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With the demands of the COVID-19 pandemic, 

 among health care professionals (HCPs) has become a major concern. Are they functioning well enough at work? Do they show signs of stress? Several reviews and surveys have attempted to evaluate and quantify the effects of these unrelenting stressors on the mental and physical health of HCPs treating patients with COVID-19.

The impact of the pandemic and subsequent lockdowns on sleep has been universal, according to Michael Grandner, PhD, MTR, CBSM, FAASM, director of the Sleep and Health Research Program and the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine in Tucson. “There is not one person anywhere whose sleep has not been affected at all by the pandemic. It’s a foundation of our biology. Paradoxically, everyone’s sleep is affected differently,” he said in an interview.

 among HCPs became a critical problem as frontline clinicians struggled to cope with the personal aspects of COVID-19 while treating those who were sick. A meta-analysis of 53 studies reported a pooled prevalence of poor sleep quality in up to 61% of nurses in general,

 whereas a 2020 survey in China showed that more than one-third of all medical staff experienced symptoms of insomnia associated with the COVID-19 pandemic.

“Health care workers, in particular, have had to work long hours with limited resources and in close proximity to COVID-19 patients during the pandemic,” William D. Killgore, PhD, director of the Social, Cognitive, and Affective Neuroscience (SCAN) Lab in the Department of Psychiatry at the University of Arizona, said in an interview. The SCAN Lab uses advanced technologies to map neurological processes and responses. “As the hospitalization rates continue to surge again, many health care workers are experiencing high levels of stress, anxiety, depression, burnout, and insomnia,” he added.

Sleep parameters affected include sleep latency, duration, and efficiency.

 Some study results suggested that insomnia, or difficulty falling asleep or remaining asleep, is reported by more than half of health care workers who worked with patients with COVID-19, Killgore said. “Many health care workers are showing signs of posttraumatic stress, which is often associated with 

. Unfortunately, sleep is important for the ability to process through emotional experiences, so sleep disruption due to anxiety, long hours, and stress can lead to a vicious circle that maintains sleep problems and the emotional effects of traumatic experiences.”

Clinicians on the front lines experienced greater sleep deprivation as a result of increased sleep restriction from extended work schedules, coupled with various insomnias once they returned home. Jessica Dietch, PhD, of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, explained that prior to the pandemic, shift work, particularly involving rotating shifts, was associated with worse sleep across the domains (latency, duration, and efficiency), which were exacerbated with the changing shift demands.

Additional stressors included extreme variability in sleep duration along with increased work and family demands, each of which may limit clinician’s sleep opportunities by restricting the amount of sleep to less than needed. “Decreased sleep duration, particularly that occurring over multiple days or weeks in a row, can lead to the accumulation of sleep debt,” Dietch explained in an interview. “We know that increases in stressors, which abound for HCPs during the COVID-19 pandemic, can precipitate new insomnia, such as difficulty falling or staying asleep, or exacerbate existing insomnia.”

“Insomnia occurs when there is a decreased ability to detach at night,” Grandner added. This causes sleep to become more fragmented and more shallow, although he noted that in laboratory studies, impairments after a night or 2 of sleep deprivation tend to be less than expected. “Impairments accumulate after a few days or nights of sleep deprivation,” he explained. “Your body will entrain arousal when you’re up night after night, leading to a pattern of chronic 

The physiological and psychological impact after sleep loss over multiple nights is significant. According to Killgore, “Sleep loss has been associated with reduced functional connectivity, ie, communication, between the emotional regions of the brain and the regions that normally regulate those areas, potentially leading to an increased tendency to view experiences from an emotionally skewed—usually negative—perspective.”

Sleep deficits begin to lead to pronounced alterations of cognition, Killgore added, with potentially serious consequences. “When a person is lacking restorative sleep, they build up a biological ‘pressure’ to fall asleep, which eventually starts to intrude upon their waking performance in the form of brief attentional lapses,” he said. “These are momentary glitches, often less than a second in duration, in ongoing cognitive processing where mental activity just seems to stop for a moment. The problem is that these lapses are uncontrollable and occur without warning.” He added lapses can be life-threatening, happening while driving or working.

The most significant impacts on job performance show up not as much in routine, repetitive tasks, according to Grandner, but “when someone has to make a novel judgment call, like when driving home and the light changes or an animal darts into the road.” This results from cognitive slowing, in which processing critical information and solving problems take longer; it potentially represents the most catastrophic effect of continued sleep loss. Killgore explained that “a sleep-deprived health care provider may not see a simple solution to a simple problem that just takes a different perspective. [Sleep deprivation] also affects judgment and willingness to take risks and how [someone] makes moral decisions. So a health care worker who is lacking sleep may make very different life-or-death decisions than they would if they were well rested.”

