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BACKGROUND: Sleep disorders are common among older adults, leading to high prevalence of over-the-counter and prescription sleep medication use. Socioeconomically disadvantaged individuals have higher prevalence of sleep disorders. Frequent use of sleep medications can increase the risk of falls. Little is known about the association between wealth and sleep medication use in older adults. METHODS: We conducted a cross-sectional analysis using a nationwide sample of 7603 Medicare beneficiaries (65+ years) from Round 1 (2011) of the National Health and Aging Trends Study. We measured self-reported wealth as the sum of assets (retirement savings, stocks/bonds, checking/savings accounts, business assets, and home value) minus liabilities (mortgage, credit card, and medical debt). Self-reported sleep medication use in the past month was categorized as frequent (5-7 nights/week), sometimes (1-4 nights/week), or never (0 night/week). We estimated differences in the prevalence of sleep medication use by quintiles of wealth using crude and adjusted binomial regression models. Individuals missing sleep medication information were excluded. RESULTS: Median wealth was $152 582 (IQR: $24 023-412 992). Sixteen percent reported frequent sleep medication use, 15% reported some use, and 70% reported no use. Frequent sleep medication use was more common in lower wealth quintiles (lowest: 20%, highest: 12%). Alternatively, some use was more common in higher wealth quintiles (lowest: 11%, highest: 18%). Results were similar after adjustment for demographic factors, anxiety, depression, and sleep disorders. CONCLUSIONS: In this study, less wealthy older adults had higher prevalence of frequent sleep medication use. This may lead to dependency or increased fall risk in this vulnerable population.

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STUDY OBJECTIVES: To examine beliefs about prescription sleep medications (hypnotics) among individuals with insomnia disorder seeking cognitive behavioral therapy for insomnia and predictors of wishing to reduce use. METHODS: Baseline data was collected from 245 adults 50 years and older enrolled in the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study. T-tests compared characteristics of prescription sleep medication users with those of nonusers. Linear regression assessed predictors of patients' beliefs about sleep medication necessity and hypnotic-related concerns. Among users, we examined predictors of wishing to reduce sleep medications, including perceived hypnotic dependence, beliefs about medications, and demographic characteristics. RESULTS: Users endorsed stronger beliefs about the necessity of sleep medications and less concern about potential harms than nonusers (P < .01). Stronger dysfunctional sleep-related cognitions predicted greater beliefs about necessity and concern about use (P < .01). Patients wishing to reduce sleep medications reported greater perceived hypnotic dependence than those disinterested in reduction (P < .001). Self-reported dependence severity was the strongest predictor of wishing to reduce use (P = .002). CONCLUSIONS: Despite expressing strong beliefs about necessity, and comparatively less concern about taking sleep medications, three-quarters of users wished to reduce prescription hypnotics. Results may not generalize to individuals with insomnia not seeking nonpharmacological treatments. Upon completion, the "RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice" study will provide information about the extent to which therapist-led and digital cognitive behavioral therapy for insomnia contribute to prescription hypnotic reduction. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The RESTING Insomnia Study: Randomized Controlled Study on Effectiveness of Stepped-Care Sleep Therapy (RESTING); URL: https://clinicaltrials.gov/ct2/show/NCT03532282; Identifier: NCT03532282. CITATION: Tully IA, Kim JP, Simpson N, et al. Beliefs about prescription sleep medications and interest in reducing hypnotic use: an examination of middle-aged and older adults with insomnia disorder. J Clin Sleep Med. 2023;19(7):1247-1257.

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AIM: We investigated the association of electroconvulsive therapy (ECT) with anxiolytic and sleep medication use in patients with major depressive disorder (MDD) and schizophrenia (SZ). METHODS: This nationwide observational study analyzed data from 3483 MDD inpatients and 6663 SZ inpatients. Patients with MDD and SZ were classified into those who underwent ECT during hospitalization and those who did not. A propensity score-matching method was performed to adjust for preadmission characteristics and clinical information, which were expected bias between the two groups. Rates of anxiolytic and sleep medication use at discharge were compared in the matched sample. RESULTS: 500 MDD patients were assigned to both groups. In the matched MDD sample, the rate of anxiolytic and sleep medication use at discharge was significantly lower in the ECT group than in the non-ECT group (64.9% vs. 75.8%, P = 1.7 × 10-4 ). In the ECT group, the rate of anxiolytic and sleep medication use at discharge was significantly lower than that prior to admission (64.9% vs. 73.2%, P = 1.2 × 10-14 ). 390 SZ patients were allocated. In the matched SZ sample, the ECT group was not significantly different from the non-ECT group in the rate of anxiolytics and sleep medications use at discharge (61.3% vs. 68.2%, P = 4.3 × 10-2 ). In the ECT group, the rate of anxiolytics and sleep medications use at discharge was significantly lower than that before admission (61.3% vs. 70.5%, P = 4.4 × 10-4 ), although this was not the primary outcome. CONCLUSION: Reduction of anxiolytic and sleep medication use may be considered positively when ECT is indicated for treatment of MDD.

