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Sleep Initiation and Maintenance Disorders: HELP
Articles from University of Sydney
Based on 60 articles published since 2008
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These are the 60 published articles about Sleep Initiation and Maintenance Disorders that originated from University of Sydney during 2008-2019.
 
+ Citations + Abstracts
Pages: 1 · 2 · 3
1 Guideline Guidelines for sleep studies in adults - a position statement of the Australasian Sleep Association. 2017

Douglas, James A / Chai-Coetzer, Ching Li / McEvoy, David / Naughton, Matthew T / Neill, Alister M / Rochford, Peter / Wheatley, John / Worsnop, Christopher. ·The Prince Charles Hospital, Brisbane, Queensland, Australia. Electronic address: n.shillabeer@elsevier.com. · Adelaide Institute for Sleep Health, Flinders Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia; Sleep Health Service, Repatriation General Hospital, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia. · Mater Medical Centre, Brisbane, Queensland, Australia. · The Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia. · WellSleep Sleep Investigation Centre, University of Otago, New Zealand. · Institute of Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia. · Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; University of Sydney at Westmead Hospital, Sydney, NSW, Australia. ·Sleep Med · Pubmed #28648224.

ABSTRACT: -- No abstract --

2 Review A systematic review and meta-analysis of placebo versus no treatment for insomnia symptoms. 2018

Yeung, Valerie / Sharpe, Louise / Glozier, Nick / Hackett, Maree L / Colagiuri, Ben. ·University of Sydney, School of Psychology, Sydney, Australia. · University of Sydney, Brain and Mind Centre, Sydney Medical School, Sydney, Australia. · University of Sydney, The George Institute for Global Health, Sydney, Australia; Faculty of Health and Wellbeing, The University of Central Lancashire, Preston, United Kingdom. · University of Sydney, School of Psychology, Sydney, Australia. Electronic address: ben.colagiuri@sydney.edu.au. ·Sleep Med Rev · Pubmed #28554719.

ABSTRACT: This systematic review and meta-analysis aimed to determine the size of the placebo effect for insomnia symptoms when comparing placebo treatment with no treatment. PsycINFO, MEDLINE, and CINAHL databases were systematically searched for studies allocating participants with insomnia symptoms (diagnosed or self-reported) to receive a placebo that they were led to believe was an active treatment or to a no treatment control group. Thirteen independent studies (n = 566) met inclusion criteria. Meta-analysis indicated a reliable placebo effect whereby placebo treatment led to improved perceived sleep onset latency (SOL; Hedges g = 0.272), total sleep time (TST; Hedges g = 0.322), and global sleep quality (GSQ; Hedges' g = 0.581), when compared with no treatment. There was no effect on objective assessment of SOL, however only a few studies reported this outcome and there were insufficient sample sizes to meta-analyse other objective outcomes. Moderator analysis indicated that the placebo effect for perceived insomnia symptoms was quite consistent across different variables. The present findings provide strong evidence for placebo effects for perceived insomnia symptoms, but not on the only objective measurement with sufficient sample size to meta-analyse, namely objective SOL. This has important implications for the treatment of insomnia symptoms and the design and interpretation of clinical trials for insomnia symptoms.

3 Review Gender differences in obstructive sleep apnoea, insomnia and restless legs syndrome in adults - What do we know? A clinical update. 2018

Theorell-Haglöw, Jenny / Miller, Christopher B / Bartlett, Delwyn J / Yee, Brendon J / Openshaw, Hannah D / Grunstein, Ronald R. ·CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia; Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Sweden. Electronic address: jenny.theorell-haglow@medsci.uu.se. · CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia. ·Sleep Med Rev · Pubmed #28495359.

ABSTRACT: Research in sleep medicine over the last decades has involved a broad variety of sleep disorders in both men and women. Gender differences have been identified in sleep physiology as well as in the three most common sleep disorders: obstructive sleep apnoea (OSA), insomnia and restless legs syndrome (RLS). However, research on gender differences in sleep medicine appears limited. This clinical review aims to give an updated overview of gender differences, in relation to prevalence, clinical presentation, treatment and quality of life in OSA, insomnia and RLS. Future research directions in the adult population will also be discussed.

4 Review A systematic review of interventions to deprescribe benzodiazepines and other hypnotics among older people. 2017

Reeve, Emily / Ong, Magdalene / Wu, Angela / Jansen, Jesse / Petrovic, Mirko / Gnjidic, Danijela. ·Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, Australia. emily.reeve@sydney.edu.au. · Aging and Pharmacology, Royal North Shore Hospital, Level 12 Kolling Building, St Leonards, NSW, Australia. emily.reeve@sydney.edu.au. · Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Sydney, Australia. · Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia. · Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), The University of Sydney, Sydney, NSW, 2006, Australia. · Department of Internal Medicine, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. ·Eur J Clin Pharmacol · Pubmed #28456823.

ABSTRACT: PURPOSE: Benzodiazepines are effective medicines for insomnia and anxiety but are commonly used beyond recommended treatment time frames, which may lead to adverse drug events. The aim of this systematic review was to critically evaluate the success of interventions used to reduce benzodiazepines and 'Z-drug' use, and the impact of these interventions on clinical outcomes in older adults. METHODS: A search was conducted in PubMed, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsychINFO, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL. Studies conducted in older adults (≥65 years) and published between January 1995 and July 2015 were included. Two authors independently reviewed all articles for eligibility and extracted the data. RESULTS: Seven studies of benzodiazepines and Z-drug withdrawal were identified. Benzodiazepine discontinuation rates were 64.3% in one study that employed pharmacological substitution with melatonin and 65.0% in a study that employed general practitioner-targeted intervention. Mixed interventions including patient education and tapering (n = 2), pharmacological substitution with psychological support (n = 1) and tapering with psychological support (n = 1) yielded discontinuation rates between 27.0 and 80.0%. Five studies measured clinical outcomes following benzodiazepine discontinuation. Most (n = 4) observed no difference in prevalence of withdrawal symptoms or sleep quality, while one study reported decline in quality of life in those who continued taking benzodiazepine vs. those who discontinued over 8 months. CONCLUSIONS: Current evidence shows that benzodiazepine withdrawal is feasible in the older population, but withdrawal rates vary according to the type of intervention. As the benefits and sustainability of these interventions are unclear, further studies should be conducted to assess this.

