Journal of Clinical Sleep Medicine最新文献

Study objectives: For Veterans living with a serious mental illness (SMI), insomnia is prevalent and harmful. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment, but Veterans with SMI experience significant environmental, psychological, and systemic barriers to receiving and benefiting from it. There is limited clinical guidance on using CBT-I with Veterans with SMI. We developed provider guidelines and patient materials for conducting CBT-I when these barriers are present for people with SMI (CBT-I for SMI) and evaluated the acceptability and preliminary efficacy of CBT-I for SMI in an assessor-blind randomized controlled trial.

Methods: Forty-seven Veterans with insomnia and SMI were randomized to either CBT-I for SMI (n = 26) or Health and Wellness (HW; n = 21), an active control condition. At baseline, post-treatment, and 3-month follow-up, participants completed: actigraphy and daily sleep diaries for two weeks and self-report measures of insomnia and functioning. At 3-month follow-up, participants completed satisfaction ratings of treatment.

Results: CBT-I for SMI participants had high treatment satisfaction and attendance. At post, compared to HW, CBT-I caused statistically significantly greater reductions in diary-measured time-in-bed, increases in diary-measured sleep efficiency, reductions in actigraphy-measured time-in-bed and total sleep time, and improvements in self-reported insomnia severity and sleep-related functioning; relative to CBT-I, HW improved community participation.

Conclusions: CBT-I for SMI is acceptable to Veterans with SMI and improves sleep and functioning. Future research should examine how sleep mediates effective functional gains, identify how CBT-I could be integrated within recovery centers, and develop preventative interventions to curtail insomnia-associated functional decline. People with serious mental illnesses experience challenges to receiving and benefiting from Cognitive Behavioral Therapy for Insomnia. To support providers and patients, we developed guidelines and materials for navigating these challenges while conducting Cognitive Behavioral Therapy for Insomnia with people with serious mental illness. In the first study to compare Cognitive Behavioral Therapy for Insomnia conducted with our materials and guidelines to an active treatment control, we found that our guideline-led Cognitive Behavioral Therapy for Insomnia improved self-reported insomnia severity, sleep-related functioning, and actigraphy and diary-measured sleep of Veterans with serious mental illness and insomnia. Veterans with serious mental illness can participate in, derive satisfaction from, and benefit from Cognitive Behavioral Therapy for Insomnia when this treatment is appropriately tailored.

Study objectives: Nightmare Disorder (NDO) is an underdiagnosed sleep disorder causing significant impairment, particularly in active duty U.S. military personnel who experience unique stressors. Despite 59.28% of referred service members reporting nightmares and 19.76% screening positive for probable NDO, baseline diagnosis rate was only 0.60%. Our quality improvement project aimed to improve identification and diagnosis of NDO among active duty service members at our sleep disorders center by increasing the confirmed diagnosis rate from 0.60% to at least 5% within 12 months.

Methods: A quality improvement initiative utilizing tiered Plan-Do-Study-Act cycles was implemented over seven months. Interventions included standardizing documentation of Nightmare Disorder Index results on polysomnography reports, targeted provider education, and chart flagging for patients screening positive for probable NDO. Diagnostic and process data were collected at baseline and following each intervention cycle.

Results: The diagnosis rate of NDO increased from 0.60% at baseline to 9.12% after three Plan-Do-Study-Act cycles. The percentage of patients with probable NDO who were ultimately diagnosed (recognition rate) rose from 3.03% to 55.32%. Interventions were implemented without delaying care or increasing staff burden, surpassing the goal diagnosis rate of at least 5% within the target timeframe.

Conclusions: Our interventions led to meaningful increases in NDO diagnoses that exceeded project goals. Given the significant effect of sleep disturbances and heightened mental health risks in the military, identification of this underdiagnosed disorder is clinically important and serves as the essential first step toward ensuring affected individuals receive appropriate treatment. Current knowledge/study rationale: Nightmare Disorder is significantly underdiagnosed in active duty service members despite causing substantial impairment and being highly prevalent in this population who face unique stressors. Sleep disorders centers often fail to identify and diagnose this condition even when service members report nightmares and screen positive on validated assessment tools. Study impact: This quality improvement initiative demonstrates that systematic interventions including standardized screening documentation, provider education, and proactive chart flagging can dramatically increase nightmare disorder diagnosis rates in military healthcare settings. The successful implementation of these workflow-oriented processes provides a replicable model for other military and civilian sleep centers to improve identification of this underdiagnosed condition, serving as an essential first step toward ensuring affected patients receive appropriate treatment.

Residual sleepiness despite effective positive airway pressure (PAP) therapy remains a persistent clinical problem in obstructive sleep apnea (OSA). This retrospective study evaluated real-world use, effectiveness, and tolerability of modafinil, armodafinil, and solriamfetol in 50 adults with OSA and residual sleepiness. Most patients received modafinil (80%) as their initial agent. Complete, partial, and poor responses occurred in 26%, 44%, and 30% of patients, respectively. Adverse events were reported in 38%-predominantly neurologic and psychiatric-and led to discontinuation in ten cases. Response did not correlate with apnea severity, body mass index, or PAP adherence, and no single agent demonstrated superior benefit. These findings contrast with the stronger efficacy and tolerability reported in randomized controlled trials, underscoring the need for individualized therapy and realistic counseling about benefits and side effects when prescribing wake-promoting agents in clinical practice.

Purpose: Idiopathic hypersomnia (IH) is characterized by excessive daytime sleepiness and an excessive need for sleep. It is unknown whether the disorder is stable or improves with time. Our goal was to characterize the evolution of clinical and sleep patterns (including measures of excessive sleep need) in patients with IH over a ten-year period.

Methods: A standardized questionnaire focusing on the progression of clinical symptoms was sent to all patients with IH. At the time of diagnosis, all patients underwent overnight polysomnography and a multiple sleep latency test (MSLT), followed by 18-h bed rest sleep monitoring. This procedure was repeated with a subset of volunteers ten years later.

Results: A total of 123 participants with IH (83.7% female, mean age 29 ± 11 years) were observed for an average of 9.8 ± 4.3 years and 44 of them had 48-h sleep recordings at baseline and follow-up. The percentage of patients with sleep attacks decreased from 58 to 28% and those with sleep drunkenness decreased from 93 to 79%. Nighttime sleep (restricted/unrestricted) decreased by 1- 3 h, and naps by 0.7 h. Despite these changes, 84/123 patients (68.3%) continued to experience hypersomnolence, while 39/123 patients showed improvement. No baseline clinical characteristics could predict long-term improvement. Ten years after their initial diagnosis, only 26/44 (59%) of the participants continued to meet the polysomnographic criteria for central hypersomnia.

Conclusion: Sleep time decreases after ten years of IH evolution, suggesting a decrease in sleep pressure with aging. However, persistent somnolence complaints indicate a stable clinical burden. Current Knowledge/Study Rationale: Idiopathic hypersomnia (IH) is a rare sleep disorder characterized by an excessive need for sleep and severe daytime sleepiness. Few studies have examined its long-term progression, and none have objectively assessed changes in sleep excess using bed rest recordings. This study re-evaluated objective sleep need in patients with IH ten years after the diagnosis using the same extended bed rest protocol. While sleep time decreases, excessive daytime sleepiness and sleep drunkenness persist. At follow-up, 41% of patients no longer met polysomnographic criteria for IH, yet most continued stimulant therapy. Complete remission remained uncommon (4%). Study Impact: These findings confirm the chronic clinical burden of IH and may prompt reconsideration of current diagnostic criteria, particularly for older patients.