Sleep in pediatric oncology

Don’t Let Your Patients Lose Sleep Over Insomnia

The topic 'Emerging Talents in Sleep Disorders' is dedicated to highlighting students and early career researchers within the field of sleep disorders. They are bringing exciting new ideas to the field. However, many of these ideas are not communicated to a broader audience. We recognize that this is because many students and early career researchers may lack a platform to share their ideas. This topic gives an opportunity to succeed with their manuscripts.Chen Tien-Yu et al., reported the prevalence and effects of sleep-disordered breathing on middle-aged patients with sedative-free generalized anxiety disorder ( https://doi.org/10.3389/fpsyt.2022.1067437 ). Generalized anxiety disorder (GAD) and sleepdisordered breathing (SDB) share similar symptoms, such as poor sleep quality, irritability, and poor concentration during daily activities. This study investigates the proportion of undiagnosed SDB and its impacts on anxiety severity and autonomic function in newly diagnosed, sedativefree GAD patients. They found that an average age 55 years and mean BMI 23 kg/m2 patients with GAD and matched controls had an undiagnosed SDB prevalence of approximately 50%. Also noticed that SDB correlated with worsening anxiety severity and reduced cardiac autonomic function. Importantly, age and BMI were major risk factors for predicting undiagnosed SDB. Nakajima S et al described the transdiagnostic association between subjective insomnia and depressive symptoms in major psychiatric disorders (https://doi.org/10.3389/fpsyt.2023.1114945). Comorbid depressive symptoms are associated with clinically important issues such as reduced quality of life, a poor prognosis, and increased suicide risk. This study investigated whether the association between insomnia and depressive symptoms is also found in other psychiatric disorders. In schizophrenia, a relation between depressive symptoms and insomnia was also found by objective sleep assessment methods using sleep EEG. Their results suggest that the association between subjective insomnia and depressive symptoms is a transdiagnostic feature in major psychiatric disorders.Ding Q et al examined validation of a portable monitor compared with polysomnography for screening of obstructive sleep apnea in polio survivors (https://doi.org/10.3389/fneur.2023.1137535). Sleep-disordered breathing (SDB) is highly prevalent in polio survivors. Obstructive sleep apnea (OSA) is the most frequent type. Full polysomnography (PSG) is recommended for OSA diagnosis in patients with comorbidities by current practice guidelines, but it is not always accessible. They studied whether type 3 portable monitor (PM) or type 4 PM might be a viable alternative to PSG for the diagnosis of OSA in post-polio subjects. The insightful study showed Type 3 PM and Type 4 PM could be alternative ways to screen OSA for polio survivors, especially for moderate to severe OSA. Sun J et al reviewed Global research on cancer and sleep: a bibliometric and visual analysis of the last two decades (https://doi.org/10.3389/fneur.2023.1139746). This systemic review analyzed the research status, hotspots, and frontiers of global research on cancer and sleep through bibliometrics and provided references and guidance for future research. Cancer and sleep disruption and the influencing factors of sleep quality is an emerging topic. This study systematically analyzed the hotspots and frontiers in the field of cancer and sleep research. The authors named multiple foal topics for further research studies such as, intervention measures for the cancer symptom cluster, the bioavailability of exogenous melatonin, the relationship between OSA and cancer, the mechanism of tumor-induced sleep disruption, the dose-response relationship between sleep duration and cancer risk.Sleep problems are a growing public health concern worldwide. The 2023 Sleep in America poll conducted by the National Sleep Foundation showed that almost 65% of adults who are dissatisfied with their sleep have mild or severe depressive symptoms (1). The International Classification of Sleep Disorders by American Academy of Sleep Medicine lists 60 specific sleep disorders, the most common of which are insomnia, sleep apnea, restless legs syndrome, and narcolepsy (2).The close association between altered sleep pattern and diseases makes sleep a valuable diagnostic biomarker for non-invasive early diagnosis of some diseases. As sleep disorders increase with age and age is considered one of the major predictors of morbidity and mortality. Despite the diverse nature of sleep disorders, they have far-reaching, detrimental effects on population health and increase both morbidity and mortality of various chronic diseases (3). The chronic effects of sleep disorders deserve more attention from doctors, researchers, and society. As well as a better understanding of the mechanisms of sleep, new approaches to diagnose and treat sleep disorders are urgently needed. The editorial team thanks reviewers for their constructive criticism.

