Subhajit Chakravorty

Habitual sleep duration associated with self-reported and objectively determined cardiometabolic risk factors

BACKGROUND Self-reported short or long sleep duration has been associated with adverse cardiometabolic health outcomes in laboratory and epidemiologic studies, but interpretation of such data has been limited by methodologic issues. METHODS Adult respondents of the 2007-2008 US National Health and Nutrition Examination Survey (NHANES) were examined in a cross-sectional analysis (N=5649). Self-reported sleep duration was categorized as very short (<5 h), short (5-6 h), normal (7-8 h), or long (≥9 h). Obesity, diabetes mellitus (DM), hypertension, and hyperlipidemia were objectively assessed by self-reported history. Statistical analyses included univariate comparisons across sleep duration categories for all variables. Binary logistic regression analyses and cardiometabolic factor as outcome, with sleep duration category as predictor, were assessed with and without covariates. Observed relationships were further assessed for dependence on race/ethnicity. RESULTS In adjusted analyses, very short sleep was associated with self-reported hypertension (odds ratio [OR], 2.02, [95% confidence interval {CI},1.45-2.81]; P<0.0001), self-reported hyperlipidemia (OR, 1.96 [95% CI, 1.43-2.69]; P<0.0001), objective hyperlipidemia (OR, 1.41 [95% CI, 1.04-1.91]; P=0.03), self-reported DM (OR, 1.76 [95% CI, 1.13-2.74]; P=0.01), and objective obesity (OR, 1.53 [95% CI, 1.03-1.43]; P=0.005). Regarding short sleep (5-6 h), in adjusted analyses, elevated risk was seen for self-reported hypertension (OR, 1.22 [95% CI, 1.02-1.45]; P=0.03) self-reported obesity (OR, 1.21 [95% CI, 1.03-1.43]; P=0.02), and objective obesity (OR, 1.17 [95% CI, 1.00-1.38]; P<0.05). Regarding long sleep (≥9 h), no elevated risk was found for any outcomes. Interactions with race/ethnicity were significant for all outcomes; race/ethnicity differences in patterns of risk varied by outcome studied. In particular, the relationship between very short sleep and obesity was strongest among blacks and the relationship between short sleep and hypertension is strongest among non-Hispanic whites, blacks, and non-Mexican Hispanics/Latinos. CONCLUSIONS Short sleep duration is associated with self-reported and objectively determined adverse cardiometabolic outcomes, even after adjustment for many covariates. Also, these patterns of risk depend on race/ethnicity.

Suicidal ideation in Veterans misusing alcohol: Relationships with insomnia symptoms and sleep duration

OBJECTIVE The aim of this investigation was to assess the relationships between suicidal ideation and insomnia symptoms in Veterans misusing alcohol. METHOD Data were extracted in this retrospective chart review of Veterans referred from primary care for a behavioral health evaluation (N=161) based on evidence of heavy drinking, drug use or another behavioral problem. Suicidal ideation (SI) was assessed using the Paykel questionnaire. Insomnia symptoms were assessed with standard diary questions in an interview format and pertained to sleep latency (SL), wake after sleep onset time (WASO), sleep quality (SQ), and habitual sleep duration (HSD). The relations between suicidal ideation and insomnia symptoms were assessed using ordinal regression analyses adjusted for socio-demographic, psychiatric and addiction-related variables. RESULTS Suicidal ideation was reported in 62 (39%) of the Veterans interviewed. In a multivariable model, only inadequate SQ was associated with suicidal ideation. Short sleepers were more likely to endorse suicidal ideation and have attempted suicide in the past year. In addition, older age, inadequate financial status, and the presence of a psychiatric disorder were also significantly associated with suicidal ideation in most of the adjusted models. CONCLUSION Given their association with suicidal ideation, insomnia symptoms in Veterans misusing alcohol should prompt an assessment of underlying psychiatric and social factors.

Covariates of Craving in Actively Drinking Alcoholics

The goal of this cross-sectional study was to assess the relationship of alcohol craving with biopsychosocial and addiction factors that are clinically pertinent to alcoholism treatment. Alcohol craving was assessed in 315 treatment-seeking, alcohol dependent subjects using the Penn Alcohol Craving Scale questionnaire. Standard validated questionnaires were used to evaluate a variety of biological, addiction, psychological, psychiatric, and social factors. Individual covariates of craving included age, race, problematic consequences of drinking, heavy drinking, motivation for change, mood disturbance, sleep problems, and social supports. In a multivariate analysis (R(2)= .34), alcohol craving was positively associated with mood disturbance, heavy drinking, readiness for change, and negatively associated with age. The results from this study suggest that alcohol craving is a complex phenomenon influenced by multiple factors.

Alcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders

Sleep-related complaints are widely prevalent in those with alcohol dependence (AD). AD is associated not only with insomnia, but also with multiple sleep-related disorders as a growing body of literature has demonstrated. This article will review the various aspects of insomnia associated with AD. In addition, the association of AD with other sleep-related disorders will be briefly reviewed. The association of AD with insomnia is bidirectional in nature. The etiopathogenesis of insomnia has demonstrated multiple associations and is an active focus of research. Treatment with cognitive behavioral therapy for insomnia is showing promise as an optimal intervention. In addition, AD may be associated with circadian abnormalities, short sleep duration, obstructive sleep apnea, and sleep-related movement disorder. The burgeoning knowledge on insomnia associated with moderate-to-severe alcohol use disorder has expanded our understanding of its underlying neurobiology, clinical features, and treatment options.

Daytime Sleepiness: Associations with Alcohol Use and Sleep Duration in Americans

The aim of the current analysis was to investigate the relationship of daytime sleepiness with alcohol consumption and sleep duration using a population sample of adult Americans. Data was analyzed from adult respondents of the National Health and Nutritional Examination Survey (NHANES) 2007-2008 (N = 2919) using self-reported variables for sleepiness, sleep duration, and alcohol consumption (quantity and frequency of alcohol use). A heavy drinking episode was defined as the consumption of ≥5 standard alcoholic beverages in a day. Logistic regression models adjusted for sociodemographic variables and insomnia covariates were used to evaluate the relationship between daytime sleepiness and an interaction of alcohol consumption variables with sleep duration. The results showed that daytime sleepiness was reported by 15.07% of the subjects. In univariate analyses adjusted for covariates, an increased probability of daytime sleepiness was predicted by decreased log drinks per day [OR = 0.74 (95% CI, 0.58–0.95)], a decreased log drinking frequency [0.90 (95% CI, 0.83–0.98)], and lower sleep duration [OR = 0.75 (95% CI, 0.67–0.84)]. An interaction between decreased sleep duration and an increased log heavy drinking frequency predicted increased daytime sleepiness (P = 0.004). Thus, the effect of sleep duration should be considered when evaluating the relationship between daytime sleepiness and heavy drinking.

The effects of quetiapine on sleep in recovering alcohol-dependent subjects: a pilot study.

Objective The aim of this hypothesis-generating pilot study was to assess prospectively the objective and subjective effects of treatment with quetiapine XR on sleep during early recovery from alcohol dependence (AD). Methods Recovering subjects with AD and sleep disturbance complaints were treated with quetiapine XR (n = 10) or matching placebo pills (n = 10) for 8 weeks. Polysomnography was used to assess sleep objectively, and the Insomnia Severity Index and Pittsburgh Sleep Quality Index were used to measure subjective insomnia. Other assessment measures included the 10-minute psychomotor vigilance task (for neurobehavioral functioning), the time-line follow-back measure (for alcohol consumption), the Penn Alcohol Craving Scale (for alcohol craving), the Patient Health Questionnaire-9 item scale (for depressive symptoms), and the Beck Anxiety Inventory (for anxiety symptoms). Results Although there was no effect of quetiapine XR on sleep efficiency (time spent asleep/total recording time), there was a pre-to-post reduction in wake after sleep onset time (P = 0.03) and nonsignificant trends for increases in sleep onset latency (SOL) and stage 2 sleep time. A time × drug interaction was seen for the subjective insomnia, such that quetiapine XR–treated subjects reported greater initial improvement in their subjective insomnia, but the difference was not sustained. There were no differences between treatment groups on other measures or medication compliance. Conclusion Quetiapine XR improves objective sleep continuity and transiently improves subjective insomnia early in recovery from AD.

Nocturnal Wakefulness as a Previously Unrecognized Risk Factor for Suicide.