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OBJECTIVE: To investigate the association between multimorbidity and sleep medication use in women. METHODS: A population-based cross-sectional study was conducted on women (20-69 years) in Southern Brazil. Sleep medications were identified using the Therapeutic and Chemical Anatomical Classification. Multimorbidity was operationalized according to two cutoff points: diagnosis of either two or more or three or more chronic conditions and presence or absence of obesity. Explanatory variables included sociodemographic, behavioral, and health factors including obesity and common mental disorders (CMD) (assessed using the Self-Reporting Questionnaire 20 for CMD). Crude and adjusted prevalence ratios (PR) and 95% confidence intervals (95%CIs) were estimated with Poisson regression with robust variance using various adjustment models. RESULTS: In a sample of 1128 women, the prevalence of sleep medications was 14.3% (95%CI 12.2-16.3). After adjustments, the association between multimorbidity and sleep medication use yielded the following PR: multimorbidity ≥ 2:1.78 (95%CI, 1.23-2.56) and multimorbidity ≥ 3:1.90 (95%CI, 1.36-2.68). When obesity was included in the model, the effect was in the same direction but smaller, indicating that the presence of multimorbidity had an independent effect on the use of sleep medications, even after adjusting for CMD. CONCLUSION: The presence of multimorbidity increased the probability of using sleep medications by approximately 80%, regardless of the observed cutoff point, inclusion of obesity in multimorbidity, and adjustment for CMD. Specific aspects of some chronic conditions may interfere with sleep quality, predisposing women to begin use of these medications at early ages and, consequently, to continue their use throughout later life.

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STUDY OBJECTIVES: Recent initiatives to discourage overprescription of sleep medications have increased awareness of their potential adverse effects; however, it is unknown whether these efforts translated into a decline in use of these medications in the United States. We assessed recent national trends in the use of medications used for sleep disturbance. METHODS: We used data from n = 29,400 participants in the 2013-2018 National Health and Nutrition Examination Survey. At each of three waves of in-person assessments, participants presented prescription bottles for all medications used in the prior month. Interviewers recorded each medication and participants self-reported duration and reasons for use. We identified all medications used for sleep disturbance and categorized medications into two categories: Food and Drug Administration-approved sleep medications and those used off-label for sleep disturbance. We examined changes in the prevalence in use of these medications across the study period. RESULTS: The odds of using medications for sleep disturbance decreased 31% between 2013 and 2018 (odds ratio = 0.69, 95% confidence interval = 0.51-0.93, P = .015). This trend was driven by declines in use of Food and Drug Administration-approved medications for sleep disturbance, especially for medium- and long-term duration of use. Notably, among those age 80+ years, we observed an 86% decline (odds ratio = 0.14, 95% confidence interval = 0.05-0.36, P < .001) in use of Food and Drug Administration-approved sleep medications over the study period. CONCLUSIONS: Use of prescription medications for sleep disturbance declined nationally, suggesting a possible effect of efforts to curb overprescription and encourage judicious use of these agents. Future research needs to examine whether these changes have coincided with improved population sleep health. CITATION: Kaufmann CN, Spira AP, Wickwire EM, et al. Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018. J Clin Sleep Med. 2022;18(10):2459-2465.

