The behavioural tendency to expand sleep opportunity to compensate for prior sleep loss is referred to as 'sleep extension.' It is believed that sleep extension (here referred to as 'sleep opportunity extension' [SOE]) is the primary perpetuating factor explaining the transition from acute to chronic insomnia. Recently, this proposition was prospectively evaluated by assessing how sleep opportunity varied, week-by-week, relative to the incidence of acute and chronic insomnia. Significant differences in sleep opportunity before and after onset of acute insomnia were not detected. In the present analysis, a more granular evaluation was undertaken to assess whether SOE occurs on the nights and/or weekends following poor sleep. The data set (n = 1243) was modelled by group (good sleepers and participants with acute insomnia) for SOE occurring on the nights and weekends following poor nights of sleep (i.e., ≥ 30 min of sleep latency and/or nocturnal wakefulness and/or early morning awakenings) for the post-acute insomnia interval. A linear mixed effects model was used to account for up to one year of night-to-night sleep per participant. During the weekdays, sleep opportunity following a poor night of sleep was not found to increase (overall or by group) (< 5 min). During the weekends, all groups tended to decrease their sleep opportunity. This counterintuitive finding casts further doubt on the proposition that SOE is responsible for the transition between acute insomnia and chronic insomnia. This finding does not, however, change the relevance of addressing the mismatch between sleep opportunity and ability as part of behavioural treatment.

Abstract Introduction Low sleep efficiency is a clinically valuable marker of poor sleep, especially in insomnia. Less is known about real-world associations between sleep efficiency and other sleep disorders symptoms. Methods Participants completed an online sleep health screener (https://sleephealthscreen.com). This consists of the Sleep Disorders Symptom Check List (SDSCL), as well as several other questions establishing demographics and respondent characteristics. All responses are anonymous. All consecutive responses to the questionnaire were included, following cleaning for duplicate and invalid entries. Responses to symptom items were recoded as “Never,” “Sometimes (< 3 times per week)” or “Often (3 or more times per week).” Sleep efficiency was calculated as [TST/TIB]*100 for self-reported habitual values. Regression analyses were adjusted for age, sex, race/ethnicity, work hours, employment, and presence of a bed partner. Results A total of 3,030 individuals provided complete data. Higher sleep efficiency was associated with insufficient sleep Sometimes (+1.59%) and sleepiness Sometimes (+2.0%). Lower sleep efficiency was observed for those who report insufficient sleep Often (-2.5%), sleep irregularity Sometimes and Often (-2.0% and -8.1%, respectively), difficulty falling asleep Sometimes and Often (-3.6% and -16.3%, respectively), difficulty staying asleep Sometimes and Often (-3.6% and -17.5%, respectively), and difficulty with early morning awakenings Sometimes and Often (-3.3% and –15.3%, respectively), fatigue Often (-7.3%), phase advance Sometimes and Often (-2.3% and -3.1%, respectively), phase delay Sometimes and Often (-1.5% and -4.0%, respectively), snoring Often (-1.9%), dry mouth Often (-3.7%), uncomfortable sensations in legs at night Often (-5.7%), urge to move legs at night Sometimes and Often (-1.7% and -5.2%, respectively), frequent awakenings Sometimes and Often (-3.4% and -13.4%, respectively), cataplexy-like symptoms Often (--5.8%), sleep hallucinations Sometimes and Often (-2.5% and -4.9%, respectively), nightmares Sometimes and Often (-2.0% and -5.0%, respectively), sudden awakenings Sometimes and Often (-3.4% and -6.9%, respectively), parasomnia-like symptoms Often (-2.3%), sleep interfering with functioning Sometimes and Often (-5.3% and -11.0%, respectively). Loud snoring, observed breathing pauses, waking up choking or gasping, sleep paralysis, and bruxism were not associated with sleep efficiency. Conclusion Sleep efficiency is negatively associated with a wide range of sleep disorders symptoms, beyond insomnia. Support (if any) R01MD011600, R01MH135978