5 Review Heart rate variability in insomnia patients: A critical review of the literature. 2017

Dodds, Kirsty L / Miller, Christopher B / Kyle, Simon D / Marshall, Nathaniel S / Gordon, Christopher J. ·Sydney Nursing School, University of Sydney, Australia; CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, NSW, Australia. · CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Australia. · Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, England, UK. · Sydney Nursing School, University of Sydney, Australia; CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, NSW, Australia. Electronic address: christopher.gordon@sydney.edu.au. ·Sleep Med Rev · Pubmed #28187954.

ABSTRACT: Heart rate variability (HRV) is an objective marker that provides insight into autonomic nervous system dynamics. There is conflicting evidence regarding the presence of HRV impairment in insomnia patients. Web-based databases were used to systematically search the literature for all studies that compared the HRV of insomnia patients to controls or reported the HRV of insomnia patients before and after an intervention. 22 relevant papers were identified. Study characteristics were summarised, HRV measures were extracted and a risk of bias assessment for each study was performed. We were limited in our ability to synthesise outcome measures and perform meta-analyses due to considerable differences in patient (and control) selection, study protocols, measurement and processing techniques and outcome reporting. Risk of bias was deemed to be high in the majority of studies. As such, we cannot confirm that HRV is reliably impaired in insomnia patients nor determine the HRV response to interventions. Whilst HRV impairment in insomnia is a widely accepted concept, it is not supported by empirical evidence. Large longitudinal studies incorporating 24-hour recordings are required to elucidate the precise nature of HRV dynamics in insomnia patients.

6 Review Exercise as an alternative treatment for chronic insomnia (PEDro synthesis). 2017

Milne, Stephen / Elkins, Mark R. ·Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia. · Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia. · Centre for Evidence-Based Physiotherapy, The George Institute for Global Health, Sydney, New South Wales, Australia. ·Br J Sports Med · Pubmed #27198542.

ABSTRACT: -- No abstract --

7 Review Insomnia in Chinese Medicine: The Heart of the Matter. 2016

O'Brien, Kylie / Weber, Daniel. ·1 Integrative Chinese Medicine, National Institute of Integrative Medicine , Hawthorn, Australia . · 2 College of Health and Biomedicine, Victoria University , Footscray, Australia . · 3 Torrens University , Adelaide, Australia . · 4 National Institute of Complementary Medicine, Western Sydney University , Sydney, Australia . · 5 Tianjin University of Traditional Chinese Medicine , Tianjin, People's Republic of China . ·J Altern Complement Med · Pubmed #27526331.

ABSTRACT: Chronic insomnia affects a significant proportion of the general population worldwide, and is associated with several serious medical conditions. From the Western scientific literature, hyper-arousal (on the cognitive-emotional, behavioral, autonomic, or central nervous system level) is a final common pathway involved in its pathogenesis. However, from a Chinese medicine (CM) perspective, it is the Heart, capitalized to denote the functional system as described in CM theory, that is the key organ involved in insomnia due to its role as the "seat of consciousness." This article explores how insomnia is understood from the CM perspective, in particular the role of the Heart, and some of the neurophysiological evidence that supports these ancient theoretical understandings. The potential role of the vagus nerve and its relationship with the (biomedical) heart and CM Heart is also examined. Finally, some of the evidence in association with mechanisms of action of acupuncture in insomnia, in particular its impact on cardiovascular variables associated with insomnia, is presented, along with findings of systematic reviews.

8 Review Towards standardisation and improved understanding of sleep restriction therapy for insomnia disorder: A systematic examination of CBT-I trial content. 2015

Kyle, Simon D / Aquino, Maria Raisa Jessica / Miller, Christopher B / Henry, Alasdair L / Crawford, Megan R / Espie, Colin A / Spielman, Arthur J. ·School of Psychological Sciences, University of Manchester, UK. Electronic address: simon.kyle@manchester.ac.uk. · School of Health Sciences, City University London, UK. · Woolcock Institute of Medical Research, University of Sydney, Australia. · Institute of Inflammation & Repair, University of Manchester, UK. · Rush University Medical Center, Chicago, USA. · Sleep & Circadian Neuroscience Institute, University of Oxford, UK. · Weill Cornell Medical College, Center for Sleep Medicine, NY, USA. ·Sleep Med Rev · Pubmed #25771293.

ABSTRACT: Sleep restriction therapy is a core element of contemporary cognitive-behavioural therapy for insomnia and is also effective as a single-component therapeutic strategy. Since its original description, sleep restriction therapy has been applied in several different ways, potentially limiting understanding of key therapeutic ingredients, mode of action, evidence synthesis, and clinical implementation. We sought to examine the quality of reporting and variability in the application of sleep restriction therapy within the context of insomnia intervention trials. Systematic literature searches revealed 88 trials of cognitive-behavioural therapy/sleep restriction therapy that met pre-defined inclusion/exclusion criteria. All papers were coded in relation to their description of sleep restriction therapy procedures. Findings indicate that a large proportion of papers (39%) do not report any details regarding sleep restriction therapy parameters and, for those papers that do, variability in implementation is present at every level (sleep window generation, minimum time-in-bed, sleep efficiency titration criteria, and positioning of sleep window). Only 7% of papers reported all parameters of sleep restriction treatment. Poor reporting and variability in the application of sleep restriction therapy may hinder progress in relation to evidence synthesis, specification of mechanistic components, and refinement of therapeutic procedures for patient benefit. We set out guidelines for the reporting of sleep restriction therapy as well as a research agenda aimed at advancing understanding of sleep restriction therapy.

