, or hyperactivity). For children who have trouble falling asleep on their own, put them to bed when they are drowsy but still awake so they learn how to independently fall asleep. They will need this skill every time they wake up in the middle of the night, which could happen 2 to 3 times. With consistency, many sleep issues improve, helping your child rest well at night and feel their best during the day.

Author/s:

Cynthia-Mae M Hunt, Lindsay A Thompson

Therapeutic Use of Cannabis and Cannabinoids: A Review

Megan George — Tue, 02 Dec 2025 16:11:48 +0000

Date Added:

December 2, 2025

Journal/Publication:

JAMA

Publication Date:

November 26, 2025

URL:

Therapeutic Use of Cannabis and Cannabinoids: A Review

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1001/jama.2025.19433

Keywords

medical marijuana

cannabis

PMID (1):

41296368

MeSH

acquired immunodeficiency syndrome

Central Nervous System Depressants

united states food and drug administration

sleep initiation and maintenance disorders

myocardial infarction

anxiety disorders

A review of the therapeutic uses for cannabinoids. James W. Mold, MD, MPH

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Importance: Approximately 27% of adults in the US and Canada report having ever used cannabis for medical purposes. An estimated 10.5% of the US population reports using cannabidiol (CBD), a chemical compound extracted from cannabis that does not have psychoactive effects, for therapeutic purposes.

Observations: Conditions for which cannabinoids have approval from the US Food and Drug Administration include HIV/AIDS-related anorexia, chemotherapy-induced nausea and vomiting, and certain pediatric seizure disorders. A meta-analysis of randomized clinical trials reported a small but significant reduction in nausea and vomiting from various causes (eg, chemotherapy, cancer) when comparing prescribed cannabinoids (eg, dronabinol, nabilone) with placebo or active comparators (eg, alizapride, chlorpromazine; standardized mean difference [SMD], -0.29 [95% CI, -0.39 to -0.18]). A meta-analysis of randomized clinical trials among patients with HIV/AIDS reported that cannabinoids had a moderate effect on increasing body weight compared with placebo (SMD, 0.57 [95% CI, 0.22 to 0.92]). Evidence-based guidelines do not recommend the use of inhaled or high-potency cannabis (≥10% or 10 mg Δ9-tetrahydrocannabinol [Δ9-THC]) for medical purposes. High-potency cannabis compared with low-potency cannabis use is associated with increased risk of psychotic symptoms (12.4% vs 7.1%) and generalized anxiety disorder (19.1% vs 11.6%). A meta-analysis of observational studies reported that 29% of individuals who used cannabis for medical purposes met criteria for cannabis use disorder. Daily inhaled cannabis use compared with nondaily use was associated with an increased risk of coronary heart disease (2.0% vs 0.9%), myocardial infarction (1.7% vs 1.3%), and stroke (2.6% vs 1.0%). Evidence from randomized clinical trials does not support the use of cannabis or cannabinoids for most conditions for which it is promoted, such as acute pain and insomnia. Before considering cannabis or cannabinoids for medical use, clinicians should consult applicable institutional, state, and national regulations; evaluate for drug-drug interactions; and assess for contraindications (eg, pregnancy) or conditions in which risks likely outweigh benefits (eg, schizophrenia or ischemic heart disease). For patients using cannabis or cannabinoids for treatment of medical conditions, clinicians should discuss harm reduction strategies, including avoiding concurrent use with alcohol or other central nervous system depressants such as benzodiazepines, using the lowest effective dose, and avoiding use when driving or operating machinery.

Conclusions and relevance: Evidence is insufficient for the use of cannabis or cannabinoids for most medical indications. Clear guidance from clinicians is essential to support safe, evidence-based decision-making. Clinicians should weigh benefits against risks when engaging patients in informed discussions about cannabis or cannabinoid use.