Clinicians and HCPs who do shift work—ie, working at times that are biologically out of alignment with their 

—also seem to be at greater risk for insomnia and other psychological problems during the pandemic.

Sleep deprivation also alters mood and emotional processing. Without sufficient sleep, individuals are prone to 

, and normally manageable tasks can easily become overwhelming.

Killgore et al found that lack of sleep leads to an increase in implicit biases, such as those against individuals of different races or ethnicities.

 “In our study, when sleep was restricted to 4 hours per night for 3 weeks, implicit biases against Arab Muslims were high, but when the same people got 8 hours of sleep a night for 3 weeks, these biases against others completely disappeared,” he said.

Lack of sleep has been associated with poor memory and difficulty with attention and concentration, Killgore added. Although causality is not conclusive, nearly every major psychiatric disorder is associated with sleep problems, he said.

Long-term sleep restriction can have many adverse health effects, Killgore explained. “Most notably, long-term insufficient sleep is associated with increased metabolic disturbances, weight gain, obesity, hypertension, diabetes, and greater risk of heart attacks and stroke, as well as weakened immune function,” he said.

Not surprisingly, continued sleep deprivation also presents a higher risk of acquiring the 

. “There’s a potential indirect pathway, in that poor sleep can exacerbate conditions that may be associated with increased risk of infection or complications from COVID-19, like cardiovascular disease,” Dietch said. “Good sleep health is important to support physical and mental health broadly during the COVID-19 pandemic.”

Killgore added, “Our own research has shown that getting more and better quality sleep is associated with greater resilience during the COVID-19 pandemic.”

Killgore pointed out that a sleep-deprived individual, even one who is normally very wise and judicious, very often will not realize that they are sleepy and prone to making mistakes. Many individuals with chronic sleep problems can get extremely tired and may even fall asleep frequently throughout the day without knowing it. Killgore suggested that it is important to take any errors in performance, even minor ones, as serious indicators of impairment. “The best option is to simply follow the science and assume that if you are sleep restricted, you are probably impaired without knowing it,” he explained. “Most people will start to show performance deficits after they have been awake longer than 18 hours straight. Performance declines rapidly overnight, from about 11 PM to about 8 AM the following morning.”

Killgore suggested that individuals probably show impairment if they are awake at a time when they would normally be sleeping. Chronic sleep restriction down to even 6 hours a night for 2 weeks causes nearly as much impairment as a single night without any sleep, he said. Killgore encourages clinicians to “take it seriously if [they] are dozing off or making simple mistakes at times when [they] should be awake and alert. These are clear signs that [they] are not getting enough sleep.”

Grandner observed that paradoxically, “one of the best clues to impairment is the feeling that you’re starting to adjust to the stress.” Another is the recognition of heightened emotional status— feeling unusually annoyed, sad, or anxious, for instance. “Feeling indecisive or defensive about decisions [is another sign] that you may be sleep impaired,” he added.

“Unfortunately,” Killgore stated, “there is no substitute for sleep. Sleep is an absolute need, and the body will start grabbing it wherever it can, even at the most inopportune moments, if you are not getting enough. The solution isn’t to swing the pendulum in the other direction—it’s to find balance.” He suggested that one of the most important things to do after work is to try to disengage from the day. Also, a number of psychological and behavioral treatments exist for insomnia (

Individuals can employ strategies to remain more alert, at least until they can catch up on sleep. The experts agreed that in the short term, caffeine can help maintain alertness—but they also noted that it should be used judiciously, as it remains in the body and can cause sleeplessness 6 to 12 hours after ingestion. “Although caffeine is very effective at sustaining immediate alertness and vigilance performance, it often produces no measurable improvements in judgment and decision-making quality,” Killgore said.

Grandner agreed, adding that “stimulants, including caffeine, all improve fatigue, reaction time, and alertness, but they don’t rescue decision-making. People just make bad decisions faster,” he said.

The experts noted there are a number of strategies to improve performance and/or wakefulness while at work, at least in the short term (

Prevalence of poor sleep quality in nursing staff: a meta-analysis of observational studies.

Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. 

COVID-19 and neurological disorders: are neurodegenerative or neuroimmunological diseases more vulnerable?

4. Alkozei A, Killgore WDS, Smith R, et al. 

Chronic sleep restriction increases negative implicit attitudes toward Arab Muslims.

5. Killgore WDS, Taylor EC, Cloonan SA, Dailey NS. 

Psychological resilience during the COVID-19 lockdown.