9 Review Bidirectional interactions between the baroreceptor reflex and arousal: an update. 2015

Silvani, Alessandro / Calandra-Buonaura, Giovanna / Benarroch, Eduardo E / Dampney, Roger A L / Cortelli, Pietro. ·PRISM lab, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy. · Autonomic Unit, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Bologna Institute of Neurological Sciences, Bologna, Italy. · Department of Neurology, Mayo Clinic, Rochester, MN, USA. · School of Medical Sciences (Physiology) and Bosch Institute for Biomedical Research, University of Sydney, Australia. · Autonomic Unit, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Bologna Institute of Neurological Sciences, Bologna, Italy. Electronic address: pietro.cortelli@unibo.it. ·Sleep Med · Pubmed #25616389.

ABSTRACT: Studies involving genetic engineering on animal models and mathematical analysis of cardiovascular signals on humans are shedding new light on the interactions between the arterial baroreceptor reflex (baroreflex) and arousal. Baroreceptor stimulation, if very mild or performed under anaesthesia, may inhibit cortical arousal. However, substantial increases or decreases in baroreflex activation cause arousal in animal models and human subjects in physiological conditions. On the other hand, cardiovascular changes during autonomic arousals and between the states of wakefulness and sleep involve changes in the baroreflex set point and balance with central autonomic commands. Neural connectivity and functional data suggest that the nucleus of the solitary tract, adrenergic C1 neurons of the medulla, and the parabrachial nucleus of the pons mediate the bidirectional interactions between the baroreflex and arousal. These interactions may constitute a positive feedback loop that facilitates sharp and coordinated brain state and autonomic transitions upon arousal: upon arousal, central autonomic commands may increase blood pressure, thereby loading baroreceptors and further increasing arousal. Anomalies of this feedback loop may play a role in the pathophysiology of disease conditions associated with cardiovascular and sleep-wake cycle alterations. These conditions include: obstructive sleep apnoea syndrome, with its association with excessive daytime sleepiness and baroreflex impairment; and insomnia, with its association with autonomic hyperarousal and hypertension. When faced with disorders associated with cardiovascular and sleep-wake cycle alterations, clinical reasoning should entertain the possibility that both conditions are strongly influenced by anomalies of baroreflex function.

10 Review A review of sleep-promoting medications used in pregnancy. 2015

Okun, Michele L / Ebert, Rebecca / Saini, Bandana. ·University of Pittsburgh, Pittsburgh, PA; University of Colorado at Colorado Springs, Colorado Springs, CO. Electronic address: mokun@uccs.edu. · University of Pittsburgh, Pittsburgh, PA. · University of Sydney, Sydney, Australia. ·Am J Obstet Gynecol · Pubmed #25448509.

ABSTRACT: Approximately 4% of adults who have symptoms of insomnia resort to various hypnotic or sedating medications for acute symptom relief. Although typically a common practice for nonpregnant adults, this is not the case for the thousands of pregnant women who also report substantial sleep issues. Unfortunately, a paucity of randomized controlled trials in this population, scant empiric evidence regarding the appropriateness of prescribing options, and the concern of subsequent teratogenicity restricts the ability of clinicians to make informed decisions. We synthesized the current research regarding hypnotics and sedating medications used (both on- and off-label) during pregnancy and their association with adverse outcomes. Medications that we investigated included benzodiazepines, hypnotic benzodiazepine receptor agonists, antidepressants, and antihistamines. Overall, the examined studies showed no correlation of increased risk of congenital malformations. However, benzodiazepines and hypnotic benzodiazepine receptor agonists may increase rates of preterm birth, low birthweight, and/or small-for-gestational-age infants. The small number of studies and the small number of subjects prohibit any definitive interpretation regarding the consequences of the use of hypnotic or sedating medications in pregnancy. Additional case reports, randomized clinical trials, and epidemiologic studies are needed urgently.

11 Review The evidence base of sleep restriction therapy for treating insomnia disorder. 2014

Miller, Christopher B / Espie, Colin A / Epstein, Dana R / Friedman, Leah / Morin, Charles M / Pigeon, Wilfred R / Spielman, Arthur J / Kyle, Simon D. ·Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Australia; Institute of Neuroscience & Psychology, University of Glasgow, UK. Electronic address: chris.miller@sydney.edu.au. · Nuffield Department of Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford, UK. · Phoenix Veterans Affairs Health Care System, USA; Arizona State University College of Nursing and Health Innovation, USA. · Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA. · Université Laval, Québec City, Québec, Canada. · Sleep & Neurophysiology Research Lab, University of Rochester Medical Center, USA; Center of Excellence for Suicide Prevention, U.S. Department of Veterans Affairs, USA. · Cognitive Neuroscience Doctoral Program, The City College of the City University of New York, USA; Weill Cornell Medical College, Center for Sleep Medicine, NY, USA. · School of Psychological Sciences, University of Manchester, UK. ·Sleep Med Rev · Pubmed #24629826.

ABSTRACT: Sleep restriction therapy is routinely used within cognitive behavioral therapy to treat chronic insomnia. However, the efficacy for sleep restriction therapy as a standalone intervention has yet to be comprehensively reviewed. This review evaluates the evidence for the use of sleep restriction therapy in the treatment of chronic insomnia. The literature was searched using web-based databases, finding 1344 studies. Twenty-one were accessed in full (1323 were deemed irrelevant to this review). Nine were considered relevant and evaluated in relation to study design using a standardized study checklist and levels of evidence. Four trials met adequate methodological strength to examine the efficacy of therapy for chronic insomnia. Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement. Standalone sleep restriction therapy is efficacious for the treatment of chronic insomnia for sleep diary continuity variables. Studies are insufficient to evaluate the full impact on objective sleep variables. Measures of daytime functioning in response to therapy are lacking. Variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy. A future research agenda is outlined.