Author/s:

Michael Hsu, Arya Shah, Ayana Jordan, Mark S Gold, Kevin P Hill

Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis

Megan George — Tue, 23 Sep 2025 14:04:10 +0000

Date Added:

September 23, 2025

Journal/Publication:

JAMA Internal Medicine

Publication Date:

September 22, 2025

URL:

Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2025.4610

Keywords

PMID (1):

40982264

MeSH

sleep

Adult

Humans

sleep initiation and maintenance disorders

chronic pain

Sleep Latency

quality of life

Irritable Bowel Syndrome

Neoplasms

stroke

chronic disease

Cognitive Behavioral Therapy

This systematic review/meta-analysis confirms the benefits of cognitive behavioral therapy for patients with insomnia in the face of chronic health challenges. James W. Mold, MD, MPH

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Importance: Insomnia is highly prevalent among individuals with chronic disease (eg, chronic pain, cardiovascular disease, and cancer) and results in poorer disease outcomes and quality of life. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for insomnia. However, concerns remain about its applicability and efficacy in people with chronic disease.

Objective: To evaluate the nature, efficacy, and acceptability of CBT-I in adults with chronic disease, and to identify moderators of treatment outcomes.

Data sources: Systematic searches were conducted in PsycINFO, Medline, Embase, and CENTRAL from database inception to June 5, 2025. Additional records were identified from reference lists of relevant reviews and studies.

Study selection: Eligible studies were randomized clinical trials (RCTs) involving adults (aged ≥18 years) with chronic disease and insomnia. Studies using CBT-I with measured sleep outcomes were included.

Data extraction and synthesis: Two assessors extracted data from RCTs. Hedges g was used to calculate effect sizes, and random effects meta-analyses were conducted. Heterogeneity was assessed via I2. Subgroup analyses examined whether outcomes varied by delivery format, chronic condition type, or control group.

Main outcomes and measures: Primary outcomes included insomnia severity, sleep efficiency, and sleep onset latency. Secondary outcomes included treatment acceptability and adverse effects.

Results: Sixty-seven RCTs (5232 participants) met inclusion criteria, including chronic diseases such as cancer, chronic pain, irritable bowel syndrome, and stroke. CBT-I was associated with significantly improved outcomes for insomnia severity (g = 0.98; 95% CI, 0.81-1.16) and moderate effect sizes regarding sleep efficiency (g = 0.77; 95% CI, 0.63-0.91) and sleep onset latency (g = 0.64; 95% CI, 0.50-0.78). Subgroup analyses revealed some sample, treatment, and methodological moderators (eg, longer treatment yielded better outcomes for sleep efficiency and sleep onset latency). Satisfaction with CBT-I was high, with a mean dropout rate of 13.3%. Treatment-related adverse effects were rare.

Conclusions and relevance: This systematic review and meta-analysis showed that CBT-I demonstrated strong efficacy and acceptability in chronic disease populations, with moderate to large effect sizes that appear comparable to those in non-chronic disease populations. Efficacy of CBT-I was similar across a range of disease subgroups. Future research should explore the role and nature of treatment adaptations for specific populations and increase access to CBT-I in medical settings.

Author/s:

Amelia J. Scott, Ashleigh B. Correa, Madelyne A. Bisby

Efficacy and Safety of Seltorexant in Insomnia Disorder: A Randomized Clinical Trial

Megan George — Tue, 02 Sep 2025 13:28:04 +0000

Date Added:

September 2, 2025

Journal/Publication:

JAMA Psychiatry

Publication Date:

August 13, 2025

URL:

Efficacy and Safety of Seltorexant in Insomnia Disorder: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamapsychiatry.2025.1999

Keywords

sleep medicine

neurology

Psychiatry and Behavioral Health

Seltorexant

Insomnia medications

sleep disorders

PMID (1):

40802194

MeSH

sleep initiation and maintenance disorders

A randomized controlled trial of a new hypnotic on sleep initiation and maintenance. James W. Mold, MD, MPH

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Importance: Existing pharmacological treatments for insomnia have significant limitations.

Objective: To assess the effective dose range, safety, and tolerability of the novel selective orexin-2 receptor antagonist seltorexant in insomnia disorder.

Design, setting, and participants: This randomized, double-blind, active- and placebo-controlled, dose-finding, polysomnography study was conducted from November 2017 to April 2019 at 55 sites in 6 countries and analyzed in August 2019. The timeline for submission of this data for publication was impacted by internal strategic decision-making. Adults (aged 18-64 years) and older adults (aged 65-85 years) with insomnia (Insomnia Severity Index score ≥15) and no psychiatric comorbidity were included.