Insomnia and snoring are common sleep disorders. The aim was to investigate the association of having a combination of insomnia symptoms and snoring with comorbidity and daytime sleepiness. The study population comprised 25,901 participants (16-75 years, 54.4% women) from 4 Swedish cities, who answered a postal questionnaire that contained questions on snoring, insomnia symptoms (difficulties initiating and/or maintaining sleep and/or early morning awakening), smoking, educational level, and respiratory and nonrespiratory disorders. Snoring was reported by 4,221 (16.2%), while 9,872 (38.1%) reported ≥ 1 insomnia symptom. A total of 2,150 (8.3%) participants reported both insomnia symptoms and snoring. The association with hypertension (adjusted odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.6), chronic obstructive pulmonary disease (adjusted OR, 1.8; 95% CI, 1.3-2.4), asthma (adjusted OR, 1.9; 95% CI, 1.6-2.3), daytime sleepiness (adjusted OR, 7.9; 95% CI, 7.1-8.8), and the use of hypnotics (adjusted OR, 7.5; 95% CI, 6.1-9.1) was highest for the group with both insomnia symptoms and snoring. Participants with both snoring and insomnia run an increased risk of hypertension, chronic obstructive pulmonary disease, asthma, daytime sleepiness, and use of hypnotics. It is important to consider snoring in patients seeking medical assistance for insomnia and, vice versa, in patients with snoring inquiring about insomnia. Hägg SA, Ilieva E, Ljunggren M, etal. The negative health effects of having a combination of snoring and insomnia. J Clin Sleep Med. 2022;18(4):973-981.

TMS and CBT-I for comorbid depression and insomnia. Exploring feasibility and tolerability of transcranial magnetic stimulation (TMS) and cognitive behavioral therapy for insomnia (CBT-I) for comorbid major depressive disorder and insomnia during the COVID-19 pandemic