12 Review Circadian rhythm disorders among adolescents: assessment and treatment options. 2013

Bartlett, Delwyn J / Biggs, Sarah N / Armstrong, Stuart M. ·Sleep and Circadian Group, Woolcock Institute of Medical Research, Sydney, NSW, Australia. delwyn.bartlett@sydney.edu.au. ·Med J Aust · Pubmed #24138360.

ABSTRACT: Delayed sleep phase disorder (DSPD) - a circadian rhythm sleep disorder - is most commonly seen in adolescents. The differential diagnosis between DSPD and conventional psychophysiological insomnia is important for correct therapeutic intervention. Adolescent DSPD sleep duration is commonly 9 hours or more. Depression may be comorbid with DSPD. DSPD has a negative impact on adolescent academic performance. DSPD treatments include bright light therapy, chronotherapeutic regimens, and administration of melatonin as a chronobiotic (as distinct from a soporific). Attention to non-photic and extrinsic factors including healthy sleep parameters is also important to enable better sleep and mood outcomes in adolescents.

13 Review The insomnia patient perspective, a narrative review. 2013

Cheung, Janet M Y / Bartlett, Delwyn J / Armour, Carol L / Saini, Bandana. ·a Faculty of Pharmacy , The University of Sydney , Australia. ·Behav Sleep Med · Pubmed #23402684.

ABSTRACT: Insomnia is a common sleep disorder associated with substantial direct and indirect costs, yet there is a strong propensity among patients to self-medicate which often delays professional help. Understanding the process which underpins the initiation, engagement and adherence to insomnia treatment(s) is a vital step for understanding this phenomenon. The current paper explores how the patient perspective has been conceptualized in the research literature and its implications for insomnia treatment and health care delivery. A literature search was conducted using Embase, Medline and PsycINFO databases. Articles have been thematically organized into patient correlates of health behaviors, patient experiences and treatment attitudes. Deferral of professional help among insomnia patients is partially related to barriers embedded in the health care system and patient health beliefs.

14 Review Sleep disturbances in Parkinson disease and their potential role in heterogeneity. 2010

Gunn, David G / Naismith, Sharon L / Lewis, Simon J G. ·Parkinson's Disease Research Clinic, Ageing Brain Centre, Brain & Mind Research Institute, University of Sydney, Camperdown, New South Wales, Australia. ·J Geriatr Psychiatry Neurol · Pubmed #20101072.

ABSTRACT: Parkinson disease (PD) is commonly conceptualized as a movement disorder. Most previous attempts to define the heterogeneity of the condition have used prospective methods based on arbitrary features such as motor symptoms or age of disease onset. However, nonmotor symptoms including neuropsychological, neuropsychiatric, and behavioral impairments have received less attention. Sleep disturbances are extremely common in PD and appear to be associated with cognitive and psychiatric problems. Recent research has begun to elucidate the links between these variables, but the origin and extent of these relationships are not clearly understood. This review outlines the importance of sleep for healthy cognition and mood, highlighting the possible implications that disturbed sleep may have with regard to patients with PD. It also emphasizes the need for further studies that explore the heterogeneity of all disease features in PD.

15 Clinical Trial Zao Ren An Shen capsule for chronic insomnia: Study protocol for a randomized, placebo-controlled trial. 2019

Birling, Yoann / Bensoussan, Alan / Sarris, Jerome / Avard, Nicole / Zhu, Xiaoshu. ·NICM Health Research Institute, Western Sydney University, Westmead, NSW. · Professional Unit, The Melbourne Clinic, Department of Psychiatry, University of Melbourne, Melbourne, VIC. · School of Science and Health, NICM Health Research Institute, Western Sydney University, Penrith, NSW, Australia. ·Medicine (Baltimore) · Pubmed #30946312.

ABSTRACT: BACKGROUND: Zao Ren An Shen (ZRAS), a Chinese Herbal Medicine product, has been proposed as an alternative to recommended treatments for chronic insomnia. There is a lack of strong evidence supporting this proposition. AIMS: To assess the efficacy and safety of ZRAS capsule for chronic insomnia compared to placebo. METHODS: A parallel-group, double-blind, randomized-controlled trial will be performed in Western Sydney University, Australia. After a 1-week placebo run-in, adults with chronic insomnia (n = 90) will be randomized in a 1:1 ratio to receive either ZRAS capsule or placebo for 4 weeks. Insomnia severity (Insomnia Severity Scale score), sleep parameters (measured with the Consensus Sleep Diary and actigraphy), fatigue levels (Fatigue Severity Scale score), psychological status (Depression Anxiety Stress Scale score), quality of life (Assessment of Quality of Life score), and adverse events will be assessed at baseline, mid-treatment, post-treatment and at a 1-month follow-up. EXPECTED OUTCOMES: We hypothesize that ZRAS capsule will improve insomnia severity, sleep parameters, fatigue levels, psychological status, and quality of life better than placebo at mid-treatment, post-treatment, and follow-up. We also hypothesize that the number of adverse events provoked by ZRAS capsule will be similar to placebo at these time-points. TRIAL REGISTRATION: Australia New-Zealand Clinical Trial Registry (Registration number ACTRN12619000140156).