Interventions: Participants were randomized 1:1:1:1:1 to receive nightly oral-seltorexant (5 mg, 10 mg, or 20 mg), placebo, or zolpidem (5-10 mg) for 14 days.

Main outcomes and measures: Primary and key secondary outcomes included the dose-response relationship of night 1 latency to persistent sleep (LPS) and wake after sleep onset over the first 6 hours (WASO-6). Other secondary outcomes included night 13 LPS and WASO-6. Due to asymmetrical distributions of LPS and WASO-6 at baseline, log transformation was applied and results were expressed as back-transformed least-squares mean (LSM) ratios for comparisons between groups.

Results: Overall, 364 participants (mean [SD] age, 57.8 [12.4] years; 246 [67.6%] female) received seltorexant, 5 mg (n = 71), 10 mg (n = 74), or 20 mg (n = 71); placebo (n = 75); or zolpidem (n = 73). The night 1 dose-response relationship for LPS was significant (with trend test t statistics ≥3.99 and adjusted P values <.001 for all 4 prespecified models), with greater improvements in seltorexant, 10 mg and 20 mg, vs placebo (10 mg: LSM ratio, 0.64; 90% CI, 0.51-0.81; 20 mg: LSM ratio, 0.51; 90% CI, 0.41-0.64) and in seltorexant, 20 mg, vs zolpidem (LSM ratio, 0.71; 90% CI, 0.57-0.88). The night 1 dose-response relationship for WASO-6 was also significant, with trend test t statistics ≥3.99 and adjusted P values <.001 for all 4 prespecified models (seltorexant, 10 mg: LSM ratio, 0.68; 90% CI, 0.55-0.85; seltorexant, 20 mg: LSM ratio, 0.60; 90% CI, 0.48-0.74). Night 1 LPS and WASO-6 improvements were maintained on night 13 for seltorexant, 10 mg and 20 mg, but diminished for zolpidem. On night 13, compared with zolpidem, seltorexant, 10 mg and 20 mg, improved LPS by 30% and 28%, respectively, and seltorexant, 20 mg, improved WASO-6 by 31%. Treatment-emergent adverse events (TEAEs) were lower across the combined seltorexant doses (73/216 [33.8%]) relative to placebo (37/75 [49.3%]) and zolpidem (31/73 [42.5%]). Two participants experienced serious TEAEs during the double-blind phase (1 in the seltorexant, 20 mg, group and 1 in the zolpidem group). Three participants in the seltorexant, 5 mg, and 1 in the seltorexant, 20 mg, group experienced asymptomatic electrocardiogram-related TEAEs leading to discontinuation.

Conclusions and relevance: Among participants with insomnia in this study, seltorexant, 10 mg and 20 mg, improved sleep initiation and maintenance throughout 14 days of treatment. Seltorexant was generally well tolerated.

Trial registration: ClinicalTrials.gov Identifier: NCT03375203.

Author/s:

Sofie Mesens, Andrew D Krystal, Rama Melkote, Haiyan Xu, Gahan Pandina, Jay B Saoud, Remy Luthringer, Adam Savitz, Wayne C Drevets

Effect of Psychological and Medication Therapies for Insomnia on Daytime Functions: A Randomized Clinical Trial

Erin Blanchette — Sun, 07 Jan 2024 19:56:39 +0000

Date Added:

January 7, 2024

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

December 28, 2023

Issue:

Volume:

URL:

Effect of Psychological and Medication Therapies for Insomnia on Daytime Functions: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2023.49638

Keywords

cognitive behavior therapy

PMID (1):

38153735

MeSH

behavior therapy

fatigue

sleep initiation and maintenance disorders

Cognitive behavioral therapy and zolpidem improve daytime functioning and symptoms equally. The combination further improves outcomes in those with inadequate response to either alone. James W. Mold, MD, MPH.

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Importance: Daytime functional impairments are the primary reasons for patients with insomnia to seek treatment, yet little is known about what the optimal treatment is for improving daytime functions and how best to proceed with treatment for patients whose insomnia has not remitted.

Objectives: To compare the efficacy of behavioral therapy (BT) and zolpidem as initial therapies for improving daytime functions among patients with insomnia and evaluate the added value of a second treatment for patients whose insomnia has not remitted.