6. Morgenthaler T, Kramer M, Alessi C, et al; American Academy of Sleep Medicine. 

Practice parameters for the psychological and behavioral treatment of insomnia: an update. an American Academy of Sleep Medicine report.

Sleep deprivation among health care workers: a growing concern. 

Physician, Heal Thyself With Sleep

Jade Wu, PhD, of Duke University School of Medicine, presented on the impact of sleep-wake disorders on mental health at the 2021 Neuroscience Education Institute Congress.

In “Counting Sheep: Improving the Recognition and Management of Insomnia,” she discussed the neurobiology of sleep and its importance; evidence-based strategies for improving the diagnosis of 

 such as insomnia; and how these strategies can be applied to help promote healthy sleep.

 for insomnia focused on encouraging behavioral changes (eg, controlling stimuli, maintaining a consistent sleep-wake schedule); cognitive changes (eg, challenging unhelpful thoughts, correcting misconceptions about sleep); and other practices such as self-monitoring and mindfulness. She also recommended common US FDA-approved pharmacological agents that are indicated specifically for insomnia, including estazolam, quazepam, eszopiclone, and zaleplon.

Improving recognition and management of insomnia is important because the problem is so widespread. According to Wu, about 5% to 15% of adults meet the diagnostic criteria for insomnia, but between 35% and 50% of adults have significant insomnia symptoms. In addition, individuals with insomnia are at increased risk of suicide, drug use, posttraumatic stress disorder, depression, anxiety, and other psychiatric disorders, and physical symptoms like pain may also be exacerbated in individuals with insomnia.

“When we improve insomnia symptoms, we’re also improving depression and anxiety,” Wu said during her presentation. “We’re reducing inflammation, and just across the board, we’re improving a lot of other psychiatric medical and quality-of-life outcomes like chronic pain, functioning, quality of life—you name it. So, in a way, treating insomnia is like raising the water for all boats.”

A board-certified behavioral sleep medication specialist and researcher at Duke University School of Medicine, Wu’s current research focus is the treatment of sleep disorders in individuals with chronic illness.

1. Wu JQ. Counting sheep: improving the recognition and management of insomnia. Presented at: 2021 Neuroscience Education Institute Congress; November 4, 2021; Colorado Springs, CO.

How can cognitive behavioral therapy improve outcomes for individuals with insomnia?

Counting Sheep

can have a lasting impact on behavioral problems for children at age 10-11 years, according to new research.

In the study, Ariel A. Williamson, PhD, and colleagues, identified whether distinct sleep problem trajectories from infancy through middle childhood were linked to multiple aspects of child well-being at ages 10-11 years.

Williamson et al used data from the first 6 waves of the Longitudinal Study of Australian Children—Birth Cohort, which involved 5107 children recruited at birth.

Each caregiver included in the study reported on sleep problems for the children at each time point; the investigator indexed child well-being outcomes at ages 10-11 years using a combination of caregiver-reported, teacher-reported, and child-completed tasks. The outcomes included emotional and behavioral functioning such as internalizing and externalizing symptoms and self-control, health-related quality of life, cognitive skills, and academic achievement.

The authors identified 5 distinct sleep problem trajectories over time using a latent class analysis,. The problems were persistent sleep problems through middle childhood (7.7% of the sample), limited infant or preschool sleep problems (9.0%), increased middle childhood sleep problems (17.0%), mild sleep problems over time (14.4%), and no sleep problems (51.9%).

The results showed children with persistent sleep problems had the greatest impairments across the different outcomes, other than cognitive skills (perceptual reasoning), with moderate to large effect sizes.

On the other hand, children with increased middle childhood sleep problems also experienced greater internalizing and externalizing symptoms with a worse quality of life.However, there were few academic impairments in this subgroup of patients.

In addition, the participants with limited infant or preschool sleep problems and mild increases over time trajectories also showed internalizing concerns and worse caregiver-reported quality of life. These effects were smaller than the other sleep trajectories.

“The linkages between sleep problems and negative child outcomes across domains underscore the importance of early identification and targeted intervention to address sleep problems and promote child well-being,” the authors wrote.

“[F]ew studies have examined the continuity of sleep concerns and their association with developmental outcomes from infancy, when behavioral sleep problems are the most prevalent,” Williamson and colleagues noted. “More research is needed that assesses the impact of sleep problems from infancy through middle childhood, particularly as the first 10–11 years of life is a period of important child development, with the acquisition of foundational psychosocial and cognitive/academic skills and the transition to a formal school setting.”