16 Clinical Trial Clusters of Insomnia Disorder: An Exploratory Cluster Analysis of Objective Sleep Parameters Reveals Differences in Neurocognitive Functioning, Quantitative EEG, and Heart Rate Variability. 2016

Miller, Christopher B / Bartlett, Delwyn J / Mullins, Anna E / Dodds, Kirsty L / Gordon, Christopher J / Kyle, Simon D / Kim, Jong Won / D'Rozario, Angela L / Lee, Rico S C / Comas, Maria / Marshall, Nathaniel S / Yee, Brendon J / Espie, Colin A / Grunstein, Ronald R. ·CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, University of Sydney, Australia. · Sydney Medical School, University of Sydney, Australia. · Sydney Nursing School, University of Sydney, Australia. · Nuffield Department of Clinical Neurosciences and Sleep & Circadian Neuroscience Institute, University of Oxford, UK. · Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, NSW, Australia. · Clinical Research Unit, Brain & Mind Centre, University of Sydney, Australia. ·Sleep · Pubmed #27568796.

ABSTRACT: STUDY OBJECTIVES: To empirically derive and evaluate potential clusters of Insomnia Disorder through cluster analysis from polysomnography (PSG). We hypothesized that clusters would differ on neurocognitive performance, sleep-onset measures of quantitative ( METHODS: Research volunteers with Insomnia Disorder (DSM-5) completed a neurocognitive assessment and overnight PSG measures of total sleep time (TST), wake time after sleep onset (WASO), and sleep onset latency (SOL) were used to determine clusters. RESULTS: From 96 volunteers with Insomnia Disorder, cluster analysis derived at least two clusters from objective sleep parameters: Insomnia with normal objective sleep duration (I-NSD: n = 53) and Insomnia with short sleep duration (I-SSD: n = 43). At sleep onset, differences in HRV between I-NSD and I-SSD clusters suggest attenuated parasympathetic activity in I-SSD (P < 0.05). Preliminary work suggested three clusters by retaining the I-NSD and splitting the I-SSD cluster into two: I-SSD A (n = 29): defined by high WASO and I-SSD B (n = 14): a second I-SSD cluster with high SOL and medium WASO. The I-SSD B cluster performed worse than I-SSD A and I-NSD for sustained attention (P ≤ 0.05). In an exploratory analysis, CONCLUSIONS: Two insomnia clusters derived from cluster analysis differ in sleep onset HRV. Preliminary data suggest evidence for three clusters in insomnia with differences for sustained attention and sleep-onset CLINICAL TRIAL REGISTRATION: Insomnia 100 sleep study: Australia New Zealand Clinical Trials Registry (ANZCTR) identification number 12612000049875. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347742.

17 Clinical Trial Physiological Markers of Arousal Change with Psychological Treatment for Insomnia: A Preliminary Investigation. 2015

Miller, Christopher B / Kyle, Simon D / Gordon, Christopher J / Espie, Colin A / Grunstein, Ronald R / Mullins, Anna E / Postnova, Svetlana / Bartlett, Delwyn J. ·Centre for Integrated Research and Understanding of Sleep (CIRUS), NeuroSleep and Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia. · Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom. · Sydney Nursing School, University of Sydney, Sydney, Australia. · Department of Respiratory and Sleep Medicine, RPAH, Sydney Local Health District, Sydney, Australia. · School of Physics, University of Sydney, Sydney, Australia. ·PLoS One · Pubmed #26683607.

ABSTRACT: OBJECTIVES: The aim of this preliminary study was to evaluate if Sleep Restriction Therapy for insomnia is associated with modifications to physiological arousal, indexed through overnight measures of plasma cortisol concentrations and core body temperature. METHODS: In a pre-to-post open label study design, eleven patients with chronic and severe Psychophysiological Insomnia underwent 5 weeks of Sleep Restriction Therapy. RESULTS: Eight (73%) patients out of 11 consented completed therapy and showed a decrease in insomnia severity pre-to-post treatment (mean (SD): 18.1 (2.8) versus 8.4 (4.8); p = .001). Six patients were analyzed with pre-to-post overnight measures of temperature and cortisol. Contrary to our hypothesis, significantly higher levels of plasma cortisol concentrations were found during the early morning at post-treatment compared to baseline (p < .01), while no change was observed in the pre-sleep phase or early part of the night. Core body temperature during sleep was however reduced significantly (overall mean [95% CI]: 36.54 (°C) [36.3, 36.8] versus 36.45 [36.2, 36.7]; p < .05). CONCLUSIONS: Sleep Restriction Therapy therefore was associated with increased early morning cortisol concentrations and decreased core body temperature, supporting the premise of physiological changes in functioning after effective therapy. Future work should evaluate change in physiological variables associated with clinical treatment response. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTR 12612000049875.

18 Clinical Trial Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder. 2014

Kyle, Simon D / Miller, Christopher B / Rogers, Zoe / Siriwardena, A Niroshan / Macmahon, Kenneth M / Espie, Colin A. ·School of Psychological Sciences, University of Manchester, Manchester, UK. · Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia. · Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK. · School of Health and Social Care, University of Lincoln, Lincoln, UK. · Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK. · Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK. ·Sleep · Pubmed #24497651.

ABSTRACT: STUDY OBJECTIVES: To investigate whether sleep restriction therapy (SRT) is associated with reduced objective total sleep time (TST), increased daytime somnolence, and impaired vigilance. DESIGN: Within-subject, noncontrolled treatment investigation. SETTING: Sleep research laboratory. PARTICIPANTS: Sixteen patients [10 female, mean age = 47.1 (10.8) y] with well-defined psychophysiological insomnia (PI), reporting TST ≤ 6 h. INTERVENTIONS: Patients were treated with single-component SRT over a 4-w protocol, sleeping in the laboratory for 2 nights prior to treatment initiation and for 3 nights (SRT night 1, 8, 22) during the acute interventional phase. The psychomotor vigilance task (PVT) was completed at seven defined time points [day 0 (baseline), day 1,7,8,21,22 (acute treatment) and day 84 (3 mo)]. The Epworth Sleepiness Scale (ESS) was completed at baseline, w 1-4, and 3 mo. MEASUREMENT AND RESULTS: Subjective sleep outcomes and global insomnia severity significantly improved before and after SRT. There was, however, a robust decrease in PSG-defined TST during acute implementation of SRT, by an average of 91 min on night 1, 78 min on night 8, and 69 min on night 22, relative to baseline (P < 0.001; effect size range = 1.60-1.80). During SRT, PVT lapses were significantly increased from baseline (at three of five assessment points, all P < 0.05; effect size range = 0.69-0.78), returning to baseline levels by 3 mo (P = 0.43). A similar pattern was observed for RT, with RTs slowing during acute treatment (at four of five assessment points, all P < 0.05; effect size range = 0.57-0.89) and returning to pretreatment levels at 3 mo (P = 0.78). ESS scores were increased at w 1, 2, and 3 (relative to baseline; all P < 0.05); by 3 mo, sleepiness had returned to baseline (normative) levels (P = 0.65). CONCLUSION: For the first time we show that acute sleep restriction therapy is associated with reduced objective total sleep time, increased daytime sleepiness, and objective performance impairment. Our data have important implications for implementation guidelines around the safe and effective delivery of cognitive behavioral therapy for insomnia.