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

No snooze button on treating sleep disorders

Insomnia and depression are highly co-morbid conditions that share a complex, bi-directional relationship. By reviewing the literature examining the links between insomnia and depression, it becomes apparent that insomnia symptoms need to be directly targeted alongside depression symptoms when co-morbidities exist for optimal outcomes. The most common treatment in Australia for co-morbid insomnia and depression is currently antidepressant medication. Because a large percentage of individuals given antidepressants fail to remit from their depression and insomnia symptoms, an effective adjunct treatment to antidepressants for co-morbid insomnia and depression is required. Cognitive behavioural therapy for insomnia (CBT-I) is an empirically validated treatment for insomnia, and is efficacious in improving insomnia that is co-morbid with depression. Recent evidence also suggests that CBT-I produces significant improvements in depression severity. The main aim of the thesis was therefore to develop a cost-effective CBT-I intervention that could be easily administered, distributed and implemented on a wide-scale basis, both on its own for insomnia, and primarily as an adjunct therapy for co-morbid insomnia and depression. A therapist manual of CBT-I, based on the latest empirical findings, was specifically developed to increase consistency and ease of treatment administration by therapists wanting to deliver CBT-I treatment. A resource booklet was also developed to give to all individuals undergoing CBT-I treatment, to ensure that they were provided with the latest information about sleep and how to reduce their insomnia severity. A randomised controlled trial was then developed to investigate the efficacy of this CBT-I intervention in individuals with co-morbid insomnia and depression whose symptoms have failed to remit through antidepressant treatment. Forty-one participants (aged 18-64 years) were randomized to receive four sessions of either CBT-I or sleep education (self-help therapy) over an 8-week period (one session every two weeks). Participants had been treated with antidepressants for at least six weeks prior to screening, but were otherwise healthy. The Insomnia Severity Index and the Beck Depression Inventory were assessed at baseline, following each session, and at 3-month follow-up. Secondary outcomes were sleep quality and duration (actigraphy and self-report), anxiety, fatigue, and daytime sleepiness. Results indicated that CBT-I, compared to sleep education, produced significantly reduced depression and insomnia severity, and improved anxiety, fatigue, sleep quality and sleep efficiency. It is the first randomised controlled trial of CBT-I for co-morbid insomnia and depression, with an active control treatment, to show significant reductions in both insomnia and depression severity at post-treatment and follow-up. Large effect sizes were found for both insomnia and depression at post-treatment, and these effect sizes increased further by three month follow-up. At follow-up, ten times more CBT-I participants were in remission from both insomnia and depression than sleep education participants. This demonstrates that CBT-I is an efficacious treatment for co-morbid insomnia and depression, and should be considered an important adjunct therapy in individuals whose symptoms have not remitted through antidepressant treatment. Following the positive results of the randomised controlled trial, the proposed mediators of CBT-I were examined to determine which aspects of the intervention had the largest influence on reductions in insomnia and depression severity at post-treatment and 3-month follow-up. Changes in time-in-bed, bedtime variability, rise-time variability, sleep hygiene practices, dysfunctional beliefs about sleep and stress levels were assessed as potential mediators. Post-treatment results indicated that the significantly reduced depression severity through CBT-I was primarily via reduced stress levels, improved sleep hygiene practices, and other therapeutic effects of CBT-I, whereas reduced insomnia severity was primarily via reduced dysfunctional beliefs about sleep. By follow-up, the significantly reduced depression severity in the CBT-I group was primarily via reduced stress levels and reduced dysfunctional beliefs about sleep, whereas reduced dysfunctional beliefs about sleep and other therapeutic effects of CBT-I explained the significantly reduced insomnia severity. These results indicate that reducing stress levels through CBT-I treatment is required for optimal depression outcomes, whereas reducing dysfunctional beliefs about sleep is essential for optimal insomnia outcomes. Improving sleeping practices behaviourally is important for initial depression improvements, but reducing dysfunctional beliefs about sleep becomes more important for longer-term remission of depression symptoms. Other non-factual therapeutic elements of CBT-I treatment appear to be important, and may lead to a greater willingness to engage in the CBT-I strategies, which can improve depression in the short-term and insomnia in the longer-term. These mediators of CBT-I treatment had not been specifically examined in individuals with co-morbid insomnia and depression before this study. Their identification suggests that relaxation and behavioural sleep interventions should be prioritized initially through CBT-I for co-morbid insomnia and depression, followed by cognitive interventions to target unhelpful beliefs about sleep. By increasing the efficiency of CBT-I, optimal treatment outcomes can be achieved for individuals with co-morbid insomnia and depression, and the risk of future relapse can be minimized.

Acceptance and Commitment Therapy (ACT) is part of the third wave of cognitive behavior therapy, and has six core components: acceptance, cognitive defusion, self as context, being present, values, and committed behavior. This study aimed to examine the efficacy of ACT for insomnia compared with cognitive behavior therapy for insomnia (CBT-I) in patients with chronic primary insomnia. The study recruited patients with chronic primary insomnia from a university hospital between August 2020 and July 2021. Thirty patients were enrolled and randomly assigned to receive either ACT (n = 15) or CBT-I (n = 15). Interventions were performed over four weeks, with four sessions of face-to-face therapy and four sessions of online therapy. The outcomes were measured using a sleep diary and a questionnaire. Post-intervention, the ACT and CBT-I groups had significantly improved sleep quality, insomnia severity, depression, beliefs about sleep, sleep onset latency (SOL), and sleep efficacy (SE) (p < 0.05). However, anxiety was significantly reduced in the ACT group (p = 0.015), but not in the CBT-I group. ACT had a significant effect on primary insomnia and secondary symptoms, especially anxiety related to insomnia. These findings suggest that ACT could be a potential intervention for individuals who do not respond to CBT-I, who have high anxiety regarding sleep problems.