Abstract Introduction The presence of a bed partner can influence sleep, but little is known about how bed sharing relates to the self-reporting of clinical sleep disorder symptoms. On one hand, bed partners may help stabilize sleep routines and identify potential symptoms such as snoring or breathing pauses; on the other, partner presence could alter subjective awareness or reporting patterns. Understanding these associations could inform both clinical screening practices and the interpretation of self-reported sleep health data. Methods Participants completed an online sleep health screener that is available to the public (https://sleephealthscreen.com). This consists of the Sleep Disorders Symptom Check List (SDSCL), which includes 25 items related to sleep disorder symptoms. Presence of a bed partner was asked as “Do you regularly have a bed partner (>3 days/week)?” All consecutive responses to the questionnaire were included, following cleaning for duplicate and invalid entries. Ordinal regression analyses were adjusted for age, sex, race/ethnicity, work hours, and work shift. Results A total of 3,091 individuals provided complete data. Those with a bedpartner were less likely to endorse insufficient sleep (oOR=0.75), irregularity (oOR=0.57), difficulty falling asleep (oOR=0.56), staying asleep (oOR=0.73), and early morning awakenings (oOR=0.84), fatigue (oOR=0.60), phase delay (oOR=0.54), sleepiness (oOR=0.85), cataplexy-like symptoms (oOR=0.78), sleep hallucinations (oOR=0.77), sleep paralysis (oOR=0.77), nightmares (oOR=0.80), sudden awakenings (oOR=0.78), and sleep problems interfering with functioning (oOR=0.62) and more likely to report more snoring (oOR=1.51), loud snoring (oOR=2.05), and breathing pauses (oOR=1.31). Conclusion Adults with a regular bed partner reported fewer insomnia-related symptoms and better-perceived sleep regularity but were more likely to endorse snoring and breathing pauses—symptoms that are often observed by others rather than self-perceived. These findings suggest that bed partners may enhance the detection of sleep-disordered breathing while potentially reducing the subjective perception or reporting of insomnia-related difficulties. Clinically, this pattern underscores the importance of incorporating collateral information from partners in both clinical assessments and population screening tools. Community-based sleep health initiatives and digital screeners could also leverage brief items about partner observations to improve identification of individuals at risk for sleep apnea or other disturbances that may go unnoticed in self-report–only contexts. Support (if any) R01MD011600, R01MH135978

Abstract Introduction Insomnia is more common among older adults and may increase risk for suicide in this population. Treating insomnia may reduce suicide risk. Cognitive behavioral therapy for insomnia is the first-line recommended therapy for insomnia and is available in a digital format (dCBT-I). This study piloted dCBT-I in older adults with both insomnia and suicidal ideation. Main outcomes included feasibility, tolerability, and intervention effect. Methods Older adults with suicidal ideation recruited from outpatient clinic referrals and internet advertising were randomized to either dCBT-I treatment (TX, N=13) or to waitlist control with crossover treatment (WLC, N=11). Treatment was provided through Sleep Health Using the Internet (SHUTi). Outcomes included the Columbia Suicide Severity Rating Scale (CSSRS), the Insomnia Severity Index (ISI), and the Center for Epidemiologic Studies Depression Scale (CESD) and treatment effects were estimated using linear mixed effects regression models. Tolerability was assessed using a self-report questionnaire. Results Mean participant age was 69.1 years and did not differ between groups (p=0.26). Out of N=19 participants that completed baseline measures (11 TX, 8 WLC), N=12 (6 TX, 54.5%; 6 WLC, 75%) completed dCBT-I or monitoring. All N=6 WLC participants crossed over to dCBT-I and completed treatment, and N=1 TX participant dropped out after dCBT-I, leaving N=11 total dCBT-I completers. The most common side effects were sleepiness (N=8/11), anxiety (N=7/11), feeling tired (N=7/11), depression (N=6/11), and apathy (N=6/11). Two participants (8.3%) discontinued due to worsening mental health. No falls, suicide attempts, or preparatory acts for suicide were reported. Baseline insomnia severity averaged 14.7 (range 6-26), depression severity averaged 25.9 (range 7-49), and suicidal ideation averaged 2.18 (range 0-5); there were no group differences at baseline. Regression models showed significant decreases in suicidal ideation (-1.1, p=0.048), insomnia (-5.6, p=0.02), and depression (-9.4, p=0.043) across groups, and a trend toward a group difference in insomnia severity before crossover (-5.9, p=0.087). Conclusion Older adults with suicidal ideation tolerated dCBT-I without severe adverse effects, although dropout was high. Future work to reduce attrition and increase engagement with dCBT-I may increase access to insomnia treatment in this population. Support (if any) K24AG055602; R25MH112473