19 Article Magnesium Intake and Sleep Disorder Symptoms: Findings from the Jiangsu Nutrition Study of Chinese Adults at Five-Year Follow-Up. 2018

Cao, Yingting / Zhen, Shiqi / Taylor, Anne W / Appleton, Sarah / Atlantis, Evan / Shi, Zumin. ·School of Medicine, University of Adelaide, SAHMRI, L7, North Terrace, Adelaide, SA 5000, Australia. yingting.cao1985@gmail.com. · Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing 210000, China. cdczsq@163.com. · School of Medicine, University of Adelaide, SAHMRI, L7, North Terrace, Adelaide, SA 5000, Australia. anne.taylor@adelaide.edu.au. · The Health Observatory, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville, SA 5000, Australia. sarah.appleton@adelaide.edu.au. · School of Medicine, University of Adelaide, SAHMRI, L7, North Terrace, Adelaide, SA 5000, Australia. E.Atlantis@westernsydney.edu.au. · School of Nursing and Midwifery, Western Sydney University, Sydney, NSW 2000, Australia. E.Atlantis@westernsydney.edu.au. · School of Medicine, University of Adelaide, SAHMRI, L7, North Terrace, Adelaide, SA 5000, Australia. zumin.shi@adelaide.edu.au. · Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing 210000, China. zumin.shi@adelaide.edu.au. · Human Nutrition Department, Qatar University, Doha 00000, Qatar. zumin.shi@adelaide.edu.au. ·Nutrients · Pubmed #30248967.

ABSTRACT: (1) Background: In clinical trials, dietary magnesium use can improve insomnia symptoms. However, little is known about the association between dietary magnesium consumption and sleep disorder symptoms including daytime falling asleep, sleepiness and snoring at the population level. (2) Methods: We used data from 1487 adults aged 20 and above attending the Jiangsu Nutrition Study. At baseline in 2002, dietary magnesium was assessed by 3-day weighed food records. At follow-up in 2007, sleep disorder symptoms, including daytime falling asleep, sleepiness and snoring at night, were gathered using a sleep questionnaire. (3) Results: The mean intake of magnesium was 332.5 mg/day. In total, 5.3%, 13.2% and 35.7% of the subjects reported daytime falling asleep, daytime sleepiness, and snoring during sleep, respectively. Compared with the lowest quartile of magnesium intake, the highest quartile was associated with decreased likelihood of falling asleep (odds ratio (OR) 0.12 (0.02, 0.57)) in women but not in men after adjusting for demographic, anthropometric, lifestyle factors, hypertension, and overall dietary patterns. No associations were found between dietary magnesium intake and daytime sleepiness nor night snoring in either gender. (4) Conclusions: Dietary magnesium intake may have long-term benefits in reducing the likelihood of daytime falling asleep in women.

20 Article The association of insomnia with future mental illness: is it just residual symptoms? 2018

Biddle, Daniel J / Kelly, Peter J / Hermens, Daniel F / Glozier, Nick. ·Brain and Mind Centre, Sydney Medical School, University of Sydney, Australia; School of Psychology, University of Wollongong, Australia. · School of Psychology, University of Wollongong, Australia. · Brain and Mind Centre, Sydney Medical School, University of Sydney, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, Sunshine Coast, QLD, Australia. · Brain and Mind Centre, Sydney Medical School, University of Sydney, Australia. Electronic address: nick.glozier@sydney.edu.au. ·Sleep Health · Pubmed #30031528.

ABSTRACT: OBJECTIVES: To evaluate whether the prospective association between insomnia and mental illness in the general population remained after controlling for multiple confounders, or whether this represented partly remitted prior mental illness. DESIGN: Cohort study. SETTING: Australian general population. PARTICIPANTS: The participants were 10,444 people aged 15 or older in the Household, Income and Labour Dynamics in Australia (HILDA) survey who did not meet K10 criteria for likely mental illness at baseline (2013-14). MEASUREMENTS: The prospective associations of insomnia (yes/no) at baseline with mental illness (yes/no) approximately 2 years later (2015-16), determined from scores on the K10, were evaluated using logistic regression. These were then adjusted for potential confounders including sociodemographic factors, physical health and health behaviors, and baseline and past mental health. RESULTS: Insomnia at baseline increased risk of mental illness onset at two-year follow up (OR 2.23, 95% CI 1.91-2.59, P < .001). This relationship was attenuated but still significant after adjustment for confounding variables (OR 1.72 95% CI 1.46-2.02). Accounting for reverse causality from prior mental ill health and baseline symptoms reduced this further but the relationship remained (OR 1.30, 95% CI 1.09-1.55, P = .003). This effect appeared more robust among those <65 years of age. CONCLUSIONS: Insomnia has a consistent prospective relationship with mental illness at two-year follow-up. Insomnia did not appear to be simply a symptom of past, or baseline subclinical, mental illness. This supports the specific targeting of insomnia symptoms in selective preventive mental health initiatives, particularly among those under 65 years of age.