Effectiveness of cognitive behavioral therapy for pharmacotherapy-resistant chronic insomnia: a multi-center randomized controlled trial in Japan

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessM.D.s Need to Be Alert To Sleep-Deprived YouthLynne LambergLynne LambergSearch for more papers by this authorPublished Online:21 May 2004https://doi.org/10.1176/pn.39.10.0030Sleep disorders may mimic or worsen psychiatric disorders; moreover, many psychiatric medications affect sleep adversely. Afternoon naps at school, even for 4-year-olds, don’t make the grade for some educators. Children attending full-day prekindergarten programs—on the rise nationwide—“need to get rid of all the baby school stuff they used to do,” Prince George’s County, Md., schools chief André Hornsby told Maryland legislators recently, according to a report in the Washington Post.“Banning naps is like taking vegetables out of these children’s lives,” countered Jodi A. Mindell, Ph.D., associate director of the sleep disorders center at the Children’s Hospital of Philadelphia.The tactic also is counterproductive, Mindell said. Sleep-deprived children are cranky, irritable, and unable to concentrate. “They won’t gain that half-hour of naptime,” she asserted. “They’ll lose the entire afternoon.”American children aged 10 or younger already get less sleep every day than sleep specialists advise, said Mindell, who chaired the National Sleep Foundation’s (NSF) 2004 Sleep in America poll. This nationwide telephone survey of 1,400 parents or other primary caregivers of children aged 10 or younger is said to be the largest study to date of children’s sleep.Poll results, released in March, show children aged 3 to 6 years average 10.4 hours of sleep daily. While individual sleep needs vary, sleep specialists suggest most children in this age group need about 11 to 13 hours of sleep a day. About 26 percent of 4-year-olds nap every day.For most children aged 3 to 11 months, the recommended amount of sleep is 14 to 15 hours; for ages 12 to 35 months, 12 to 14 hours; and for ages 7 to 10 years, 10 to 11 hours. Across age groups, children averaged about 30 to 60 minutes less sleep than recommended.The developing brain needs sufficient sleep, noted Ronald Dahl, M.D., the Staunton Professor of Pediatrics and Psychiatry at the University of Pittsburgh Medical Center. Sleep benefits learning and memory in the broadest sense, he said. It’s vital for cognitive processing and procedural and emotional learning.A bidirectional relationship exists between sleep and behavioral/emotional regulation, Dahl said. Insufficient sleep interferes with self-control of behavior and mood, and problems with behavior and mood can undermine sleep.Epidemiological surveys suggest about 25 percent of children have sleep disorders. The NSF poll found, however, that 2 in 3 children have trouble falling asleep, awaken at night, snore or have trouble breathing, wet the bed, convey nighttime fears, have nightmares, or experience other problems with sleep several times a week.About 1 in 3 children, including 14 percent of school-aged children, awakens in need of help or attention at least once a night. Parents or caregivers report that about 1 in 4 children ages 6 and under seems sleepy or overtired in the daytime.To researchers’ surprise, however, only 11 percent of parents or caregivers said “yes” when asked, “Does your child have a sleep problem?”“There’s a disconnect here,” Mindell asserted. Parents or caregivers see problem behavior but often don’t realize it may signal a sleep disorder. In more than half of pediatric visits, physicians fail to ask about the child’s sleep. That’s a serious oversight, Mindell noted, since most children’s sleep disorders are treatable.Psychiatrists who see children also need to have sleep on their radar screen, advised Judith Owens, M.D., M.P.H., director of the pediatric sleep disorders clinic and the learning, attention, and behavior program at Hasbro Children’s Hospital in Providence, R.I.Look for underlying or comorbid sleep problems in any child who presents with behavioral, affective, mood, anxiety, or attentional problems, she suggested.Primary sleep disorders, including sleep apnea, restless legs syndrome, or periodic limb movements, may account for much of the child’s symptomatology, Owens said. Sleep clinic studies show these problems are far more common than most physicians suspect.Psychiatric Symptoms ExacerbatedComorbid sleep disorders may exacerbate daytime symptoms of many psychiatric disorders, particularly attention-deficit/hyperactivity disorder (ADHD). Fidgeting and restlessness attributed to ADHD also may be behavioral