Ngan Yin Chan

Eveningness and Insomnia: Independent Risk Factors of Nonremission in Major Depressive Disorder

BACKGROUND It is unclear whether there is an association between chronotype and nonremission of depression, and whether the association is related to the confounding effect of insomnia. METHOD A cohort of patients with major depressive disorder were assessed for chronotype (by Morningness-Eveningness Questinnaire [MEQ]), depressive symptoms, insomnia severity and clinical outcomes in a naturalistic follow-up study. RESULTS Of the 253 recruited subjects (age 50.8 ± 10.2 y; female: 82.6%; response rate 90.0%), 19.4%, 56.1% and 24.5% patients were classified as eveningness, intermediate, and morningness, respectively. Evening-type subjects had higher insomnia severity, more severe depressive symptoms, and higher suicidality. Eveningness was associated with nonremission of depression with an odds ratio (OR) of 3.36 (95% confidence interval [CI] 1.35-8.34, P < 0.01), independent of insomnia severity. In addition, insomnia was an independent significant factor in contributing to nonremission of depression (OR = 1.12; 95% CI 1.05-1.19, P < 0.001). CONCLUSION The independent association of eveningness with nonremission of depression suggested a significant underpinning of circadian involvement in major depressive disorder. Our findings support the need for a comprehensive assessment of sleep and circadian disturbances as well as integration of sleep and chronotherapeutic intervention in the management of depression.

A School-Based Sleep Education Program for Adolescents: A Cluster Randomized Trial

OBJECTIVES: To evaluate the effectiveness of a multilevel and multimodal school-based education program. METHODS: A cluster randomized controlled trial with 14 secondary schools in Hong Kong and a total of 3713 students (intervention: 1545 vs control: 2168; 40.2% boys; mean age ± SD: 14.72 ± 1.53 years) were included in the final analysis. The intervention included a town hall seminar, small class workshops, a slogan competition, a brochure, and an educational Web site. Their parents and teachers were offered sleep education seminars. The control schools did not receive any sleep program. Data were collected before and 5 weeks after the intervention. RESULTS: The students in the intervention group had significantly improved sleep knowledge compared with the control group (mean difference: 3.64 [95% confidence interval (CI): 3.21 to 4.07]; Cohen’s d = 0.51) as measured by using a sleep knowledge questionnaire. Weekday sleep duration was reduced in both groups, and the significant difference in weekday sleep duration was lost in the intention-to-treat analysis (mean difference: 0:01 [95% CI: –0:00 to 0:04]). In addition, the intervention group had a lower incidence of consuming caffeine-containing energy drinks (adjusted odds ratio: 0.46 [95% CI: 0.22 to 0.99]) and had better behavioral (mean difference: –0.56 [95% CI: –1.02 to –0.10]; Cohen’s d = 0.13) and mental health (mean difference: –0.30 [95% CI: –0.15 to –0.46]; Cohen’s d = 0.11) outcomes. CONCLUSIONS: A school-based sleep education program was effective in enhancing sleep knowledge and improving behavioral and mental health, but it had no significant impact on sleep duration or pattern among adolescents.

Emergence of Sex Differences in Insomnia Symptoms in Adolescents: A Large-Scale School-Based Study

STUDY OBJECTIVES This study aimed to explore the moderation of pubertal status on the onset of sex differences in the prevalence of insomnia symptoms and their health correlates. METHODS A total of 7,507 children and adolescents (weighted percentage of female: 48.5%) aged between 6-17 y were recruited from thirty-one primary and secondary schools. Participants with difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), and/or early morning awakening (EMA) ≥ 3 times/week in the past month were considered as having insomnia symptoms. The severity of insomnia was measured by the Insomnia Severity Index (ISI). RESULTS The prevalence of insomnia symptoms increased from 3.4% to 12.2% in girls (3.6-fold) and from 4.3% to 9.1% in boys (2.1-fold) from Tanner stage 1 to 5. There was a significant interaction between sex and Tanner stage in the prevalence of insomnia (P < 0.001) with an emergence of female preponderance at Tanner stage 4 even after controlling for age, family income, and school start time. Similar sex-Tanner stage interactions were found in DIS, DMS, and ISI total score but not EMA. Insomnia symptoms were strongly associated with behavioral problems, poor mental health, and poor general health in both sexes. Boys with insomnia would report more maladaptive lifestyles (smoking, alcohol, and energy drinks) whereas girls with insomnia were more susceptible to emotional and relationship difficulties. CONCLUSIONS Pubertal maturation was associated with a progressive increase in the prevalence of insomnia symptoms with the emergence of female preponderance in both the prevalence and severity of insomnia symptoms at late puberty. CLINICAL TRIALS REGISTRATION Chinese Clinical Trial Register, http://www.chictr.org.cn, ID: ChiCTR-TRC-12002798.

Help-seeking behaviors for insomnia in Hong Kong Chinese: a community-based study

OBJECTIVES To determine the prevalence and correlates of help-seeking behaviors for insomnia in Hong Kong Chinese middle-aged adults and their offspring. METHODS A total of 2231 middle-aged adults (54.2% females, mean age 45.8 years) and 2186 children and adolescents (51.9% females, mean age 13.4 years) completed a questionnaire on insomnia symptoms, daytime functioning, health condition and treatments sought for insomnia. RESULTS A total of 40% of adults and 10% of children and adolescents with insomnia reported having sought treatment for insomnia. Conventional Western medicine was the commonly preferred treatment in 33.3% of adults and 13.3% of children and adolescents who sought help for insomnia, while a higher proportion of individuals with insomnia (34.5% of adults and 26.7% of children and adolescents) sought help from complementary and alternative medicine (CAM) therapies. Female gender (odds ratio [OR] [95% confidence interval, CI] = 2.14 [1.01-4.53]), higher family income (≥15,000 HKD/month) (OR [95% CI] = 3.15 [1.27-6.34]), severity of insomnia (Insomnia Severity Index ≥14) (OR [95% CI] = 2.12 [1.10-4.12]), chronic medications (OR [95% CI] = 4.71 [2.27-9.79]), and psychiatric disorders (OR [95% CI] = 2.83 [1.01-7.96]) were associated with help-seeking behaviors in adults. Presence of morning headache was associated with help-seeking behaviors in children and adolescents (OR [95% CI] = 8.66 [1.72-43.70]). CONCLUSIONS It is uncommon for Hong Kong Chinese to seek help for insomnia, despite the high prevalence of insomnia. The significant unmet need argues for timely intervention to promote sleep-health literacy and to enhance the awareness and accessibility of evidence-based treatment for insomnia.