A version of this article was originally published by our sister publication 

1. Williamson AA, Mindell JA, Hiscock H, Quach J. 

Longitudinal sleep problem trajectories are associated with multiple impairments in child well-being

Researchers highlight the need for early interventions.

Study Explores Link Between Early Sleep Disturbances and Later Behavioral Problems 

Parasomnias are undesirable physical, experiential, or behavioral phenomena that occur exclusively during sleep onset, sleep, or arousals from sleep. Their manifestations may be easily confused with psychiatric disorders, when bizarre motor and/or emotional behavior is mistakenly interpreted as symptomatic of waking aberrance. For some, there may be associations with psychiatric disorders, their treatments, and/or their contribution to predisposition. Underlying the various parasomnias is the actuality that they are not mutually exclusive. Below are fast facts to better recognize and treat them (an in-depth look at the topic can be found online

Their manifestations may be easily confused with psychiatric disorders, when bizarre motor and/or emotional behavior is mistakenly interpreted as symptomatic of waking aberrance.

Non-rapid eye movement (NREM) sleep arousal disorders.

 Although not specified in DSM-5, the simplest of the disorders of arousal is confusional—hence disordered—arousal, which is partial awakening with periods of apparent confusion and inappropriate or absent responsiveness to others while in bed. There is typically amnesia for the event and minimal or no recall of dream mentation. This can evolve into spells that include intense autonomic activation with vocalization, tachycardia, tachypnea, mydriasis, diaphoresis, and sleep terrors or sleepwalking. Confusional arousals occurred in 15.2% of a large community sample, and more than half reported at least 1 episode every week.

Substance- or medication-induced sleep disorder.

 Parasomnias resembling disorders of arousal can be related to the use of many psychotropic drugs, in particular sedative-hypnotics. Sleepwalking and other amnestic complex sleep-related behaviors have been reported among psychiatric patients taking 

. Behaviors can be prolonged and include amnestic nocturnal eating, sexual activity, and even sleep driving. The first step in treatment is to identify and treat comorbid sleep disorders—in particular, restless legs syndrome and obstructive sleep apnea.

, nightmare disorder is now recognized as a REM sleep phenomenon, distinct from NREM sleep terrors. As defined in DSM-5, this includes repetitive, extended, extremely dysphoric, and well-recalled dreams that involve threats to survival, security, or physical integrity; episodes usually occur during the second half of the sleep period. Typically, the individual becomes rapidly alert and oriented. Emotional manifestations of fear, anger, and sadness may predominate. Nightmares occur in 5% to 8% of adults, more commonly women and individuals with type A personality characteristics.

 Patients with RBD are most frequently older men who experience a prolonged, chronic course. They typically dream of themselves as defenders, rarely as aggressors. Violent dream enactment can result in injury to the patient and/or bed partner, whose presence is often incorporated into the dream content. RBD spells are likely to occur during the latter part of the night, when REM sleep tends to be more prolonged and intense. For about 25% of patients, there is a prodromal period with increased action-packed dream content along with vocalization and limb jerking that can progress over several years. As RBD becomes established, there is a tendency for abrupt, often violent movement concordant with recalled dream content.

 Sleep paralysis is essentially the atonia of REM sleep that has become dissociated and occurs at times other than the typical periods of REM sleep during the night. It can either intrude at sleep onset or persist into awakening at sleep offset, and it is often experienced as discomforting or frightening. It is classically found in association with narcolepsy, but not exclusively. Lifetime prevalence of isolated sleep paralysis appears to be 2.3% to 40%, depending on the population under study. Unless the history includes hypersomnia or cataplexy, there is no need for polysomnography.

Sleep-related events not specified in DSM-5.

 Clinical features of nocturnal spells can resemble panic disorder, but diagnostic caution must be emphasized. It is important to look at other disorders that can masquerade as nocturnal panic, such as sleepwalking/sleep terrors, RBD, seizures, gastroesophageal reflux, 

, bruxism, nocturnal asthma, and nocturnal cardiac arrhythmias. Sleep disturbances have figured prominently in descriptions of dissociative identity disorder, dissociative amnesia, and other disorders. Specifically, sleep disturbances have figured prominently in descriptions of posttraumatic stress disorder; they include initial insomnia, sleep discontinuity with increased arousal, limb movements, night terrors, nightmares, and even purposeful behavior, which can result in injury to a bed partner when a threat is perceived. Other rare but relevant disorders with sleep-related manifestations that can confound psychiatrists include sleep-related epilepsy, exploding head syndrome, dementia with Lewy bodies, and other brain pathology (peduncular hallucinosis).

is an associate professor of psychiatry at the University of Minnesota Medical School and a staff psychiatrist at the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center, Minneapolis. He is co-chairman of the committee on parasomnias for the upcoming revisions of the International Classification of Sleep Disorders.

is a clinical professor in the Department of Psychiatry at the University of Oklahoma.