Abstract Introduction Previous research has found that Black, Hispanic, and Asian individuals generally have lower sleep duration, lower sleep quality, and higher sleepiness. Few studies have explored how a wider array of sleep outcomes vary across race/ethnicity. Methods Participants completed an online sleep health screener that is available to the public (https://sleephealthscreen.com). This consists of the Sleep Disorders Symptom Check List (SDSCL), which includes 25 items related to sleep disorder symptoms. Race/ethnicity categories allowed for multiple selections. Therefore, analyses for each category examined a “Yes” vs “No” endorsement for each, irrespective of endorsement for other categories. All responses are anonymous. All consecutive responses to the questionnaire were included, following cleaning for duplicate and invalid entries. Ordinal regression analyses were adjusted for age, sex, work shift, work hours, and presence of a bed partner. Results A total of 3,091 individuals provided complete data. White respondents reported more fatigue, frequent awakenings, sleep hallucinations, sleep paralysis, nightmares, sudden awakenings, parasomnia-like symptoms, bruxism, and sleep interfering with functioning. Black respondents were more likely to report irregularity, more difficulty falling asleep and staying asleep, more fatigue, gasping, frequent awakenings, sleep hallucinations, sleep paralysis, sudden awakenings, parasomnia-like symptoms, and sleep interfering with functioning. Hispanic/Latino respondents were more likely to report insufficient sleep, irregularity, difficulty falling asleep and staying asleep and early morning awakenings, more fatigue, morning dry mouth, breathing pauses, frequent awakenings, cataplexy-like symptoms, sleep hallucinations, sleep paralysis, nightmares, sudden awakenings, bruxism, and sleep interfering with functioning. Asian respondents were less likely to report difficulty staying asleep and early morning awakenings, and more likely to report phase delay. Conclusion Among real-world completers of an online sleep disorders screening questionnaire, there were reporting differences across groups. Hispanic/Latino individuals reported the highest number of sleep symptoms, though White and Black respondents also reported more symptoms than those who did not indicate being a member of those groups. Asian individuals reported the fewest sleep-related symptoms. Support (if any) R01MD011600, R01MH135978

Abstract Introduction Specific sleep disorders symptoms most strongly associated with reduced sleep time in a real-world setting are not well characterized. Hence, this study analyzes data from a screening questionnaire to explore how the frequency of common sleep symptoms relates to self-reported sleep duration. Methods Participants completed an online sleep health screener (https://sleephealthscreen.com). This consists of the Sleep Disorders Symptom Check List (SDSCL), as well as several questions establishing respondent characteristics. All responses are anonymous. All consecutive responses to the questionnaire were included, following cleaning for duplicate and invalid entries. Responses to symptom items were recoded as “Never,” “Sometimes (< 3 times per week)” or “Often (3 or more times per week).” Sleep duration was self-reported in hours and minutes. Regression analyses were adjusted for age, sex, race/ethnicity, work hours, employment, and presence of a bed partner. Results A total of 3,030 individuals provided complete data. Shorter sleep duration was observed for those who report insufficient sleep Often (-60.7mins), sleep irregularity Often (-34.6mins), difficulty falling asleep Often (-57.7mins), difficulty staying asleep Sometimes and Often (-20.9mins and -94.9 mins, respectively), and difficulty with early morning awakenings Sometimes and Often (-19.1mins and -92.1mins, respectively), fatigue Often (-28.2mins), sleepiness Sometimes (-9.3mins), phase advance Sometimes and Often (-51.1mins and -31.3mins, respectively), snoring Often (-13.9 mins), dry mouth Often (-21.4mins), loud snoring Often (-14.3 mins), observed breathing pauses Often (-19.2mins), waking up choking or gasping Often (-32.6mins), uncomfortable sensations in legs at night Often (-19.6 fewer mins), urge to move legs at night Often (-21.1mins), frequent awakenings Sometimes and Often (-11.8mins and -65.7mins, respectively), cataplexy-like symptoms Often (-26.4mins), sudden awakenings Sometimes and Often (-9.0mins and -30.2mins, respectively), parasomnia-like symptoms Often (-15.3mins), sleep interfering with functioning Sometimes and Often (-23.7mins and -39.9mins, respectively). Phase delay, sleep hallucinations, sleep paralysis, nightmares, and bruxism were not associated with sleep duration. Conclusion Frequent insomnia-related symptoms are most strongly associated with shorter self-reported sleep duration, though symptoms consistent with sleep disorders such as sleep apnea, restless legs syndrome, and narcolepsy are also associated. These results highlight the value of utilizing broad symptom screeners for identifying individuals at risk for clinically significant sleep loss. Support (if any) R01MD011600, R01MH135978