OBJECTIVE Suicide is a major public health problem and the 10th leading cause of death in the United States. The identification of modifiable risk factors is essential for reducing the prevalence of suicide. Recently, it has been shown that insomnia and nightmares significantly increase the risk for suicidal ideation, attempted suicide, and death by suicide. While both forms of sleep disturbance may independently confer risk, and potentially be modifiable risk factors, it is also possible that simply being awake at night represents a specific vulnerability for suicide. The present analysis evaluates the frequency of completed suicide per hour while taking into account the percentage of individuals awake at each hour. METHODS Archival analyses were conducted estimating the time of fatal injury using the National Violent Death Reporting System for 2003-2010 and the proportion of the American population awake per hour across the 24-hour day using the American Time Use Survey. RESULTS The mean ± SD incident rate from 06:00-23:59 was 2.2% ± 0.7%, while the mean ± SD incident rate from 00:00-05:59 was 10.3% ± 4.9%. The maximum incident rate was from 02:00-02:59 (16.3%). Hour-by-hour observed values differed from those that would be expected by chance (P < .001), and when 6-hour blocks were examined, the observed frequency at night was 3.6 times higher than would be expected by chance (P < .001). CONCLUSIONS Being awake at night confers greater risk for suicide than being awake at other times of the day, suggesting that disturbances of sleep or circadian neurobiology may potentiate suicide risk.

Insomnia severity is associated with decreased executive functioning in patients with suicidal ideation and drug abuse.

To the Editor: Insomnia has been associated with decreased executive functioning in those without substance use disorders.1 Although numerous studies have linked impulsivity with substance abuse and suicidal ideation, its relationship with insomnia in the substance-abusing population is unclear.2–6 In this preliminary study, we explore the relationship of insomnia severity with objective and subjective impulsivity measured by computerized behavioral tests and a self-report questionnaire, respectively, in patients with suicidal ideation/behavior attending a psychiatric emergency department. We hypothesized that a higher insomnia severity would be associated with increased objective impulsivity (a decrease in executive functioning) and higher subjective impulsivity scores. Method. This investigation involved secondary analyses of cross-sectional data from an ongoing study (N.S., J.L.E., unpublished data, 2012). Subjects were adults (N = 21, ≤ 65 years of age) who presented with suicidal ideation/behavior between July 2012 and December 2012 to the emergency department, where they were observed until their symptoms stabilized. We excluded patients with any motor response, visual or hearing disorders, psychotic symptoms, or inability to read or comprehend English. The instruments used in this study included the following: The Stop-Signal Reaction-Time Task,7 which assesses objective impulsivity through response inhibition (a facet of executive functioning) based on correct responses and reaction times7,8; The UPPS Impulsive Behavior Scale,9 which is a 45-item self-report measure that assesses personality aspects of subjective impulsivity (the “S” sensation-seeking component was excluded in this protocol); The sleep question from the Center for Epidemiology Studies-Depression Scale (CES-D),10 which assesses insomnia by inquiring, “Over last week, my sleep was restless….” with the responses arrayed as “less than a day,” “1–2 days,” “3–4 days,” and “5–7 days.” The responses were categorized into “frequent” (ie, those with restless sleep for ≥ 5 nights/wk) or “infrequent” (those with ≤ 4 nights/wk) insomnia on the basis of the distribution of responses, clinical significance, and similarity to analyses from prior literature11; The remaining CES-D items, which assess depressive symptoms. The institutional review board approved the study, and subjects signed informed consent prior to participation. Results. The demographic variables included the following: the mean age was 38.3 (SD = 10.1) years, 18 (85.7%) identified themselves as African American, 18 (85.7%) were male, 9 (42.9%) were single, 16 (76.2%) were unemployed, 8 (38.1%) had ≥ 12 years of education, and 12 (57.1%) reported being homeless. Urine drug screens at admission were positive in 14 (66.7%) for cocaine, 6 (28.6%) for cannabis, 5 (23.8%) for phencyclidine, 4 (19.0%) for sedative-hypnotic medications, and 3 (14.3%) for opioids. Four subjects (19.0%) reported use of only 1 drug (cocaine). Subjects with frequent insomnia had significantly higher CES-D scores. In analyses adjusted for demographic and mood covariates, those with frequent insomnia (as compared to those with infrequent insomnia) had a significantly decreased number of correct responses and a higher mean reaction time at 160 ms. Similarly, a higher reaction time was seen at 320 ms for this group, although this was not statistically significant. Those with frequent insomnia (in comparison to those with infrequent insomnia) had nonsignificantly lower scores on the UPPS impulsivity scales (see Table 1). Table 1 Measures of Impulsivity Across Insomnia Groups The limitations associated with this preliminary study include the lack of a formal standardized insomnia rating instrument, the small sample size, and its cross-sectional nature. Despite the limitations, we observed that frequent sleep impairment was associated with a lower response inhibition on the Stop Signal Reaction Time Task without any difference in the personality aspects of impulsivity in this complex sample. These results suggest that improving sleep in this population might help improve mood and executive functioning and thus reduce the likelihood of behaviors precipitating visits to the emergency department. Future studies should assess for subjective and objective insomnia using standardized instruments and expand the range of impulsivity facets being assessed.

Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed

Journal of Clinical Sleep Medicine, Vol. 13, No. 8, 2017 Insomnia is likely the most common sleep disorder, with population estimates generally showing that approximately 10% of the United States population meets criteria for an insomnia disorder.1 This prevalence is even higher in the Veteran population with an estimate of 26%.2 Insomnia is a major risk factor for neuropsychiatric disorders,3 suicide,4 cardiometabolic disease risk,5 and all-cause mortality.6 It is frequently comorbid with psychiatric, chronic medical and addictive disorders, conditions commonly reported in the Veteran population. Fortunately, efficacious and effective treatments exist, most notably cognitive behavioral therapy for insomnia (CBT-I),7 which is the recommended first-line treatment for the disorder,8 even in the context of comorbidities.9 Efficacious medication regimens also exist when CBT-I is not available.10 Although other sleep disorders such as sleep apnea and narcolepsy are typically referred for treatment by sleep medicine specialists, insomnia is often neglected or dealt with in the context of primary care. This can potentially lead to problems, because primary care clinicians often lack training regarding importance, screening, assessment, and management of insomnia. The Veterans Affairs (VA) network is an especially salient context to examine the diagnosis and treatment of insomnia in the context of primary care. As an organization, the VA has made efforts and allocated resources to recognize the importance of mental health in the context of primary care, including those for insomnia. In addition, the VA has engaged a nationwide training and education program focused on insomnia diagnosis and treatment.11 It is with this information in mind that the paper by Ulmer and colleagues in this issue of Journal of Clinical Sleep Medicine explores the beliefs, attitudes, and behaviors of VA primary care clinicians regarding insomnia.12 Overall, the results of this study show that insomnia is frequently misreported or not reported in the medical record, on many occasions mishandled through provision of suboptimal care, and often just plain missed—not discussed or brought up at all. Ulmer and colleagues report that the plurality of clinicians surveyed believed that insomnia symptoms were experienced by 20% to 39% of their patients. Prior work by this group has shown that the prevalence of poor sleep quality may COMMENTARY

Sleep Duration and Insomnia Symptoms as Risk Factors for Suicidal Ideation in a Nationally Representative Sample

OBJECTIVE Suicidal behavior (suicidal ideation, suicide attempts, and suicide completion) has been increasingly linked with difficulty initiating sleep, maintaining sleep, and early morning awakenings. However, the relationship between suicidal behavior and sleep duration abnormalities is unclear, especially at the population level. The present study used a nationally representative sample to examine the association of suicidal ideation with extreme sleep durations and insomnia symptoms. METHOD Cross-sectional data from adult respondents (≥ 18 years of age, N = 6,228) were extracted from the 2007-2008 wave of the National Health and Nutritional Examination Survey. Ordinal logistic regression analyses were used to evaluate the relationship of suicidal ideation with sleep duration, global insomnia, and individual insomnia symptoms in models adjusted for sociodemographic, socioeconomic, and health-related covariates. RESULTS Suicidal ideation was associated with abnormalities of sleep duration. This relationship ceased to exist once the model was adjusted for depressive symptoms. As expected, an increased level of suicidal ideation was consistently associated with insomnia. Of the insomnia symptoms, difficulty maintaining sleep was found to be the most predictive of suicidal ideation, followed by difficulty initiating sleep (P< .05). CONCLUSIONS Abnormalities of sleep duration and continuity should prompt a clinical assessment for suicide risk.