manifestations of sleepiness. “Sleep deprivation and psychiatric disorders show a huge overlap in their effects on prefrontal cortex executive functioning,” Owens said.Children with ADHD typically have more trouble falling asleep, take longer to fall asleep, awaken more often, and are harder to rouse in the morning than control subjects. Actigraphy studies show children with ADHD have greater night-to-night variability in the time they go to bed and get up, and in the total amount of sleep they get, compared with control subjects. (Actigraphy is used to measure sleep quantity and quality in people who may have a sleep disorder. Data are collected via a device that looks like a wristwatch.)About 60 percent of the children Owens sees in her ADHD clinic, a referral population, have significant sleep problems, often related to medications used to treat ADHD or to comorbid conditions such as anxiety or depression.In prescribing medications for ADHD, asthma, and other illnesses, Dahl reported, clinicians often target symptoms of the primary disorder and do not think about sleep. “It’s a background issue rather than a foreground issue,” he said.He cautioned against prescribing hypnotics for children, however. “We don’t understand enough about which aspects of sleep are truly restorative and exactly how these agents work,” he said. “It’s also hard to change sleep with a primarily pharmacological approach.”Behavioral techniques, though time consuming to implement, work better long term, he said. The physician needs to persuade the family to remove the television, telephone, video games, and similar distractions from the child’s bedroom; modify bedtime schedules; restrict caffeine; and avoid family conflict at night.According to the NSF poll, 43 percent of school-aged children and 30 percent of preschoolers have a television in their bedrooms. These children go to sleep about 20 minutes later and sleep less overall than those without a television in their bedrooms. Parents and caregivers reported that more than half of these children have one or more sleep problems. And about 1 in 10 school-aged children has a telephone and computer in the bedroom.Additionally, 26 percent of children aged 3 and older consume at least one caffeinated beverage, typically a soft drink, every day. These children get about 3.5 hours less sleep each week than those who do not drink such beverages.Parents’ Sleep Affected as WellChildren’s sleep problems, not surprisingly, disrupt the sleep of parents and caregivers, who averaged about 6.8 hours of sleep a night. Two-thirds of parents and caregivers said they are not able to get as much sleep as they need. Earlier NSF polls showed American adults average about seven hours of sleep, an hour less than sleep specialists say most adults need to feel and function optimally.Sleep-deprived parents feel stressed and often angry, Dahl said. A child’s sleep problem may cause conflict between parents. Advice from a mother-in-law, friend, or even a physician may escalate tension. Parents may communicate their distress to their child at an important time of learning about emotions, leading to negative parent-child interactions.Parents of children with severe sleep problems have told Dahl they came close to expressing inappropriate anger toward their child. “My strong clinical impression is that such reports reflect the tip of the iceberg,” he said. In some parents, frustration over struggling to get a child to sleep may precipitate shaken-baby syndrome or other child abuse.Physicians should aim to shift the spiral to a positive direction, Dahl said, by helping parents manage feelings better and promoting parent-child bonding at bedtime.In extreme situations—caring for a child with severe physical and mental handicaps—parents often do a wonderful job of coping 16 hours a day, Dahl said. But if they can’t get the sleep they need because their child is up at night and at risk for self-injury, the child’s sleep problems can tip the balance toward institutional care.Owens, Mindell, and Carol Rosen, M.D., of Rainbow Babies and Children’s Hospital in Cleveland recently surveyed members of the American Academy of Child and Adolescent Psychiatry about their use of pharmacological treatment for children with significant difficulties initiating and/or maintaining sleep. While data analysis is still in progress, the same researchers found in a previous survey that community-based pediatricians frequently prescribe or recommend sedatives and hypnotics for children with insomnia, especially children with ADHD, mental retardation, or autism. They reported these findings in the May 2003 Pediatrics. ▪ ISSUES NewArchived