21 Article Association of sleep duration and sleep quality with the physical, social, and emotional functioning among Australian adults. 2018

Lallukka, Tea / Sivertsen, Børge / Kronholm, Erkki / Bin, Yu Sun / Øverland, Simon / Glozier, Nick. ·Finnish Institute of Occupational Health, P.O. Box 18, FIN 00032 Helsinki, Finland; Department of Public Health, P.O. Box 20 (Tukholmankatu 8 B), FIN-00014, University of Helsinki, Finland; Sydney Medical School, Sleep Group, D17 - Charles Perkins Centre, University of Sydney NSW, Australia 2006. Electronic address: tea.lallukka@ttl.fi. · Department of Research and Innovation, Helse-Fonna HF Haugesund Hospital, Postbox 2170, 5504, Haugesund, Norway; Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaesgate 7, 5015 Bergen, Norway. · Finnish Institute of Occupational Health, Lemminkäisenkatu 14-18 B, FI-20032, Turku, Finland. · Sydney Medical School, Sleep Group, D17 - Charles Perkins Centre, University of Sydney NSW, Australia 2006. · Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaesgate 7, 5015 Bergen, Norway; Department of Psychosocial Science, University of Bergen, Postboks 7807, 5020 Bergen, Norway. · Sydney Medical School, Sleep Group, D17 - Charles Perkins Centre, University of Sydney NSW, Australia 2006; Brain and Mind Centre, University of Sydney, Sydney, 94 Mallett Street, Camperdown, NSW 2050, Australia. ·Sleep Health · Pubmed #29555134.

ABSTRACT: OBJECTIVES: We aimed to evaluate the interaction of two key determinants of sleep health, quantity and quality, with physical, emotional, and social functioning, in the general population. DESIGN: Nationally-representative Australian cross-sectional study. SETTING: General population. PARTICIPANTS: 14,571 people aged 15 or older in Household, Income and Labor Dynamics in Australia (HILDA) in 2013. MEASUREMENTS: The associations of sleep quality (good/poor) in combination with mid-range (6-8 hours), short (<6) or long (>8) sleep duration with functioning, determined from the SF-36, were evaluated using logistic regression adjusting for sociodemographic, relationships, health behaviors, obesity, pain, and mental and physical illness confounders. RESULTS: After adjusting for gender, and age, poor sleep quality in combination with short, mid-range and long sleep was associated with worse physical, emotional and social functioning. Pain and comorbid illness explained much of these associations, while attenuation from other covariates was minor. The associations of poor sleep quality with worse functioning remained after full adjustment regardless of sleep duration, while among people with good quality sleep, only those with long sleep duration reported poorer functioning. CONCLUSIONS: Poor sleep quality has robust associations with worse functioning regardless of total duration in the general population. There appears to be a substantial number of functional short sleepers with good quality sleep.

22 Article Patient Preferences for Managing Insomnia: A Discrete Choice Experiment. 2018

Cheung, Janet M Y / Bartlett, Delwyn J / Armour, Carol L / Saini, Bandana / Laba, Tracey-Lea. ·Faculty of Pharmacy, The University of Sydney, Pharmacy and Bank Building A15, Sydney, NSW, 2006, Australia. janet.cheung@sydney.edu.au. · CIRUS, Centre for Integrated Research and Understanding of Sleep, The Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia. janet.cheung@sydney.edu.au. · CIRUS, Centre for Integrated Research and Understanding of Sleep, The Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia. · Clinical Management Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia. · Sydney Local Health District, Sydney, NSW, Australia. · Faculty of Pharmacy, The University of Sydney, Pharmacy and Bank Building A15, Sydney, NSW, 2006, Australia. · The George Institute for Global Health, The University of New South Wales, Sydney, NSW, Australia. ·Patient · Pubmed #29502237.

ABSTRACT: BACKGROUND: Despite the rapid development of effective treatments, both pharmacological and non-pharmacological, insomnia management remains suboptimal at the practice interface. Patient preferences play a critical role in influencing treatment outcomes. However, there is currently a mismatch between patient preferences and clinician recommendations, partly perpetuated by a limited understanding of the patients' decision-making process. OBJECTIVES: The aim of our study was to empirically quantify patient preferences for treatment attributes common to both pharmacological and non-pharmacological insomnia treatments. METHOD: An efficient dual-response discrete choice experiment was conducted to evaluate patient treatment preferences for managing insomnia. The sample included 205 patients with self-reported insomnia and an Insomnia Severity Index ≥ 14. Participants were presented with two unlabelled hypothetical scenarios with an opt-out option across 12 choice sets. Data were analyzed using a mixed multinomial logit model to investigate the influence of five attributes (i.e. time, onset of action, maintainability of improved sleep, length of treatment, and monthly cost) on treatment preferences. RESULTS: Treatments were preferentially viewed if they conferred long-term sleep benefits (p < 0.05); had an ongoing, as opposed to a predefined, duration of treatment course (p < 0.05); required some, as opposed to no, additional time commitment (p < 0.05); and had lower monthly out-of-pocket treatment costs (p < 0.001). However, treatment onset of action had no influence on preference. Age, help-seeking status, concession card status and fatigue severity significantly influenced treatment preference. CONCLUSION: Participants' prioritization of investing time in treatment and valuing the maintainability of therapeutic gains suggests a stronger inclination towards non-pharmacological treatment, defying current assumptions that patients prefer 'quick-fixes' for managing insomnia.