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Cyclin-dependent kinase-like 5 (CDKL5) gene pathogenic variants result in CDKL5 deficiency disorder (CDD). Early onset intractable epilepsy and severe developmental delays are prominent symptoms of CDD. Comorbid sleep disturbances are a major concerning symptom for families. We aimed to explore the relationship between insomnia, daytime sleepiness, sleep medications and quality of life in children with CDD. Caregivers of 129 children with CDD in the International CDKL5 Disorder Database completed the Quality-of-Life Inventory-Disability (QI-Disability) questionnaire and "Disorders of Maintaining Sleep" (DIMS) and the "Disorders of Excessive Somnolence" (DOES) items of the Sleep Disturbance Scale for Children. Adjusting for covariates, a unit increase in DOES score was associated with reduced quality of life total (coefficient -3.06, 95% confidence interval [CI] 1.35-7.80), physical health (coefficient -7.20, 95% CI -10.64, -3.76) and negative emotions (coefficient -3.90, 95% CI -7.38, -0.42) scores. Adjusting for covariates, a unit increase in DIMS score was associated with reduced negative emotions (coefficient -6.02, 95% CI -10.18, -2.86). Use of sleep medications had small influences on the effect sizes. This study highlights the importance of sleep problems as a determinant of quality of life in children with CDD, consistent with effects observed for other groups of children with intellectual disability. Excessive daytime sleepiness was particularly associated with detrimental effects on quality of life. Further research in optimal behavioural and pharmaceutical management of sleep problems for this population is required.

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OBJECTIVE: The presence of insomnia in the general military population is not well known. This study aimed to determine the prevalence of probable clinical insomnia and identify factors leading to new-onset insomnia and/or sleep medication use in a large military population. DESIGN: Cross-sectional and longitudinal analyses of a prospective cohort study. PARTICIPANTS: A tri-service US military and veteran cohort (sample range 99,383-137,114). MEASUREMENTS: Participants were surveyed in 2013 (Time 1 [T1]) and 2016 (Time 2 [T2]) using the clinically validated Insomnia Severity Index. The prevalence of insomnia and sleep medication use was quantified at both times. Multivariable models identified military factors associated with new-onset insomnia and/or sleep medication use while adjusting for covariates. RESULTS: The prevalence of insomnia at T1 and T2 was 16.3% and 11.2%, respectively. New-onset insomnia at T2 was reported by 6.0% of participants screening negative at T1; risk factors included Army service, combat deployment experience, and separation from military service. The prevalence of sleep medication use at T1 and T2 was 23.1% and 25.1%, respectively. Sleep medication use at T2 was newly-reported by 17.1% of participants not reporting sleep medication use at T1; risk factors included number of deployments and having a healthcare occupation. CONCLUSIONS: The prevalence of probable clinical insomnia in this large general military population is within the range of previous reports in military and civilian populations. Certain military factors that predict new-onset insomnia and/or sleep medication use should be considered when designing and implementing sleep interventions in military populations.

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BACKGROUND: Sleep quality has a significant impact on the physical and mental health of the young population. STUDY AIM: To evaluate sleep efficiency, sleep disturbances, and use of sleep medication among university students in Jordan and to examine differences in these problems in relation to selected demographic and health-risk behaviors. METHODS: The study used a cross-sectional design and a multi-stage sampling technique. Three public universities were randomly selected from three major governorates in Jordan. The Arabic version of the Pittsburgh Sleep Quality Index was used to measure sleep efficiency, sleep disturbances, and the use of sleep medication. Descriptive statistics and Kruskal-Wallis tests were used to analyze the data. RESULTS: Of 1308 students who participated in the study, 27% reported sleep efficiency less than 85%, 45% of the students reported nocturnal awakening, 30% reported getting up to use the bathroom, and 9% reported using medication to help sleep. Differences in sleep efficiency, sleep disturbances, and use of sleep medication were found in relation to students' gender, income, marital status, smoking status, and academic achievement. CONCLUSIONS: Poor sleep efficiency, sleep disturbances, and the use of sleep medications are significant problems affecting sleep quality among university students. Students' gender, marital status, income, smoking status, and academic achievement are important factors associated with sleep quality. IMPLICATIONS: Sleep screening among university students is required to identify and provide treatment for sleep problems. Furthermore, educating university students about the effects of smoking on health in general and on sleep in particular should be mandated.