Abstract Self-report measures have been the core of behavioral sleep medicine (BSM) assessments and interventions since the field’s inception. While these remain the gold standard, there are times when objective accessible assessments are needed. The aim is to trace the development and progression of actigraphy as a key tool in sleep research and clinical practice. The authors outline the historical foundations of actigraphy, from early motion-sensing devices to modern wrist-worn accelerometers, highlighting technological advancements that have improved sensitivity, specificity, and integration with BSM. They explore the clinical application of actigraphy, presenting evidence for and against its use in assessing and treating specific sleep and circadian disorders across the life span. Additionally, the authors examine contemporary applications, including wearable consumer devices, remote patient monitoring, and big data analytics in sleep medicine. They conclude by addressing current limitations and future directions, emphasizing the need for standardization and performance evaluation.

Abstract Introduction While shift work is linked to sleep disruption, less is known about the impact specific work characteristics on clinical sleep symptoms. We examined whether employment status and schedule were associated with different sleep disorder symptom reports. Methods Participants completed an online sleep health screener that is posted online and available to the public (https://sleephealthscreen.com). This consists of the Sleep Disorders Symptom Check List (SDSCL), which includes 25 items related to sleep disorder symptoms, rated as “Never,” “Once a month,” “1-2 times a week,” “3-4 times a week,” or “5-7 times a week.” Employment and work shift was addressed with an item where respondents indicated whether they primarily worked a day shift (9am-5am), morning shift (4am-12pm), night shift (12am-8am), multiple shifts, if they worked from home, if they were retired, or if they were unemployed. All responses are anonymous. All consecutive responses to the questionnaire were included, following cleaning for duplicate and invalid entries. Ordinal regression analyses were adjusted for age, sex, race/ethnicity, work hours, and presence of a bed partner. Results A total of 3,091 individuals provided complete data. Compared to people who generally work a day shift (9am-5am), those working morning hours (4am-12pm) were more likely to endorse insufficient sleep, irregularity, and phase advance. Those working night shift (12am-8am) were more likely to report difficulty falling asleep and early morning awakenings, more fatigue, and more interference with functioning. They were less likely to report bruxism. Those who report that they primarily work from home were less likely to endorse insufficient sleep but more likely to report difficulty falling asleep and staying asleep and early morning awakenings, more fatigue, sleepiness, dry mouth, breathing pauses, gasping, uncomfortable sensations in legs, urge to move legs, frequent awakenings, and more interference with functioning. Those working multiple shifts across the day reported more bruxism. Retired individuals were more likely to report insufficient sleep. Conclusion Although night shift work has become recognized as having adverse impacts on sleep, more research is needed to explore whether working early morning hours and working from home adversely impact sleep health. Support (if any) R01MD011600, R01MH135978