1. Hurwitz TD, Schenck CH, Khawaja IS. Parasomnias: what psychiatrists need to know. 

™. 2015;32(9). Updated March 2021. Accessed November 10, 2021. 

https://www.psychiatrictimes.com/view/parasomnias-what-psychiatrists-need-know

Parasomnias: Fast Facts

Patients can experience sleep dysfunction due to many different physical, psychiatric, and psychological causes. Being an adult victim of peer victimization is one of the causes that is becoming more recognized in the medical literature as a source of patient distress and health risks. The terminology to define this type of experience is inconsistent and vague, and it can be described as being a victim of bullying, intimidation, harassment, narcissist abuse, or being a part of frenemy relationships.

 Generally, the intensity is defined as mild to moderate, and it is seen as a recurrent behavior. There is not an established screening tool that is used to identify adult recipients of peer victimization, and some patients might not consciously consider it a cause of their health issues. In fact, some patients may not recognize 

sleep as the source of their health issues

 that can occur as a result of this type of experience may include various patterns of insomnia.

 This may lead to an increased need for sleep or can cause daytime symptoms of sleep deprivation, such as anxiety, irritability, and hunger. A large Scandinavian survey that included public and private sector employees specifically noted that participants who were defined as victims of bullying reported waking up during sleep and experiencing a lack of restful sleep.

Traditionally, patients and physicians consider bullying to be a childhood problem. Adult peer bullying can occur in the workplace, in social settings, and in family situations. It is loosely defined as a recurrent pattern in which 1 or more people demonstrates power through actions such as belittling, insulting, embarrassing, dividing work or compensation unfairly, and more. One particular type that has been described is the indirect experience in which a person becomes confused about whether someone is their friend or not due to inconsistent patterns of behavior.

 The effects of peer victimization can vary depending on many factors, including the recipient’s baseline coping mechanisms, the level of connection they had anticipated to have with their peers, the naturally expected duration of exposure, and the estimated future need for contact. Workplace bullying has been found to affect witnesses, people who personally experience the behavior frequently, and people who experience the behavior infrequently. Those who experience the behavior more frequently are more likely to experience disturbances outside of work, such as sleeping problems.

Interestingly, a unique study published in 

 noted that participants who were found to have the miR-146a GG genotype were more likely to experience associated distress and insomnia when they were exposed to negative social acts in the workplace. While the results were unique, the researchers suggested that the genetic variability of the participants could affect the response of the hypothalamus and functions of the autonomic nervous system that play a role in 

, distress, and sleep. They also noted that this gene mediates actions of the innate immune response.

 An interplay between the immune response and autonomic nervous system is noted in many medical conditions, which could have further implications.

Managing sleeping problems requires a comprehensive approach to diagnosis and intervention. The treatment of sleep impairment that is associated with adult bullying may be more effective if it is focused on the emotional and behavioral aspects, rather than pharmacologic therapies, such as 

, anxiolytics, or antidepressants. Certainly, adult peer victimization that has a substantial effect on a patient can pose complex challenges in terms of medical treatment.

The initial step of awareness and defining the problem can help direct the discussion so that patients can express their preference for which approaches they would like to consider for managing the problem. Physicians can directly offer reassurance that the patient’s experience is not uncommon, and that the experience is recognized as a cause of distress, even among health care professionals.

 Strategies for patient support and symptom management may include individual therapy and direction to consider participating in a support group. Goals can include learning ways to avoid the external cause of distress. Patients may also benefit from follow-up to monitor changes in sleep patterns and the cause of the sleep problems.

is associate editor, humanities in Neurology; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Frenemy: a new addition to the bullying circle.

2. Nielsen MB, Pallesen S, Einarsen SV, et al. 

Associations between exposure to workplace bullying and insomnia: a cross-lagged prospective study of causal directions.

3. Hansen ÅM, Gullander M, Hogh A, et al. 

Workplace bullying, sleep problems and leisure-time physical activity: a prospective cohort study.

4. Hansen AM, Hogh A, Garde AH, Persson R. 

Workplace bullying and sleep difficulties: a 2-year follow-up study

5. Rajalingam D, Jacobsen DP, Nielsen MB, et al. 

Exposure to workplace bullying, distress, and insomnia: the moderating role of the miR-146a genotype.