To develop and demonstrate interrater reliability for a Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Sleep Disorders (SCISD). The SCISD was designed to be a brief, reliable, and valid interview assessment of adult sleep disorders as defined by the DSM-5. A sample of 106 postdeployment active-duty military members seeking cognitive behavioral therapy for insomnia in a randomized clinical trial were assessed with the SCISD prior to treatment to determine eligibility. Audio recordings of these interviews were double-scored for interrater reliability. The interview is 8 pages long, includes 20 to 51 questions, and takes 10 to 20 minutes to administer. Of the nine major disorders included in the SCISD, six had prevalence rates high enough (ie, n ≥ 5) to include in analyses. Cohen kappa coefficient (κ) was used to assess interrater reliability for insomnia, hypersomnolence, obstructive sleep apnea hypopnea (OSAH), circadian rhythm sleep-wake, nightmare, and restless legs syndrome disorders. There was excellent interrater reliability for insomnia (1.0) and restless legs syndrome (0.83); very good reliability for nightmare disorder (0.78) and OSAH (0.73); and good reliability for hypersomnolence (0.50) and circadian rhythm sleep-wake disorders (0.50). The SCISD is a brief, structured clinical interview that is easy for clinicians to learn and use. The SCISD showed moderate to excellent interrater reliability for six of the major sleep disorders in the DSM-5 among active duty military seeking cognitive behavioral therapy for insomnia in a randomized clinical trial. Replication and extension studies are needed. Registry: ClinicalTrials.gov; Title: Comparing Internet and In-Person Brief Cognitive Behavioral Therapy of Insomnia; Identifier: NCT01549899; URL: https://clinicaltrials.gov/ct2/show/NCT01549899.

To analyze complaints about sleep disorders and assess the incidence of various sleep disorders, using relevant scales, in patients with medication-overuse headache (MOH) in comparison with patients without MOH. The prospective case-control study included 171 patients, aged 18 years and older, with MOH (main group), and173 patients with primary headaches without MOH (control group). A neurologist conducted an initial examination and professional interview before the start of treatment. To diagnose sleep disorders, the International Classification of Sleep Disorders (3rd edition, 2014) was used. Additionally, an assessment was made using the Insomnia Severity Index Scale, the Epworth Sleepiness Scale (ESS) and the Lausanne Obstructive Sleep Apnea Syndrome Scale (NoSAS). Statistically significant differences were revealed in the prevalence of the following complaints about sleep disorders in patients with MOH: lack of sleep (51.5%), frequent awakenings during sleep (43.3%), discomfort in legs before falling asleep or at rest in the evening (37.4%). Difficulties falling asleep occurred equally often in both patients with MOH (43.9%) and without MOH (37.0%), as well as daytime sleepiness (40.4% vs 36.4%) and the presence of snoring (13% of patients in each group). Patients with MOH were significantly more likely to suffer from chronic insomnia (60.2% and 47.4%, respectively, p=0.02; OR 1.7; 95% CI 1.1-2.6) and restless legs syndrome (37.4% and 22.0%, respectively, p=0.002; OR 2.1; 95% CI 1.3-3.4). The incidence of hypersomnia and obstructive sleep apnea syndrome did not have statistically significant differences. Patients with MOH compared to patients without MOH have a significantly higher incidence of main complaints of sleep disorders, chronic insomnia and restless legs syndrome, which indicates the importance of sleep disorders in the pathogenesis of medication-overuse headaches and requires timely diagnosis and treatment to prevent the progression of both headaches and sleep disorders.