Abstract Introduction At present the uncodified standard for the medical treatment of insomnia is to use hypnotics as needed or intermittently (3-5x per week). While both approaches are dose sparing, neither may provide for the highest rate of treatment responding. Based on prior work, it was hypothesized that intermittent dosing without the interspersion of placebos would be the least effective strategy. Methods A four group RCT with longitudinal follow-up was used to evaluate a two-step treatment protocol. In Step-1, all patients were treated nightly with zolpidem (5mg or 10mg) for one month. In Step-2, treatment responses were maintained for up to 3 months with one of four strategies: nightly dosing; intermittent dosing; or intermittent dosing w/ placebos interspersed (either 1 or 3 active doses per week). Group differences were evaluated with an omnibus exact test for response rates, a Log-Rank test for time to relapse, and a GEE model was used to assess sleep continuity. Results 115 subjects with chronic insomnia were enrolled in Step-1. 10% of subjects were lost to follow-up. 82 subjects (71%) exhibited treatment responses and were randomized in Step-2 to one of the four maintenance treatment conditions. The positive clinical effects in Step-1 were on sleep latency (reduced by 43%), wake after sleep onset (reduced by 44%), and total sleep time (increased by 8%). Early morning awakening was largely unaffected (reduced by about 3%). In step-2, the four maintenance strategies did not significantly differ with respect to: relapse rates; latency to relapse; or average sleep continuity. As assessed with a weekly medical symptom check list, the groups did not differ with respect to the incidence, frequency, or severity of medical symptoms. Conclusion As expected, Step-1 produced good treatment outcomes. Contrary to expectation, all forms of intermittent dosing used for maintenance therapy were sufficient to maintain treatment response. These results suggest that an optimal strategy for the long-term medical treatment of insomnia is to utilize a two-step regimen: nightly dosing for one month (to maximize treatment responding) and (2) intermittent dosing for maintenance therapy (to reduce the amount of a drug required to maintain therapeutic effects). Support (if any) N/A

Abstract Introduction Insomnia is a common and persistent concern among breast cancer survivors, often continuing well beyond active treatment. Although Cognitive Behavioral Therapy for Insomnia (CBT-I) improves sleep continuity, the optimal dose of the intervention in oncology settings remain unclear. This study assessed the feasibility of a multi-dose CBT-I protocol and examined trajectories of sleep continuity, and adherence over the course of treatment. Methods Breast cancer survivors aged 25–85 (n=28; 78.6% White), within 6 years of completing treatment, were enrolled. Eligible participants endorsing clinically significant insomnia and fatigue (85.7% insomnia+fatigue) were randomized to one of four CBT-I dose groups (4, 8, 10, or 12 sessions). All treatment was delivered weekly via HIPAA-compliant telehealth by a CBT-I clinician. Primary outcomes included feasibility metrics: recruitment [goal, n=60] & retention (enrolled through final session) and adherence (deviation [minutes] between prescribed & actual time-in-bed and stimulus-control schedules). Exploratory outcomes included diary-derived sleep latency (SL), wake after sleep onset (WASO), and early morning awakenings (EMA). Group differences in sleep continuity over time were evaluated with a GEE model. Secondary models tested group differences in adherence. Results Recruitment goals were successfully achieved, with 61 participants enrolled. With respect to retention, approximately half of the subjects were subsequently disenrolled due to factors such as cancer recurrence, psychosocial stressors, loss to follow-up, and the discovery of medical comorbidities (e.g., newly identified sleep apnea). Of the remaining participants, 35 initiated the study protocol, and 28 ultimately completed the trial. With respect to sleep continuity, GEE models demonstrated significant time effects, with reductions in SL, WASO and EMA across all groups (all β_time < 0, p < .001). Finally, with respect to adherence, dose did not moderate differences in groups, indicating parallel trajectories across randomized groups (all interaction p > .10). Conclusion A multi-dose CBT-I protocol is feasible for breast cancer survivors. Preliminary results suggest that across all groups, participants showed statistically significant improvements in sleep continuity over time (i.e., they fell asleep faster, spent less time awake during the night, and had fewer early awakenings). However there is no effect of CBT-I dosage on adherence. Analyses are ongoing. Support (if any) 1R21CA27098701