Design, setting, and participants: In this sequential multiple-assignment randomized clinical trial conducted at institutions in Canada and the US, 211 adults with chronic insomnia disorder were enrolled between May 1, 2012, and December 31, 2015, and followed up for 12 months. Statistical analyses were performed on an intention-to-treat basis in April and October 2023.

Interventions: Participants were randomly assigned to either BT or zolpidem as first-stage therapy, and those whose insomnia had not remitted received a second-stage psychological therapy (BT or cognitive therapy) or medication therapy (zolpidem or trazodone).

Main outcomes and measures: Study outcomes were daytime symptoms of insomnia, including mood disturbances, fatigue, functional impairments of insomnia, and scores on the 36-item Short-Form Health Survey (SF-36) physical and mental health components.

Results: Among 211 adults with insomnia (132 women [63%]; mean [SD] age, 45.6 [14.9] years), 104 were allocated to BT and 107 to zolpidem at the first stage. First-stage treatment with BT or zolpidem yielded significant and equivalent benefits for most of the daytime outcomes, including depressive symptoms (Beck Depression Inventory-II mean score change, -3.5 [95% CI, -4.7 to -2.3] vs -4.3 [95% CI, -5.7 to -2.9]), fatigue (Multidimensional Fatigue Inventory mean score change, -4.7 [95% CI, -7.3 to -2.2] vs -5.2 [95% CI, -7.9 to -2.5]), functional impairments (Work and Social Adjustment Scale mean score change, -5.0 [95% CI, -6.7 to -3.3] vs -5.1 [95% CI, -7.2 to -2.9]), and mental health (SF-36 mental health subscale mean score change, 3.5 [95% CI, 1.9-5.1] vs 2.5 [95% CI, 0.4-4.5]), while BT produced larger improvements for anxiety symptoms relative to zolpidem (State-Trait Anxiety Inventory mean score change, -4.1 [95% CI, -5.8 to -2.4] vs -1.2 [95% CI, -3.0 to 0.5]; P = .02; Cohen d = 0.55). Second-stage therapy produced additional improvements for the 2 conditions starting with zolpidem at posttreatment in fatigue (Multidimensional Fatigue Inventory mean score change: zolpidem plus BT, -3.8 [95% CI, -7.1 to -0.4]; zolpidem plus trazodone, -3.7 [95% CI, -6.3 to -1.1]), functional impairments (Work and Social Adjustment Scale mean score change: zolpidem plus BT, -3.7 [95% CI, -6.4 to -1.0]; zolpidem plus trazodone, -3.3 [95% CI, -5.9 to -0.7]) and mental health (SF-36 mental health subscale mean score change: zolpidem plus BT, 5.3 [95% CI, 2.7-7.9]; zolpidem plus trazodone, 2.0 [95% CI, 0.1-4.0]). Treatment benefits achieved at posttreatment were well maintained throughout the 12-month follow-up, and additional improvements were noted for patients receiving the BT treatment sequences.

Conclusions and relevance: In this randomized clinical trial of adults with insomnia disorder, BT and zolpidem produced improvements for various daytime symptoms of insomnia that were no different between treatments. Adding a second treatment offered an added value with further improvements of daytime functions.

Trial registration: ClinicalTrials.gov Identifier: NCT01651442.

Author/s:

Charles M Morin, Si-Jing Chen, Hans Ivers, Simon Beaulieu-Bonneau, Andrew D Krystal, Bernard Guay, Lynda Bélanger, Ann Cartwright, Bryan Simmons, Manon Lamy, Mindy Busby, Jack D Edinger

Seasonal Affective Disorder

Erin Blanchette — Wed, 03 Jan 2024 21:04:47 +0000

Date Added:

January 3, 2024

Journal/Publication:

National Institutes of Health

Publisher:

U.S. Department of Health & Human Services

Issue:

NIH Publication No. 23-MH-8138

URL:

Seasonal Affective Disorder

Type:

Patient Education Materials

Format:

Web Page

Keywords

Seasonal Affective Disorder

MeSH

Seasonal Affective Disorder

depression

sleep initiation and maintenance disorders

Social Isolation

Appetite

sleep

A summary of information on seasonal affective disorder for patients from the US Dept. of Mental Health and Substance Abuse Disorders. James W. Mold, MD, MPH

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What is seasonal affective disorder?