23 Article Distress and sleep quality in young amphetamine-type stimulant users with an affective or psychotic illness. 2018

Crouse, Jacob J / Lee, Rico S C / White, Django / Moustafa, Ahmed A / Hickie, Ian B / Hermens, Daniel F. ·Youth Mental Health Team, Brain and Mind Centre, University of Sydney, NSW, Australia. Electronic address: jcro8838@uni.sydney.edu.au. · Youth Mental Health Team, Brain and Mind Centre, University of Sydney, NSW, Australia; Brain and Mental Health Laboratory, Monash University, VIC, Australia. · Youth Mental Health Team, Brain and Mind Centre, University of Sydney, NSW, Australia. · School of Social Sciences and Psychology, Western Sydney University, NSW, Australia. · Youth Mental Health Team, Brain and Mind Centre, University of Sydney, NSW, Australia; Sunshine Coast Mind and Neuroscience Thompson Institute, University of the Sunshine Coast, QLD, Australia. ·Psychiatry Res · Pubmed #29475104.

ABSTRACT: Misuse of amphetamine-type stimulant (ATS) drugs may disrupt key neurodevelopmental processes in young people and confer protracted neurocognitive and psychopathological harm. ATS users with a co-occurring psychiatric illness are typically excluded from research, reducing generalisability of findings. Accordingly, we conducted a cross-sectional examination of key clinical, sleep, socio-occupational and neurocognitive measures in current, past and never users of ATS drugs who were accessing a youth mental health service (headspace) for affective- or psychotic-spectrum illnesses. Contrary to hypotheses, groups did not differ in psychotic symptomology, socio-occupational functioning or neurocognitive performance. Current ATS users were however significantly more distressed and reported poorer subjective sleep quality and greater subjective sleep disturbances than never users, with a trend toward greater depressive symptomology in current users. Regression analyses revealed that depressive symptoms, daily ATS use and socio-occupational functioning predicted distress, and depressive symptoms and distress predicted subjective sleep quality. Our findings suggest that distress and poor sleep quality reflect a particular pathophysiology among ATS-using patients, which may negatively impact treatment engagement. Delineating the factors that disrupt social and neurobiological development in young people (such as substance use) warrants further investigation, including longitudinal study.

24 Article Integrated primary care insomnia management in Australia. 2018

Sake, Fatema-Tun-Naher / Wong, Keith / Bartlett, Delwyn J / Saini, Bandana. ·Faculty of Pharmacy, The University of Sydney, NSW, Australia; Woolcock Institute of Medical Research, NSW, Australia. Electronic address: fsak5337@uni.sydney.edu.au. · Woolcock Institute of Medical Research, NSW, Australia; Faculty of Medicine, The University of Sydney, NSW, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. · Woolcock Institute of Medical Research, NSW, Australia; Faculty of Medicine, The University of Sydney, NSW, Australia. · Faculty of Pharmacy, The University of Sydney, NSW, Australia. ·Res Social Adm Pharm · Pubmed #28262515.

ABSTRACT: BACKGROUND: There is growing support to expand the roles of pharmacists by recognizing their knowledge and skills beyond those around dispensing of medications. Introducing non-dispensing pharmacists at the premises of General Practitioners (GPs) for a collaborative service can potentially and significantly help to provide more effective and efficient health services, for example, in under-recognized or mismanaged conditions such as insomnia. Such a collaborative service could also reduce the costs and risks associated with long-term use of sedatives, besides improving patient's quality of life. OBJECTIVE: This study aimed to elicit the perceptions of Australian GPs on the integration of pharmacists into general practice settings for providing sleep health services, especially insomnia services. METHOD: Face to face interviews were conducted with a purposive convenience sample of GPs using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and the transcribed data were thematically analyzed using the principles of framework analysis to identify emergent themes. RESULTS: Twenty-four interviews (46% female participants) were conducted with GPs from greater Sydney Metropolitan area in New South Wales. Based on the Collaborative Working Relationship (CWR) framework, the current relationship between the participating GPs and pharmacists appeared to be at the early stage. Thematic analysis of the interviews indicated that despite citing some barriers such as funding models, infrastructure and perceived patient attitudes, most participants expressed a positive attitude towards this service model. The integrated insomnia service model was believed to be facilitating the provision of comprehensive care for patients with insomnia. CONCLUSIONS: The results of this study suggest that there is a willingness among GPs to utilize pharmacist support in insomnia management. Various facilitators, barriers, and methods of collaborative services were identified. A professional practice framework needs to be developed and established to implement the proposed model and ensure a better healthcare service for patients with insomnia.

25 Article To Drug or Not to Drug: A Qualitative Study of Patients' Decision-Making Processes for Managing Insomnia. 2018

Cheung, Janet M Y / Bartlett, Delwyn J / Armour, Carol L / Laba, Tracey-Lea / Saini, Bandana. ·a Faculty of Pharmacy , The University of Sydney , Sydney , NSW , Australia. · b Sleep and Circadian Research Group, The Woolcock Institute of Medical Research , Sydney , NSW , Australia. · c Clinical Management Group, The Woolcock Institute of Medical Research , Sydney , NSW , Australia. · d Sydney Local Health District , Sydney , NSW , Australia. · e The George Institute for Global Health , Sydney , NSW , Australia. ·Behav Sleep Med · Pubmed #27191585.

ABSTRACT: Treatment preferences play a key role in dictating sleep health outcomes. However, patients' treatment beliefs, attitudes, and experiences that inform preference conceptualization remain an unknown phenomenon. Therefore, this study aims to explore patient perceptions toward pharmacotherapy and the nonpharmacological management of insomnia. Fifty-one patients with insomnia were recruited from specialist clinics and general community settings. Participants completed a brief questionnaire followed by an in-depth semistructured interview that was digitally recorded, transcribed verbatim, and subjected to Framework Analysis to identify emergent themes. Three key themes were identified: Resolving Insomnia, Self-Imposed Treatment Boundaries, and Treatment Uptake. Patients' illness, treatment, and psychosocial beliefs and experiences are closely linked to treatment choice. Being attuned to these influences during the clinical encounter can facilitate treatment selection that is meaningful for the patient.

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