6. Alshawush K, Hallett N, Bradbury-Jones C. 

The impact of transition programmes on workplace bullying, violence, stress and resilience for students and new graduate nurses: a scoping review.

Peer victimization can cause patient distress and health risks, including issues with sleep. 

Adult Bullying and Sleeping Problems

Most patients are well aware that anxious thoughts at bedtime can keep them up at night. Recent research also shows that it is not just nighttime thoughts that interfere with sleep—daytime thoughts can interfere with sleep as well. Additionally, anxious thoughts involve several distinct features. Worry and rumination are specific types of anxious thoughts. While they often coexist and have some similar features, worry and rumination are not the same, and they each independently impact 

Patients often do not seek professional help for managing anxious thoughts. However, many patients do seek help to get treatment for symptoms of fatigue, sleepiness, low energy, and other effects of sleep deprivation. While these issues can be caused by medical problems that should be ruled out, like anemia and heart disease, insufficient sleep due to insomnia is a common cause of daytime symptoms.

Daytime sleepiness caused by insomnia can manifest with difficulty concentrating, diminished ability to multitask, impaired emotional regulation, and falling asleep during activities such as meetings and driving. Objective sleep measures may also reflect shortened daytime sleep latency.

A research study involving 459 adults published in 

 considered worry and rumination as 2 separate constructs, a distinction that had been established in previous literature. Worry is thinking about future events that may have undesirable outcomes, particularly if there are factors that a person may not be able to control. Rumination involves recurrent negative thoughts and can include repeatedly thinking about problems or events (usually negative events), especially those that have happened in the past and cannot be changed. Using patient self-reports, the researchers found that each of these factors individually contributes to daytime sleep-related impairment. Furthermore, analysis specifically showed that worry was a predictor of sleep disturbance, and that rumination predicted sleep-related daytime impairment.

 This suggests that each of these may have a different impact on patients’ 

, and that each is important enough to be addressed independently.

 is thought to be associated with nighttime thoughts. However, daytime worry and rumination may affect sleep as well. A small research study involving 27 insomnia patients and 20 healthy controls published in 

 found a significant relationship between daytime levels of repetitive thought and participants’ sleep using objective sleep measures obtained by polysomnography. The researchers reported that heightened worry levels were related to an augmented wake after sleep onset and a diminished total sleep time, reduced sleep efficiency, and lower percentage of REM sleep. They also found that rumination was associated with an increase of sleep latency and a decrement of sleep efficiency.

The impact of daytime thoughts on nighttime sleep suggests that strategies for reducing worry and rumination at the time of sleep might not be enough to alleviate insomnia. To have a greater impact, strategies to reduce worry and rumination can also address the problems of anxious daytime thoughts. Several approaches are used to manage worry and rumination. Habits that help with problem solving and with providing a frequent sense of closure can reduce rumination and worry and may help alleviate anxious daytime thoughts. Additionally, rumination-focused cognitive behavioral therapy can be administered by a qualified therapist. This can relieve symptoms of rumination and has been used as a treatment for different age groups.

 Treatments using a mobile app may be effective for helping patients who have these problems as well.

In general, worry and rumination are not uncommon, and they can affect patients who do not have a psychiatric condition. Most patients recognize the effects of nighttime anxious thoughts on their sleep. But the impact of daytime 

 on sleep are not as well-known and are often ignored in the management of insomnia. For many patients, awareness of this interaction is a first step in alleviating the problem. The key component to resolving the issue is to provide patients with tools to help them manage their recurrent thoughts during both their waking hours and their sleeping hours. This often involves instruction and therapy, as it can be difficult for patients who are experiencing anxious thoughts to create solutions in the midst of anxiety-provoking circumstances, or when they are distracted by recurrent thoughts.

is associate editor, Humanities in Neurology; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Worry and rumination have distinct associations with nighttime versus daytime sleep symptomology.

2. Galbiati A, Giora E, Sarasso S, et al. 

Repetitive thought is associated with both subjectively and objectively recorded polysomnographic indices of disrupted sleep in insomnia disorder.

Guided, internet-based, rumination-focused cognitive behavioural therapy (i-RFCBT) versus a no-intervention control to prevent depression in high-ruminating young adults, along with an adjunct assessment of the feasibility of unguided i-RFCBT

, in the REducing Stress and Preventing Depression trial (RESPOND): study protocol for a phase III randomised controlled trial. 

Reducing worry and rumination in young adults via a mobile phone app: study protocol of the ECoWeB (Emotional Competence for Well-Being in Young Adults) randomised controlled trial focused on repetitive negative thinking.