Many people go through short periods when they feel sad or unlike their usual selves. Sometimes, these mood changes begin and end when the seasons change. Many people feel "down" or have the "winter blues" when the days get shorter in the fall and winter and feel better in the spring when longer daylight hours return.

Sometimes, these mood changes are more serious and can affect how a person feels, thinks, and behaves. If you have noticed significant changes in your mood and behavior when the seasons change, you may be experiencing seasonal affective disorder (SAD).

In most cases, SAD symptoms start in the late fall or early winter and go away during the spring and summer, known as winter-pattern SAD or winter depression. Other people experience depressive symptoms during the spring and summer months, known as summer-pattern SAD or summer depression. Summer-pattern SAD is less common.

Bedbugs

Aubrey Delammermore — Sat, 27 May 2023 05:00:00 +0000

Date Added:

May 27, 2023

Journal/Publication:

CMAJ

Publisher:

CMA Impact

Publication Date:

May 23, 2023

Issue:

Volume:

195

Pages:

E709

URL:

Bedbugs

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

37220928

Keywords

bedbugs

insecticide resistance

bedbug bites

antihistamines

anxiety

PMID (1):

10.1503/cmaj.221454

MeSH

Bedbugs

Insecticide Resistance

sleep initiation and maintenance disorders

Bedding and Linens

Ectoparasitic Infestations

A concise review of what clinicians need to know about bedbugs. James W. Mold, MD, MPH

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A resurgence in bedbugs is a result of increased travel and insecticide resistance
Many bedbug populations are resistant to pyrethroid, a chemical contained in most currently used insecticides.1 Bedbugs multiply exponentially, with thousands of bugs per infestation after 2–3 months.

Author/s:

Freedman, A., McDougall, L., Lamy, P.

Mortality and concurrent use of opioids and hypnotics in older patients: A retrospective cohort study

Saige Blanchard — Fri, 06 Aug 2021 05:00:00 +0000

Date Added:

August 6, 2021

Journal/Publication:

PLoS Medicine

Publication Date:

July 15, 2021

Issue:

Volume:

Pages:

1-17

URL:

Mortality and concurrent use of opioids and hypnotics in older patients: A retrospective cohort study

Type:

Clinical Research Results

Format:

Article

DOI (1):

https://doi.org/10.1371/journal.pmed.1003709

Keywords

PMID (1):

34264928

MeSH

analgesics, opioid

Trazodone

Benzodiazepines

Hypnotics and Sedatives

sleep initiation and maintenance disorders

Propensity Score

retrospective studies

This large retrospective cohort study found that the combination of benzodiazepines and opioids hastens mortality in older adults.

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Background: Benzodiazepine hypnotics and the related nonbenzodiazepine hypnotics (z-drugs) are among the most frequently prescribed medications for older adults. Both can depress respiration, which could have fatal cardiorespiratory effects, particularly among patients with concurrent opioid use. Trazodone, frequently prescribed in low doses for insomnia, has minimal respiratory effects, and, consequently, may be a safer hypnotic for older patients. Thus, for patients beginning treatment with benzodiazepine hypnotics or z-drugs, we compared deaths during periods of current hypnotic use, without or with concurrent opioids, to those for comparable patients receiving trazodone in doses up to 100 mg.