In his famous monograph “An Essay in Shaking Palsy,” James Parkinson provided astute descriptions of impaired sleep in his case series of patients with Parkinson's disease (PD) two centuries ago. It is only three decades ago that sleep dysfunction started to attract attention of medical and scientific communities involved in the clinical care and research of PD. Tremendous advancements in our understanding of impaired sleep and alertness associated with PD have developed since then. Sleep problems are one of the major, challenging issues in patients with PD, affecting a significant number of patients. The etiology of sleep problems is multifactorial, including disease-related nocturnal symptoms, medication adverse effects, and primary sleep disorders including restless legs syndrome, rapid eye movement sleep behavior disorder, and sleep apnea syndrome. These causes of impaired sleep-wake cycles in the PD population often coexist or even overlap, rendering the management of sleep problems in PD patients difficult. Also, excessive daytime sleepiness is observed in a significant number of patients. In PD patients, therefore, appropriate assessment of disease-related nocturnal disturbances and primary sleep disorders is imperative. This special issue addresses unmet need for understanding PD-related sleep problems. PD sleep scale 2 (PDSS-2) is a recently developed tool for screening and managing sleep disturbance in PD patients, consisting of 15 items which are clinically relevant to nocturnal problems including nonmotor and motor problems in PD [1]. The original PDSS-2 (German and English) has been translated into several languages, including Japanese [2] and Italian [3]. The PDSS-2 has been used to observe treatment response. In a double-blind, placebo-controlled trial, including 287 PD patients, mean PDSS-2 total score decreased by −5.9 points with rotigotine and by −1.9 points with placebo [4]. In this special issue, K. Horvath et al. estimated the threshold representing minimal clinically important difference of the PDSS-2 total score: the study results showed −3.44 points for detecting improvement or the threshold of 2.07 points for observing worsening. This finding is important when planning studies using the PDSS-2 as outcome measures. Full-night polysomnography (PSG) is a gold standard for diagnosing sleep apnea syndrome; however, applying PSG is often difficult in patients with PD, who have severe parkinsonism or psychiatric comorbidity. P. Gros et al. evaluated the usefulness of unattended portable monitoring (PM) for diagnosis of obstructive sleep apnea (OSA) in patients with PD. Although discrepancy between portable monitoring and PSG was greater in PD patients with more motor dysfunction, the authors confirmed the usefulness of portable monitoring in diagnosing moderate to severe OSA in PD patients. These results provide the rationale for the use of portable sleep monitoring in PD and are very relevant for circumstances where a complete PSG in a sleep laboratory is not available and/or feasible. M. Kaminska et al. performed a review on the relationship between OSA and PD. Although the clinical significance of OSA in PD has been controversial [5, 6], the authors suggest the possibility that treatment of OSA could delay cognitive decline or motor dysfunction in patients with PD. This area of research is of high significance as it is important to assess the prevalence of OSA and the impact of its treatment in the PD population. D. Martinez-Ramirez et al. correlated PSG findings and sleep disorders with clinical characteristics in PD patients and found that sleep disorders and sleep architecture were poorly predictable by clinical characteristic of PD patients. This comprehensive study demonstrates the complexity of sleep dysfunction associated with PD and its complex associations with metrics of PD. In a fine and thoughtful study K. Suzuki et al. provided an interesting insight into the complex relationship between PD and restless legs syndrome (RLS) and leg motor restlessness (LMR). A significant relationship between RLS and PD is suggested by observing a favorable response to dopaminergic treatment in both disorders. However, RLS prevalence in PD patients varies according to different studies. Recently, LMR, characterized by an urge to move the legs that does not fulfill the diagnostic criteria for RLS, has been reported more frequently in patients untreated with PD than healthy controls. This review article may provide a new insight into the relationship between RLS, LMR, and PD. Finally, the complex and still only partially understood interaction of impulse control disorders in PD and sleep is discussed in a review from the clinic of one of the guest editors. In summary, sleep problems are common but underreported by PD patients and underdiagnosed by health professionals. Further understanding of mechanisms that underlie impaired sleep and alertness in PD will allow for development of much needed treatment approaches for this nonmotor manifestation of PD. Koichi Hirata Birgit Hogl Eng King Tan Aleksandar Videnovic