Recent research shows that daytime thoughts can interfere with sleep just as much as nighttime thoughts. 

Daytime Negative Thoughts Have an Impact on Sleep 

Sleep complaints are common among older adults.

 Such complaints may reflect their concerns about normative age-related changes in sleep, such as reduced total sleep time, lighter sleep, and increased wakefulness at night,

 as well as the prevalence of common sleep disorders in late life, including sleep-disordered breathing and chronic insomnia. 

 displays common sleep disorders in older adults and associated risk factors and correlates.

Sleep-disordered breathing describes respiratory events that occur during sleep, ranging from simple snoring to pathological hypopneas (decreased air flow) and/or apneas (temporary breathing cessation). Obstructive sleep apnea (OSA) is defined as the apnea-hypopnea index (average hypopnea and apnea events rate per hour) being above 5. The general prevalence rate of OSA is approximately 22% in men and 17% in women, and it increases with age.

 Chronic insomnia, characterized by difficulties initiating and maintaining sleep, is also prevalent in the older population, with estimates of insomnia symptoms close to 50%, although estimates of insomnia diagnosis are variable.

Both OSA and chronic insomnia are linked with various psychiatric concerns. OSA is associated with increased risks of vascular dementia, Alzheimer disease,

 Insomnia is also associated with the onset of depression, anxiety, alcohol abuse, and psychosis.

 Sleep disturbances may potentiate symptoms of mental illness via several mechanisms: disruptions of memory consolidation processes that normally occur during sleep; increases in irritability and fatigue; and negative impacts on cognitive function.

It is important to note the bidirectional relationship between sleep disorders and psychiatric disorders in older adults. That is, psychiatric disorders can be both the cause and consequence of sleep disturbances. Therefore, the challenge is to determine whether sleep disruption should be the primary target for intervention or whether there are also comorbid psychiatric symptoms that need to be addressed for treatment to be successful.

It is helpful to start with a detailed history regarding the nature of the patient’s sleep complaints, other areas of functioning, and any other comorbid conditions that might be impacting their sleep. It can be helpful to walk through a typical 24-hour period to review sleep problems in greater detail, including onset, duration, frequency of disturbances, and possible contributions of sleep environment (eg, temperature, noise, etc). A sleep diary can also provide a sampling of a typical week of sleep. Reported sleep difficulties often have daytime consequences, so it is important to ask about their daytime behaviors (eg, napping, canceling plans) used to counteract or cope with perceived and real sleep loss. This information sheds light on the patient’s relationship with their sleep, including whether sleep impacts their ability to function and their level of concern surrounding the possible downstream effects of sleep loss. The 

Medical conditions, medications, pain level, and alcohol or drug use should be discussed, as these factors can adversely affect sleep. 

 shares screening measures that are useful for gathering information about other contributing factors to poor sleep, including possible comorbid sleep disorders.

 For example, the Pittsburgh Sleep Quality Index, a global measure of sleep quality, may help identify the presence of potential sleep disturbance due to medical comorbidities (eg, pain, waking to use bathroom), psychiatric comorbidities (eg, nightmares), and use of sleep medications, including over-the-counter sleep medications. Furthermore, assessment of daytime sleepiness and screening for sleep apnea may be helpful to determine whether a sleep study is needed.

To make a diagnosis of OSA, home study (level 3 study) or in-lab polysomnography (PSG; level 1 sleep study) are required. In-lab polysomnography is considered a gold-standard sleep study; home study is less accurate because fewer sensors are involved.

 Home study is usually indicated for the confirmation of OSA diagnosis in patients with a high pretest probability of OSA. In-lab PSG is recommended for patients with comorbidities such as congestive heart failure, chronic lung disease, or neurologic conditions.

Finally, it is crucial to ask the patient what they are currently doing to manage their symptoms and their level of optimism around efforts to help. This information will be helpful in designing a treatment plan that not only improves the quality and quantity of their sleep, but also addresses the psychological impact through psychoeducation, support, and problem solving.

Obstructive sleep apnea. Positive airway pressure (PAP), a device that helps keep the airway open during sleep through a stream of compressed air, is the first-line medical treatment for moderate or severe sleep apnea. Several types of PAP devices exist; the most commonly used is continuous PAP, and other advanced options include bilevel PAP. For individuals with difficulty adhering to PAP use, other treatment options can be considered, including oral appliances (eg, mandibular advancement devices) and surgical options (either soft or hard tissue surgery or implantation of a nerve stimulation device). Improvements in sleep quality, daytime symptoms, and cognitive functions are often observed when OSA is adequately addressed.

