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Study Objectives: Insomnia with objective short sleep duration has been associated with higher risk of cardiometabolic morbidity. In this study, we examined the association between insomnia with objective short sleep duration, also based on subjective sleep duration, with incident hypertension in the Sleep Heart Health Study. Methods: We analyzed data from 1,413 participants free of hypertension or sleep apnea at baseline from the Sleep Heart Health Study, with a median follow-up duration of 5.1 years. Insomnia symptoms were defined based on difficulty falling asleep, difficulty returning to sleep, early morning awakening, or sleeping pill use more than half the days in a month. Objective short sleep duration was defined as polysomnography-measured total sleep time < 6 hours. Incident hypertension was defined based on blood pressure measures and/or use of antihypertensive medications at follow-up. Results: Individuals with insomnia who slept objectively < 6 hours had significantly higher odds of incident hypertension compared to normal sleepers who slept ≥ 6 hours (odds ratio = 2.00, 95% confidence interval = 1.09–3.65) or < 6 hours (odds ratio = 2.00, 95% confidence interval = 1.06–3.79) or individuals with insomnia who slept ≥ 6 hours (odds ratio = 2.79, 95% confidence interval = 1.24–6.30). Individuals with insomnia who slept ≥ 6 hours or normal sleepers who slept < 6 hours were not associated with increased risk of incident hypertension compared to normal sleepers who slept ≥ 6 hours. Finally, individuals with insomnia who self-reported sleeping < 6 hours were not associated with significantly increased odds of incident hypertension. Conclusions: These data further support that the insomnia with objective short sleep duration phenotype based on objective, but not subjective measures, is associated with increased risk of developing hypertension in adults. Citation: Dai Y, Chen B, Chen L, et al. Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension:the Sleep Heart Health Study. J Clin Sleep Med . 2023;19(8):1421–1428.

Study Objectives: Since subjective sleep duration (SSD) is considered to be longer than objective sleep duration (OSD), results of SSD minus OSD (SSD−OSD) might always be thought to be positive. Some recent reports showed different results, but exact results have not been obtained. The difference between SSD and OSD may change according to OSD. We investigated this difference and its association with sleep-disordered breathing (SDB) or nonrestorative sleep. Methods: This cross-sectional study evaluated 6,908 community residents in Nagahama, Japan. SSD was determined by self-administered questionnaire. OSD was measured by wrist actigraphy and sleep diary. SDB was assessed according to the 3% oxygen desaturation index adjusted for OSD. Results: Worthy of notice was that SSD was shorter than OSD for those with SSD longer than 6.98 hours in all participants, 7.36 hours in males, and 6.80 hours in females. However, SSD was longer than OSD (mean ± SD: 6.49 ± 1.07 vs 6.01 ± 0.96; P < .001) overall, as SSD is considered to be longer than OSD. In patients with SDB, the difference between SSD−OSD was greater when OSD was s horter. The difference also depended on SDB severity. The degree of positivity between OSD and SSD was a significant factor in nonrestorative sleep (odds ratio: 2.691; P < .001). Conclusions: When OSD was slightly less than 7 (6.98) hours, participants reported or perceived SSD > OSD. When OSD was > 6.98 hours, participants reported or perceived SSD < OSD. Patients with SDB reported longer SSD than OSD according to severity of SDB. Evaluating SSD, OSD, and their differences may be useful for managing sleep disturbances, including nonrestorative sleep. Citation: Takahashi N, Matsumoto T, Nakatsuka Y, et al. Differences between subjective and objective sleep duration according to actual sleep duration and sleep-disordered breathing: the Nagahama Study. J Clin Sleep Med . 2022;18(3):851–859.

Background Sleep deprivation and overload have been associated with increased risks of both depression and mortality. However, no study has quantitatively compared the effects of objective and subjective sleep duration on mortality or examined the mediating role of depressive symptoms in these associations. Methods Utilizing data from the NHANES 2011–2014, this study employed structural equation modeling (SEM) to explore the impact of depressive symptoms, measured by Patient Health Questionnaire (PHQ-9) scores, on the relationship between both objective and subjective sleep durations and all-cause mortality. Results The study included 7838 participants, comprising 4392 women (55.96%) with a mean age of 46.51 (0.46) years. Over a median 6.83-year follow-up, 582 deaths occurred. The restricted cubic spline curves demonstrated a J-shaped relationship between objective sleep duration and the all-cause mortality risk, and a U-shaped relationship between subjective sleep duration and the all-cause mortality risk. SEM analysis revealed that when subjective sleep duration was < 7 h/day, the indirect effect of sleep duration on all-cause mortality was − 0.013 ( P  = 0.003), and the mediation proportion of PHQ-9 scores was 40.63%. When objective sleep duration ≥ 7 h/day, the indirect effect of sleep duration on all-cause mortality was 0.003 ( P  = 0.028), and the mediation proportion of PHQ-9 scores was 2.10%. Conclusions The study confirmed a J-shaped and a U-shaped correlation for objective and subjective sleep duration with mortality risk. Depressive symptoms significantly mediated the association between shorter subjective sleep duration and mortality. This suggests that there is a need to focus on the co-morbidity of subjective sleep deprivation and depression.