Prior research indicates that individuals with Mild Cognitive Impairment (MCI) or Alzheimer’s Disease (AD) exhibit higher-than-normal levels of sleep disturbance. Epidemiologic studies suggest that poor sleep may be a risk factor for the progression of Alzheimer’s Disease and Related Dementias (ADRD). Despite these findings, the literature is non-specific regarding the types of sleep disturbances that present in this population. We aimed to assess the various forms of sleep disturbance in individuals with and without minor memory complaints (MMC). Data were obtained from an online sleep and health survey, with participants directed to the site via advertisements on platforms such as Facebook, Google, TV, and local newspapers. The survey includes sections on general sleep, health conditions, and chronic diseases, and takes approximately 20 minutes to complete. In 2024, three questions regarding memory function were added: (1) recent memory issues, (2) use of supplements or over-the-counter medications for memory, and (3) diagnosis or treatment for memory problems. Two groups were formed based on reported memory problems, distinguishing those with minor memory complaints (MMC) from those without. Analyses focused on sleep patterns (e.g., Time in Bed, Wake After Sleep Onset, Sleep Efficiency), insomnia severity, and frequency of sleep disorders. Bivariate contrasts were conducted with an alpha level set at p< 0.01. The sample included 308 participants (mean age 46.0 ± 12.9, 64% female, 14% non-white). Of these, 134 had MMC and 174 did not. The groups did not differ demographically, but those with MMC exhibited a subtle sleep phase delay (~30 minutes), increased insomnia severity (related to daytime function), and a higher frequency of parasomnic behaviors (e.g., nightmares). Subjects with MMC demonstrated more severe sleep disturbance, particularly with phase delays and parasomnias. These findings suggest that sleep disturbance may occur early in cognitive decline and could serve as a potential early indicator of MCI. Given the connection between sleep and memory function, these results may offer insight into the pathophysiology of ADRD. Analyses are ongoing.

'How much sleep does one need?' is a critical question that has been difficult to answer. The long history of sleep research has culminated in population-derived normative values of 7 to 9 h of sleep per night to avoid dysfunction. Such a wide range is sufficiently large that one cannot know what is required for any given individual. 'Sleep need' cannot currently be directly measured, might not be represented by one number (given the multiple functions that sleep subserves), and likely varies from individual-to-individual and from day-to-day. This said, the concept should be embraced and can be considered alongside more easily operationalised and routinely measured constructs of 'sleep opportunity' (e.g., time in bed) and 'sleep ability' (i.e., the obtained sleep, such as sleep duration). Considering the dynamics of all three constructs together may drive greater understanding about sleep health, sleep insufficiency, and sleep disorder pathology. In this article, we describe a new theory called Sleep Opportunity, Need, and Ability and provide a rationale for why this theory has both theoretical and clinical value.

Insomnia Disorder (ID) is a highly debilitating disorder affecting up to 10% of the general population. In recent years, the number of studies in this area has increased rapidly, resulting in a wealth of accumulated knowledge. ID is generally regarded as a hyperarousal disorder affecting cognitive, emotional, cortical and physiological domains. Nevertheless, there is still a significant lack of knowledge about the pathophysiology of ID. For example, the existence of insomnia subtypes is discussed, albeit no uniform definition has yet been found. Significant progress has been made in understanding the neurobiology of insomnia, which points to a dysfunction in emotion regulation. However, neuroimaging studies frequently have small sample sizes and allow only for limited causal conclusions. The assessment of sleep has been significantly influenced by the increasing availability of methods for ambulatory sleep measurement. While these methods enable sleep to be measured more cost-effectively than polysomnography, many devices lack sufficient empirical evidence of validity. In terms of insomnia treatment, cognitive behavioural therapy for insomnia (CBT-I) has been shown to be highly effective. However, the underlying mechanisms of CBT-I remain partially unclear, and the optimal sequence for applying the individual components, as well as the effectiveness of CBT-I in cases of comorbidity, remain open questions. Furthermore, many widely applied pharmacological treatment approaches are used off-label with only a limited empirical evidence base. This narrative review aims to summarise the current state of research on ID and attempts to outline a selection of the important future challenges in insomnia research.