Chronic insomnia: pharmacological approaches. There are several US Food and Drug Administration-approved prescription hypnotics for insomnia, including benzodiazepines (eg, estazolam, temazepam), nonbenzodiazepines (eg, eszopiclone, zolpidem), melatonin receptor agonists (eg, ramelteon), orexin/hypocretin receptor antagonists (eg, suvorexant), and an antihistamine (doxepin). Other pharmacological drugs with sedating effects that are commonly prescribed for sleep include trazodone, mirtazapine, gabapentin; other sedative antipsychotics include quetiapine. However, many sedative hypnotics have negative side effects. Benzodiazepines, in particular, are not recommended for late-life insomnia due to their increased risks of cognitive impairment and falls.

 Nonpharmacological approaches are therefore regarded as the first line of treatment for insomnia, as they have been found to be more effective, with minimal side effects.

Nonpharmacological approaches. Cognitive behavioral therapy for insomnia (CBTI) is an evidence-based, multicomponent therapy that is recommended as the first line of treatment for insomnia, with strong empirical support for the general population

 In the context of medical and psychiatric comorbidities, CBTI was found to improve sleep and comorbid psychiatric symptoms.

 To optimize CBTI for older adults with comorbid psychiatric symptoms, 

 illustrates CBTI intervention components as well as adaptation considerations for older adults

 and modifications in the context of comorbid depression and anxiety.

For older adults with psychiatric comorbidities, additional modifications may be warranted. Depressive symptoms, such as low motivation and energy, may be associated with lower adherence in the behavioral recommendations of CBTI, highlighting the need for motivational enhancement strategies. Incorporating positive mood strategies into CBTI, such as behavioral activation (eg, daily pleasant activity scheduling), cognitive reframing (eg, thought records focusing on depression-related thoughts), and positive affirmation (eg, positive data logs and cue cards), could all help address comorbid insomnia and depression.

For older adults who have anxiety, considerations include assessing sleep anxiety, as certain CBTI strategies may become less effective among those who are significantly anxious about sleep. For example, sleep restriction, intended to promote sleep drive, may be less effective in consolidating sleep due to heightened arousal levels masking sleep drive.

 To address heightened arousal at night, there may be benefits in introducing relaxation exercises (eg, diaphragmatic breathing or progressive muscle relaxation) and other cognitive-behavioral strategies for managing anxiety (eg, constructive worry).

More research is needed to better understand whether to treat these comorbid conditions sequentially or concurrently in order to optimize treatment outcomes for both sleep and psychiatric symptoms. Recent data support further development of transdiagnostic treatments that concurrently target common cognitive, behavioral, and biological underpinnings across psychiatric disorders, such as sleep disturbances. One example is the Transdiagnostic Sleep and Circadian Intervention, a transdiagnostic treatment targeting sleep and circadian problems for individuals with comorbid psychiatric disorders.

 This approach is informed by CBTI and other circadian optimization strategies. Although more studies on transdiagnostic treatments are underway, CBTI is appropriate for older adults with comorbid insomnia and psychiatric disorders.

Sleep disturbance often co-occurs among older adults with psychiatric symptoms and disorders. A thorough assessment, looking at difficulty initiating and maintaining sleep, daytime sleepiness/dysfunction, and other physical markers (eg, snoring), will help providers identify the presence of sleep disorders, such as OSA or chronic insomnia, that co-occur with psychiatric conditions. Modifications can optimize the treatment of sleep disturbance in the presence of such psychiatric conditions as depression and anxiety.

Appropriate treatment is essential, as the long-term consequences of not addressing sleep disturbances may be severe. Interactions between sleep disruption and mental health symptoms even may set into motion a cascade of neurodegeneration that can ultimately lead to dementia.

 Mood disorders also increase risk of dementia, potentially through accelerated brain aging from stress exposure that leads to pathological changes in the brain, termed the brain-age gap. Sleep disturbances may constitute a type of stressor that increases the brain-age gap. Treatment of these common, yet complex, patients with evidenced-based methods is essential to improving their symptoms, quality of life, and brain health.

is a clinical assistant professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

is an instructor (affiliated) in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. She is a research health science specialist in the Veterans Administration (VA) Palo Alto Health Care System. 

is a clinical professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. 

 is a clinical associate professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

is associate director for education and evaluation at the VA Palo Alto Health Care System’s Geriatric Research, Education, and Clinical Center. She is also a clinical assistant professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

Dr Juang is a member of the advisory board for Koko. Dr Gould receives research funding from Meru Health, Inc. None of the other authors have any disclosures to report.

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