Methods and findings: The retrospective cohort study in the United States included 400,924 Medicare beneficiaries 65 years of age or older without severe illness or evidence of substance use disorder initiating study hypnotic therapy from January 2014 through September 2015. Study endpoints were out-of-hospital (primary) and total mortality. Hazard ratios (HRs) were adjusted for demographic characteristics, psychiatric and neurologic disorders, cardiovascular and renal conditions, respiratory diseases, pain-related diagnoses and medications, measures of frailty, and medical care utilization in a time-dependent propensity score-stratified analysis. Patients without concurrent opioids had 32,388 person-years of current use, 260 (8.0/1,000 person-years) out-of-hospital and 418 (12.9/1,000) total deaths for benzodiazepines; 26,497 person-years,150 (5.7/1,000) out-of-hospital and 227 (8.6/1,000) total deaths for z-drugs; and 16,177 person-years,156 (9.6/1,000) out-of-hospital and 256 (15.8/1,000) total deaths for trazodone. Out-of-hospital and total mortality for benzodiazepines (respective HRs: 0.99 [95% confidence interval, 0.81 to 1.22, p = 0.954] and 0.95 [0.82 to 1.14, p = 0.513] and z-drugs (HRs: 0.96 [0.76 to 1.23], p = 0.767 and 0.87 [0.72 to 1.05], p = 0.153) did not differ significantly from that for trazodone. Patients with concurrent opioids had 4,278 person-years of current use, 90 (21.0/1,000) out-of-hospital and 127 (29.7/1,000) total deaths for benzodiazepines; 3,541 person-years, 40 (11.3/1,000) out-of-hospital and 64 (18.1/1,000) total deaths for z-drugs; and 2,347 person-years, 19 (8.1/1,000) out-of-hospital and 36 (15.3/1,000) total deaths for trazodone. Out-of-hospital and total mortality for benzodiazepines (HRs: 3.02 [1.83 to 4.97], p < 0.001 and 2.21 [1.52 to 3.20], p < 0.001) and z-drugs (HRs: 1.98 [1.14 to 3.44], p = 0.015 and 1.65 [1.09 to 2.49], p = 0.018) were significantly increased relative to trazodone; findings were similar with exclusion of overdose deaths or restriction to those with cardiovascular causes. Limitations included composition of the study cohort and potential confounding by unmeasured variables.

Conclusions: In US Medicare beneficiaries 65 years of age or older without concurrent opioids who initiated treatment with benzodiazepine hypnotics, z-drugs, or low-dose trazodone, study hypnotics were not associated with mortality. With concurrent opioids, benzodiazepines and z-drugs were associated with increased out-of-hospital and total mortality. These findings indicate that the dangers of benzodiazepine-opioid coadministration go beyond the documented association with overdose death and suggest that in combination with opioids, the z-drugs may be more hazardous than previously thought.

Author/s:

W. A., Chung, C. P., Murray, K. T., Malow, B. A., Daugherty, J. R., Stein, C. M.

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Devin Evans — Wed, 24 Feb 2021 06:00:00 +0000

Date Added:

February 24, 2021

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

February 22, 2021

URL:

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.9049

Keywords

Telephone Cognitive Behavioral Therapy

PMID (1):

33616613

MeSH

aged

sleep initiation and maintenance disorders

Sleep Hygiene

osteoarthritis

Cognitive Behavioral Therapy

Telephone

Cognitive behavioral therapy is apparently the most effective way to help people sleep better, even if provided virtually. James W. Mold, MD, MPH

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Importance: Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

Objective: To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

Design, setting, and participants: This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

Interventions: Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

Main outcomes and measures: The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

Results: Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

Conclusions and relevance: In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

Author/s:

McCurry, Susan M., Zhu, Weiwei, Von Korff, Michael, Wellman, Robert, Morin, Charles M., Thakral, Manu, Yeung, Kai, Vitiello, Michael V.

Overcoming Barriers to the Diagnosis and Treatment of Insomnia

Devin Evans — Thu, 14 Jan 2021 06:00:00 +0000

Date Added:

January 14, 2021

Journal/Publication:

The Journal of Family Practice

Publication Date:

September 1, 2020

Issue:

Volume:

Pages:

S45-S50

URL:

Overcoming Barriers to the Diagnosis and Treatment of Insomnia

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Insomnia

cognitive behavioral therapy

Insomnia medications

PMID (1):

33104107

MeSH

sleep initiation and maintenance disorders

Cognitive Behavioral Therapy

Combined Modality Therapy

Patient Care Planning

A nice review of the diagnosis and management of insomnia. James W. Mold, MD, MPH

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Apply evidence-based diagnostic guidelines for patients who have clinical features consistent with insomnia. Use evidence-based guidelines to develop comprehensive treatment plans that include cognitive-behavioral therapy, pharmacologic treatment, and combination therapies to achieve optimal outcomes Identify basic elements of cognitivebehavioral therapy for insomnia Differentiate among medications FDA-approved for treating insomnia by discussing mechanism of action, safety, efficacy, and use.