Abstract Introduction Insomnia and Cancer-related fatigue (CRF) are highly prevalent during acute illness and survivorship, with almost 100% of cancer patients experiencing at least one of these at some point during treatment. Concerningly, insomnia and CRF have long-term effects on quality of life, daytime function, and are associated with medical and psychiatric morbidity. No studies to date have assessed concurrent change in CRF and insomnia with radiation therapy. Thus, the present analysis aimed to characterize insomnia & CRF prevalence and severity pre- and post-radiation. Methods Insomnia and fatigue were assessed pre- and post-radiation among 32 adults diagnosed with cancer (Mage=58.22 years, SDage=10.54, 46.9% female, 62.5% White). Subjects were asked to complete the Insomnia Severity Index, Functional Assessment of Chronic Illness Therapy – Fatigue Scale (FACIT-F), Brief Fatigue Inventory (BFI) and PROMIS-SF Fatigue 7A at each timepoint. Descriptive statistics are used characterize the severity of insomnia and CRF at each timepoint and exploratory t-tests examined whether sex was associated with change in insomnia and fatigue severity from pre- to post-radiation. Results The mean ISI total score was 8.25 (SD=5.01) pre-radiation, and 8.50 (SD=3.46) post-radiation. The mean FACIT-F total score was 40.34 (SD=9.01) pre-radiation and 34.67 (SD=8.69) post-radiation. There was one (3.12%) case of new-onset clinical insomnia and five (15.63%) cases of new-onset clinical fatigue from pre- to post-radiation. Females reported greater increases in fatigue from pre- to post-radiation compared to males (t(31)=-4.612, p < 0.001, d=-1.44). Conclusion Insomnia and fatigue are highly prevalent in patients diagnosed with cancer at both pre- and post-radiation. Overall, insomnia stayed relatively stable while fatigue increased over treatment. This suggests that separate mechanisms may drive cancer-related fatigue and insomnia. Fatigue increased over treatment for both men and women, however this effect was stronger for women. A better understanding of mechanisms of insomnia and CRF may allow for earlier detection of insomnia and CRF as well as the use of targeted interventions for individuals struggling with CRF and/or insomnia during cancer treatment and recovery, especially among women. Support (if any) University of Pennsylvania, Radiation Oncology, Chair's Summer Research Grant

Abstract Introduction Suicide is the second-leading cause of death among young adults. Disrupted sleep and circadian rhythms may contribute to the risk of suicide in this age group. Nocturnal wakefulness, for example, may create changes in brain function that contribute to increased incidence of suicide. However, there are limited data on whether suicidal cognitions vary across the day. Methods A sample of N=143 individuals aged 18-25 were recruited to participate in a week-long ecological momentary assessment study of sleep and suicidal thoughts. Sleep was sampled daily using a sleep diary, and suicide-related cognitions were sampled five times per day using automated text messages. Text surveys were scheduled across 24 hours (roughly at 2AM, 7AM, 12PM, 5PM and 10PM) and grouped into 6-hour bins (2300-0459, 0500-1059, 1100-1659, 1700-2259). Individuals with unusual or elevated levels of suicidal ideation were followed-up by study personnel for safety. Results A total of N=3442 text surveys were collected from N=134 participants. Participants provided an average of 26 surveys each (SD=8.3). A total of N=93 (2.8%) of surveys reported suicidal ideation. As a proportion of all surveys, suicidal ideation was most prevalent from 2300-0459 (N=18, 3.2%) and least from 0500-1059 (N=20, 2.2%). Among suicidal ideators, the desire to die was most elevated from 1100-1659 (1.8 out of 4, SD = 1.19), the intention to die was greatest from 1100-1659 (0.9 out of 3, SD=0.8), and the ability to resist the urge to die was lowest in the 0500-1059 (3.1 out of 4, SD=1.12). However, there were no statistical differences across time categories for the presence of suicidal ideation or severity/intensity of these thoughts. Conclusion Suicidal ideation was measured in nearly every hour of the 24-hour day, and severity of suicidal ideation appeared to fluctuate over time. Nevertheless, the presence of suicidal ideation and its severity did not differ statistically across the day, likely due to the small number of reported suicidal cognitions across the sample. Additional work will examine how sleep continuity and/or regularity may influence these findings. Support (if any)