The individual prevalence of sleep-disordered breathing (SDB), short sleep duration, and obesity is high and increasing. The study aimed to investigate potential associations between SDB, objective sleep duration, obesity, diabetes and hypertension across genders, and the effect of pre- or post-menopausal status. A cross-sectional study evaluated 7051 community participants with wrist actigraphy for a week, and nocturnal oximetry ≥ 2 nights. SDB was assessed by 3 per cent oxygen desaturation index (ODI) corrected for sleep duration obtained from wrist actigraphy. Moderate-to-severe SDB was defined as ODI3% levels ≥ 15 per hour. Both logODI3% and body mass index showed independent negative associations with sleep duration (β = -0.16, p < 0.001 and β = -0.07, p < 0.001, respectively). Moderate-to-severe SDB (men/premenopausal women/postmenopausal women; 23.7/1.5/9.5%, respectively) was associated with a higher risk of diabetes in premenopausal women (OR 28.1; 95%CI 6.35-124.6; p < 0.001) and postmenopausal women (OR 3.25; 95%CI 1.94-5.46; p < 0.001), but not in men (OR 1.47; 95%CI 0.90-2.40; p = 0.119). Moderate-to-severe SDB was associated with a higher risk of hypertension in men (OR 3.11; 95%CI 2.23-4.33; p < 0.001), premenopausal women (OR 3.88; 95%CI 1.42-10.6; p = 0.008), and postmenopausal women (OR 1.96; 95%CI 1.46-2.63; p < 0.001). Short sleep duration was not associated with diabetes or hypertension. The associations of obesity with diabetes or hypertension were indirectly mediated by SDB (24.0% and 21.5%, respectively), with possible sex differences emerging (men/women; 15.3/27.8% and 27.0/16.9%, respectively). Notwithstanding the cross-sectional design, SDB and obesity, but not short sleep duration, were independently associated with diabetes and hypertension, with gender and menopausal status-related differences in risk emerging.

Sleep enhances the antibody response to vaccination, but the relationship between sleep and mRNA vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not fully understood. In this prospective observational study, we investigated the influence of sleep habits on immune acquisition induced by mRNA vaccines against SARS-CoV-2 in 48 healthy adults (BNT-162b2, n=34; mRNA-1273, n=14; female, n=30, 62.5%; male, n=18, 37.5%; median age, 39.5 years; interquartile range, 33.0-44.0 years) from June 2021 to January 2022. The study measured sleep duration using actigraphy and sleep diaries, which covered the periods of the initial and booster vaccinations. Multivariable linear regression analysis showed that actigraphy-measured objective sleep duration 3 and 7 days after the booster vaccination was independently and significantly correlated with higher antibody titers (B=0.003; 95% confidence interval, 0.000-0.005; Beta=0.337; p=0.02), even after controlling for covariates, including age, sex, the type of vaccine, and reactogenicity to the vaccination. Associations between acquired antibody titer and average objective sleep duration before vaccination, and any period of subjective sleep duration measured by sleep diary were negligible. Longer objective, but not subjective, sleep duration after booster vaccination enhances antibody response. Hence, encouraging citizens to sleep longer after mRNA vaccination, especially after a booster dose, may increase protection against SARS-CoV-2. This study is registered at the University Hospital Medical Information Network Center (UMIN: https://www.umin.ac.jp) on July 30, 2021, #UMIN000045009.

Insomnia is one of the most common mental disorders and the most frequent sleep disorder encountered in clinical practice, with a prevalence of about 7% in the European population. Insomnia Disorder (ID) is defined as a disturbance of sleep initiation or maintenance, followed by a feeling of non-restorative sleep and several diurnal consequences ranging from occupational and social difficulties to cognitive impairment. Cognitive-Behavioral Therapy for Insomnia (CBT-I) is considered the first-choice therapy for this disorder because its effectiveness has been proven to be greater in the long term with fewer side effects in comparison to pharmacotherapy. Although its effectiveness has been well established, it has been reported that nearly 40% of patients do not achieve remission after treatment. This finding could be the consequence of heterogeneity of ID between patients. It has been proposed that this heterogeneity might be ascribable to indices that are not related to sleep quality and quantity, such as comorbidities, life events, and personality traits. However, several works focused on the role of sleep markers, in particular objective total sleep time, for the phenotypization of ID and treatment response. The aim of this work is to summarize the available scientific literature regarding the impact of ID subtype on CBT-I response.

Based on previous studies on the role of objective sleep duration in predicting morbidity in individuals with insomnia, we examined the role of objective sleep duration in differentiating behavioral profiles in adolescents with insomnia symptoms. Adolescents from the Penn State Child Cohort (n = 397, ages 12–23, 54.7% male) underwent a nine-hour polysomnography (PSG), clinical history, physical examination and psychometric testing, including the Child or Adult Behavior Checklist and Pediatric Behavior Scale. Insomnia symptoms were defined as a self-report of difficulty falling and/or staying asleep and objective “short” sleep duration as a PSG total sleep time ≤7 h. A significant interaction showed that objective short sleep duration modified the association of insomnia symptoms with internalizing problems. Consistently, adolescents with insomnia symptoms and short sleep duration were characterized by depression, rumination, mood dysregulation and social isolation, while adolescents with insomnia symptoms and normal sleep duration were characterized by rule-breaking and aggressive behaviors and, to a lesser extent, rumination. These findings indicate that objective sleep duration is useful in differentiating behavioral profiles among adolescents with insomnia symptoms. The insomnia with objective short sleep duration phenotype is associated with an increased risk of depression earlier in the lifespan than previously believed.