Author/s:

Roth, Thomas

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Brian Desmarais — Tue, 18 Feb 2020 17:15:18 +0000

Date Added:

February 18, 2020

Journal/Publication:

Annals of Internal Medicine

Publication Date:

February 18, 2020

URL:

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.7326/M19-3575

Keywords

evaluation

sleep apnea

chronic insomnia

MeSH

sleep initiation and maintenance disorders

This is a guideline for evaluation and management of obstructive sleep apnea and chronic insomnia developed by the VA and DoD. The recommendations are concise and useful. James W. Mold, MD, MPH

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Abstract

Description:

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

Methods:

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Recommendations:

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

The National Institutes of Health has estimated that insomnia and obstructive sleep apnea (OSA) are 2 of the most common sleep disorders in the general U.S. population and in the military and veteran populations (1). Insomnia symptoms are the most common sleep symptoms among U.S. adults, occurring in approximately 20% to 30% of adults, and the prevalence of chronic insomnia disorder ranges from 6% to 10% (2–6). The prevalence of OSA ranges from 9% to 38% and is associated with older age, higher body mass index, male sex, and menopause.

Sleep disorders are more prevalent in the populations served by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) than in the general civilian population. In the RAND report “Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers,” 48.6% of military personnel surveyed had poor sleep quality (Pittsburgh Sleep Quality Index score >5) (7). The prevalence of insomnia symptoms has been reported to be as high as 41% in service members deployed to combat and 25% in noncombatants (8). In a large cohort of soldiers preparing for deployment, 19.9% met criteria for insomnia according to the Insomnia Severity Index (ISI) (8). A more recent study evaluated the incidence of insomnia and OSA in the entire population of U.S. Army soldiers from 1997 to 2011 (9) and showed unprecedented increases in the incidence of both conditions (652% and 600%, respectively) during this period. In military personnel referred for sleep evaluations, sleep-disordered breathing is the most frequently diagnosed disorder, and some studies have found that military personnel have high rates of comorbid insomnia and OSA (10, 11). Further, military personnel with sleep disorders often also have posttraumatic stress disorder (PTSD), symptoms of anxiety and depression, and traumatic brain injury, which can complicate diagnosis and management (11–13).

Sleep disturbances are also common in veterans (14–16). Similar to findings from active-duty service members, the National Veteran Sleep Disorder Study found that the number of veterans diagnosed with sleep disorders increased nearly 6-fold from 2000 to 2010. In this study, 4.5% of veterans were diagnosed with sleep-disordered breathing, and 2.5% were diagnosed with insomnia. However, the actual prevalence of insomnia disorder among veterans is likely to be considerably higher (17) because it is often not documented in the medical record (18, 19). Comorbid PTSD was associated with a 7.6-fold greater risk for OSA and a 6.3-fold greater risk for insomnia (15). Because veterans have high rates of cardiovascular disease and PTSD, and because OSA is more prevalent in patients with these disorders (20), there is likely a large percentage of veterans who have not yet been diagnosed with OSA (21).

Author/s:

Mysliwiec, V., Martin, J.L., Ulmer, J.S., Chowdhuri, S., Brock, M.S., Spevak, C.

Cannabidiol (CBD) - What we know and what we don't

Jeffrey Wilson — Wed, 24 Apr 2019 15:32:45 +0000

Date Added:

April 24, 2019

Journal/Publication:

Harvard Health Blog

Publisher:

Harvard University

Publication Date:

August 24, 2018

URL:

Cannabidiol (CBD) - What we know and what we don't

Type:

Patient Education Materials

Format:

Web Page

Keywords

MeSH

sleep initiation and maintenance disorders

chronic pain

This patient-friendly review of what we currently know about CBD includes a warning that CBD oil reduces the metabolism of warfarin and other drugs metabolized by the CYP450 enzyme system (the same system affected by grapefruit juice) causing elevation of the INR and increased risk of bleeding. James W. Mold, MD, MPH

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Cannabidiol (CBD) has been recently covered in the media, and you may have even seen it as an add-in booster to your post-workout smoothie or morning coffee. What exactly is CBD? Why is it suddenly so popular?

Author/s:

Grinspoon, Peter