Importance:Chronic insomnia disorder is highly prevalent, disabling, and costly. Cognitive behavioral therapy for insomnia (CBT-I), comprising various educational, cognitive, and behavioral strategies delivered in various formats, is the recommended first-line treatment, but the effect of each component and delivery method remains unclear. Objective:To examine the association of each component and delivery format of CBT-I with outcomes. Data Sources:PubMed, Cochrane Central Register of Controlled Trials, PsycInfo, and International Clinical Trials Registry Platform from database inception to July 21, 2023. Study Selection:Published randomized clinical trials comparing any form of CBT-I against another or a control condition for chronic insomnia disorder in adults aged 18 years and older. Insomnia both with and without comorbidities was included. Concomitant treatments were allowed if equally distributed among arms. Data Extraction and Synthesis:Two independent reviewers identified components, extracted data, and assessed trial quality. Random-effects component network meta-analyses were performed. Main Outcomes and Measures:The primary outcome was treatment efficacy (remission defined as reaching a satisfactory state) posttreatment. Secondary outcomes included all-cause dropout, self-reported sleep continuity, and long-term remission. Results:A total of 241 trials were identified including 31 452 participants (mean [SD] age, 45.4 [16.6] years; 21 048 of 31 452 [67%] women). Results suggested that critical components of CBT-I are cognitive restructuring (remission incremental odds ratio [iOR], 1.68; 95% CI, 1.28-2.20) third-wave components (iOR, 1.49; 95% CI, 1.10-2.03), sleep restriction (iOR, 1.49; 95% CI, 1.04-2.13), and stimulus control (iOR, 1.43; 95% CI, 1.00-2.05). Sleep hygiene education was not essential (iOR, 1.01; 95% CI, 0.77-1.32), and relaxation procedures were found to be potentially counterproductive(iOR, 0.81; 95% CI, 0.64-1.02). In-person therapist-led programs were most beneficial (iOR, 1.83; 95% CI, 1.19-2.81). Cognitive restructuring, third-wave components, and in-person delivery were mainly associated with improved subjective sleep quality. Sleep restriction was associated with improved subjective sleep quality, sleep efficiency, and wake after sleep onset, and stimulus control with improved subjective sleep quality, sleep efficiency, and sleep latency. The most efficacious combination-consisting of cognitive restructuring, third wave, sleep restriction, and stimulus control in the in-person format-compared with in-person psychoeducation, was associated with an increase in the remission rate by a risk difference of 0.33 (95% CI, 0.23-0.43) and a number needed to treat of 3.0 (95% CI, 2.3-4.3), given the median observed control event rate of 0.14. Conclusions and Relevance:The findings suggest that beneficial CBT-I packages may include cognitive restructuring, third-wave components, sleep restriction, stimulus control, and in-person delivery but not relaxation. However, potential undetected interactions could undermine the conclusions. Further large-scale, well-designed trials are warranted to confirm the contribution of different treatment components in CBT-I.

Abstract Introduction Suicide is the second-leading cause of death among young adults. Feelings of thwarted belongingness and perceived burdensomeness may accompany or precipitate suicidal thoughts. It is unclear how these negative cognitions vary across the day. Methods Individuals aged 18-25 (N=143) participated in a week-long ecological momentary assessment study of sleep (measured by daily sleep diaries) and feelings of social belonging and perceived burdensomeness (measured by text message surveys sent five times per day). Each dimension was assessed by three questions with ratings from 1 (not true at all for me) to 7 (very true for me). Text surveys were scheduled across the day (roughly at 2AM, 7AM, 12PM, 5PM and 10PM), and responses were categorized by whether the individual reported suicidal ideation at that time or not. Results A total of N=3442 text surveys were collected from N=134 participants. Participants provided an average of 26 of 35 possible surveys (SD=8.3). Non-ideators reported consistently elevated feelings of social belonging (5.41 out of 7, SD=1.71) and consistently low feelings of perceived burdensomeness (1.54 out of 7, SD=1.13). Suicidal ideators, however, reported generally low social belonging (2.8 out of 7, SD=1.84) and elevated perceived burdensomeness (4.31 out of 7, SD=1.99). Two-way ANOVAs found that social belonging varied significantly by suicidal ideation (p < 0.001) and marginally for time by suicidal ideation (p = 0.069). Perceived burdensomeness varied only by suicidal ideation (p < 0.001); there was no significant interaction of time by suicidal ideation. Conclusion Feelings of social belonging and perceived burdensomeness varied substantially only for individuals experiencing suicidal ideation, and only marginally over time among suicidal ideators. Additional work is needed to determine how sleep continuity and regularity may influence these findings. Support (if any)