Study Objectives: Temporomandibular disorders (TMDs) were linked to poor sleep on the Pittsburgh Sleep Quality Index (PSQI), whereas polysomnography revealed no major sleep disturbances, implying sleep state misperception. This study investigates sleep state misperception in TMD and control participants; correlates sleep state misperception with objective short sleep duration (SSD), depression symptoms, daytime sleepiness, and orofacial pain; and compares objective SSD between the groups. Methods: General linear models were used to compare second-night polysomnography total sleep time, sleep latency, sleep efficiency (SE), and wake after sleep onset with homologous PSQI-derived variables in 124 women with myofascial TMD and 46 age and body mass index matched controls. PSQI variables were regressed onto objective SSD, depression symptoms, daytime sleepiness, and pain. Lastly, objective SSD was related to TMD presence. Results: Compared to controls, TMD cases misperceived SE ( P = .02); depression symptoms explained PSQI-derived SE ( P = .002) and mediated the effect of pain ( P < .001). PSQI variables were unrelated to respective polysomnography measures or objective SSD, except a significant self-reported-objective correlation in SE among controls only ( P = .002). Objective SSD was more frequent in TMD cases ( P = .02, odds ratio = 2.95), but it was unrelated to depression symptoms, daytime sleepiness, or prepolysomnography pain. Conclusions: The study demonstrates misperception of SE among TMD cases, which was accounted for by depression symptoms. Objective SSD nearly tripled in TMD cases; however, it was unrelated to PSQI variables, depression, daytime sleepiness, or pain, suggesting that sleep state misperception and objective SSD are 2 independent sleep features in TMD. Citation: Chan C, Dubrovsky B, Bouchard M, Tartter VC, Raphael KG. Sleep misperception in women with myofascial temporomandibular disorder. J Clin Sleep Med . 2025;21(1):55–64.

ObjectiveInsomnia disorder with objective short sleep duration (ISS) has been considered as a biologically severe subtype. The aim of this meta-analysis was to reveal the association of the ISS phenotype and cognitive performance.MethodsWe searched PubMed, EMBASE, and the Cochrane Library for studies that observed an association of cognitive performance and insomnia with objective short sleep duration (ISS) phenotype. The “metafor” and “MAd” packages in R software (version 4.2.0) were used to calculate the unbiased standardized mean difference (Hedge’s g), which was adjusted so that a negative value indicated worse cognitive performance.ResultsThe pooled analysis with 1339 participants revealed that the ISS phenotype was associated with overall cognitive impairments (Hedges’ g = − 0.56 [− 0.89, − 0.23]), as well as specific cognitive domains including attention (Hedges’ g = − 0.86 [− 1.25, − 0.47]), memory (Hedges’ g = − 0.47 [− 0.82, − 0.12]), and executive function (Hedges’ g = − 0.39 [− 0.76, − 0.02]). However, cognitive performance was not significantly different between insomnia disorder with objective normal sleep duration (INS) and good sleepers (p > .05).ConclusionInsomnia disorder with the ISS phenotype, but not the INS phenotype, was associated with cognitive impairments, suggesting the possible utility of treating the ISS phenotype to improve cognitive performance.

Based on previous studies reporting on the association of objective sleep duration and physiologic changes (i.e., increased cortisol) in children, we examined the role of objective sleep duration on differentiating behavioral profiles in children with insomnia symptoms. Seven hundred children (ages 5-12, 47.8% male) from the Penn State Child Cohort underwent a nine-hour polysomnography and parent completed Pediatric Behavior Scale. Insomnia symptoms were defined as parent report of difficulty falling and/or staying asleep, sleep disordered breathing as an AHI of [greater than or equal to]1, and objective short sleep duration as a total sleep time < 7.7 h. Children with insomnia symptoms demonstrated more overall behavioral problems than controls. Significant interactions between insomnia symptoms and objective sleep duration on scores of externalizing behaviors, mood variability and school problems were found. Profile analyses showed that children with insomnia symptoms and normal sleep duration were associated with clinically elevated externalizing behaviors, inattention, mood variability, and school problems, while children with insomnia and short sleep duration were associated with an overall elevated profile in which internalizing behaviors were more prominent. Childhood insomnia symptoms are associated with a wide array of behavioral problems, for which objective sleep duration is useful in differentiating behavioral profiles. Children with insomnia symptoms and normal sleep duration had a behavioral profile consistent with limit-setting and rule-breaking behaviors, while children with insomnia symptoms and short sleep duration had a behavioral profile more consistent with internalizing behaviors resembling that of psychophysiological disorders.