Insomnia is a prevalent condition in Australia that increases the risk of depression and anxiety symptoms. Cognitive behaviour therapy for insomnia (CBT-i) is the recommended 'first line' treatment but is accessed by a minority of people with insomnia. To improve CBT-i access in Australia, we aimed to develop and test a self-guided interactive digital CBT-i program. An online randomised controlled trial was conducted from August 2022 to August 2023 to investigate the effect of digital CBT-i, versus digital sleep education control, on symptoms of insomnia (ISI), depression (PHQ-9), anxiety (GAD-7), fatigue, sleepiness and maladaptive beliefs about sleep at 8-week follow-up. The control group accessed the intervention after the 8-week follow-up. Questionnaires were additionally administered at 16 and 24 weeks. Intent-to-treat mixed models and complete-case chi-squared analyses were used. Participants included 62 adults with insomnia symptoms (age M (SD) = 52.5 (16.3), 82% female, ISI = 18.6 (2.9)). There were no between-group differences in baseline characteristics or missing 8-week data (14.5%). After adjusting for baseline scores, CBT-i was associated with lower insomnia (Diffadj (95% CI) = 7.32 (5.0-9.6), P < 0.001, d = 1.64), depression (3.36 (1.3-5.4), p = 0.002, d = 0.84), fatigue (5.2 (2.5-7.9), P < 0.001, d = 1.00) and maladaptive beliefs about sleep (11.0 (4.1-18.0), P = 0.002, d = 0.82), but not anxiety symptoms at 8 weeks (1.84 (-0.1 to 3.8), p = 0.060, d = 0.50). Compared to control, CBT-i was associated with greater rates of insomnia remission (ISI <8; 0.0%, vs 40.0%, P < 0.001) and response at 8 weeks (ISI reduction ≥6; 7.1% vs 72.0%, P < 0.001). Improvements in insomnia and depression were maintained at 24 weeks in the CBT-i group. This interactive digital CBT-i program resulted in large and sustained improvements in symptoms of insomnia, depression, fatigue and maladaptive beliefs about sleep in Australian adults with insomnia symptoms. Implementation programs are required to increase digital CBT-i access and uptake.

Cognitive-Behavioral Therapy for Insomnia (CBT-I) is the gold-standard treatment for insomnia, which is common among breast cancer survivors (BCS). This pilot randomized controlled trial tested the first CBT-I intervention for Spanish-speaking BCS delivered using eHealth. Participants (N = 30) were Spanish-speaking BCS with insomnia symptoms recruited in Puerto Rico and randomized to a 6-week eHealth CBT-I group intervention or a waitlist control. Primary outcomes were acceptability (recruitment, treatment satisfaction) and feasibility (retention, attendance). Secondary outcomes were group differences in sleep outcomes post-treatment (i.e., insomnia symptoms, sleep disturbance, sleep efficiency). Recruitment (95%) and retention (97%) were excellent. All CBT-I participants (100%) attended ≥ 3 of 6 sessions. Satisfaction with CBT-I was acceptable. Post-intervention, there were medium to large group differences for average insomnia symptoms (d = 1.02), sleep disturbance (d = 1.25), and sleep efficiency (d = 0.77) favoring CBT-I. There were small/medium to medium/large group differences for the proportion of participants with clinically significant insomnia symptoms (d = 0.52), sleep disturbance (d = 0.67), and low sleep efficiency (d = 0.33) favoring CBT-I. Spanish-language eHealth CBT-I for BCS was acceptable and feasible and showed preliminary efficacy.ClinicalTrials.gov TRN: NCT04101526 (Posted September 24, 2019).