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BACKGROUND: Primary care physicians and child and adolescent psychiatrists often treat sleep disturbances in children and adolescents with mood disorders using medications off-label, in the absence of clear evidence for efficacy, tolerability and short or long-term safety. This study is the first to report Canadian data about prescribing preferences and perceived effectiveness reported by child and adolescent psychiatrists regarding medications used to manage sleep disturbances in children and adolescents with depression. METHODS: Canadian child and adolescent psychiatrists were surveyed on their perception of effectiveness of a range of medications commonly prescribed for sleep disturbances, their ranked preferences for these medications, reasons for avoiding certain medications, and perceived side effects. RESULTS: Sixty-seven active child and adolescent psychiatrists completed the survey. Respondents reported noting significant sleep issues in 40% of all their patients. Melatonin and trazodone were identified as the first treatment of choice by 83% and 10% of respondents respectively, and trazodone was identified as the second treatment of choice by 56% of respondents for treating sleep disturbances in children and adolescents with depression. Melatonin (97%), trazodone (81%), and quetiapine (73%) were rated by a majority of respondents as effective. Doxepin, zaleplon, tricyclic antidepressants, zolpidem, or lorazepam were rarely prescribed due to lack of evidence and/or concerns about adverse effects, long-term safety, suitability for youth, suicidality, and dependence/tolerance. CONCLUSIONS: Melatonin and certain off-label psychotropic drugs are perceived as being more effective and appropriate to address sleep disturbances in children and adolescents with depression. More empirical evidence on the efficacy, tolerability and indications for using these medications and newer group of sleep medications in this population is needed.

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PURPOSE OF REVIEW: Adverse effects of sedative-hypnotic medications on cognition are concerning. Past studies have examined benzodiazepine (BZD) use and cognitive outcomes; however, few studies have examined newer non-BZD hypnotic agents (nBHs; e.g. zolpidem). This systematic review examined observational studies assessing the association between nBH use and cognitive outcomes. RECENT FINDINGS: Five studies met eligibility requirements and were included in the review. Most studies did not find an association between nBH use and dementia diagnosis; however, we found no studies assessing other cognitive outcomes such as cognitive performance (e.g., word recall tasks). Characterization of nBH use mostly consisted of incident new use; one study assessed nBH dosing; none examined duration of use. Studies included were of strong quality. SUMMARY: This review found no association between nBH use and dementia diagnosis, although there is a need for more research on more cognitive outcomes and nBH use patterns.

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OBJECTIVES: Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use. DESIGN AND SETTING: National cross-sectional population-based residential mail survey on sleep and other symptoms. PARTICIPANTS: Random sample of women veteran VA users who completed a postal survey (N = 1533). INTERVENTIONS: None. MEASUREMENTS: The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month. RESULTS: A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11). CONCLUSIONS: Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.

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BACKGROUND: The prevalence of pregnancy-associated insomnia is high. Although insomnia may flow from normal physiologic features of pregnancy, it may also be an early warning sign of a relapse, or a trigger for a relapse, of a psychiatric illness. Those at risk for psychiatric illnesses may require medications as well as behavioral and psychotherapeutic interventions, to prevent relapse in the perinatal period. Unfortunately, few reviews of psychotropics used to treat pregnancy-related sleep disorders exist. OBJECTIVE: We discuss issues related to sleep and sleep disorders in pregnancy in the context of co-morbid psychiatric illness, and review the literature on the commonly-used medications (e.g., benzodiazepines, sedative-hypnotics, antihistamines, trazodone, and melatonin) for insomnia during pregnancy.

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Study Objectives: Cross-sectional studies suggest that insomnia symptoms are associated with falls in later life. This longitudinal study examines the independent and interactive effects of the extent of insomnia symptoms (i.e., multiple co-existing insomnia symptoms) and sleep medications on fall risk over a 2-year follow-up among community-dwelling older adults. Methods: Using data from the Health and Retirement Study (2006-2014, N = 6882, Mage = 74.5 years ± 6.6 years), we calculated the extent of insomnia symptoms (range = 0-4) participants reported (i.e., trouble falling asleep, waking up during the night, waking up too early, and not feeling rested). At each wave, participants reported recent sleep medications use and falls since the last wave, and were evaluated for balance and walking speed. Results: A greater burden of insomnia symptoms and using physician-recommended sleep medications at baseline independently predicted falling after adjusting for known risk factors of falling. The effects of insomnia symptoms on fall risk differed by sleep medications use. The extent of insomnia symptoms exhibited a positive, dose-response relation with risk of falling among those not using sleep medications. Older adults using physician-recommended sleep medications exhibited a consistently higher fall risk irrespective of the extent of insomnia symptoms. Conclusions: The number of insomnia symptoms predicts 2-year fall risk in older adults. Taking physician-recommended sleep medications increases the risks for falling in older adults, irrespective of the presence of insomnia symptoms. Future efforts should be directed toward treating insomnia symptoms, and managing and selecting sleep medications effectively to decrease the risk of falling in older adults.

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