@article{pmid39739397,

title = {Cognitive-behavioural therapy for insomnia mechanism of action: Exploring the homeostatic K-complex involvement},

author = {Marco Sforza and Charles M Morin and Thien Thanh Dang-Vu and Florence B Pomares and Aurore A Perrault and Jean-Philippe Gouin and Jitka Bušková and Karolina Janků and Alexandros Vgontzas and Julio Fernandez-Mendoza and Celyne H Bastien and Dieter Riemann and Chiara Baglioni and Giacomo Carollo and Francesca Casoni and Marco Zucconi and Vincenza Castronovo and Andrea Galbiati and Luigi Ferini-Strambi},

doi = {10.1111/jsr.14452},

issn = {1365-2869},

year  = {2025},

date = {2025-08-01},

journal = {J Sleep Res},

volume = {34},

number = {4},

pages = {e14452},

abstract = {Investigating the mechanisms of action of cognitive-behavioural therapy for insomnia (CBT-I), the first-line treatment for chronic insomnia disorder (ID), can contribute to the overall understanding of insomnia and its treatment. To date, no study has examined the relationship between K-complexes (KC) and CBT-I, despite the known homeostatic and protective function of this relevant sleep brainwave. This retrospective multicentre study aims to explore the relationship between electroencephalographic (EEG) indices and CBT-I, with a particular focus on evaluating an index of sleep homeostasis identified by KC. This research is designed to assess the predictive value of this index for treatment outcomes and to examine its variations before and after intervention. Ninety eight patients with ID underwent a 6-8 week in-person CBT-I programme, with pre-and post-treatment evaluation conducted using polysomnography (PSG) and the Insomnia Severity Index (ISI). The main outcome was determined by calculating the slope of the linear equation indexing the KC density (number of KC/minutes of N2) in each non-artifacted NREM stage 2 epoch throughout the night (KCSlope). Furthermore, the sample was categorised into Responders (ISIdecrease ≥8) and non-Responders (ISIdecrease <8). The results indicate that the KC Slope is effective not only to predict treatment response (one-way ANOVA, F = 7.831 p = 0.007; Responders = -2.954*10 ± 3.346*10, non-Responders = -5.583*10 ± 5.305*10; adjusted for PSG wake after sleep onset at the baseline), but also to detect a statistically significant improvement in sleep pressure following CBT-I (Wilcoxon signed-rank test W = 3074.000 p = 0.022; KCSlope pre-treatment = -4.054*10 ± 4.446*10, KCSlope post-treatment = -4.797*10 ± 5.710*10). These findings suggest that CBT-I increases sleep pressure in patients with chronic insomnia, highlighting a novel and relevant biomarker in this context.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40373353,

title = {Stepped care for insomnia in primary care using digital and face-to-face cognitive behavioral therapies: A pragmatic nonrandomized clinical trial},

author = {Charles M Morin and Si-Jing Chen and Kathleen Lemieux and Hans Ivers and Janet M Y Cheung and Manon Lamy and Lee Ritterband},

doi = {10.1016/j.sleep.2025.106551},

issn = {1878-5506},

year  = {2025},

date = {2025-08-01},

journal = {Sleep Med},

volume = {132},

pages = {106551},

abstract = {OBJECTIVE: To evaluate the effectiveness of a stepped-care intervention for insomnia in primary care.nnMETHODS: In this non-randomized pragmatic clinical trial, patients from primary care clinics and with chronic insomnia disorder were allowed to choose between continuing their usual treatment (prescribed sleep medication) or receiving digital CBT-I (dCBT-I), either alone or in combination with medication. After the first treatment step, non-remitters were provided with the choice of receiving face-to-face CBT-I (FtFCBT-I), medication, or no additional treatment. The primary outcome was insomnia symptoms as measured by the Insomnia Severity Index.nnRESULTS: Among 154 adults with insomnia, 73 were allocated to dCBT-I, 66 to combined treatment and 15 to medication alone based on their preference. When compared to medication alone, first-step treatment with dCBT-I or combined treatment both produced significantly larger effects on reducing insomnia severity (dCBT-I vs Med, difference in the mean changes = -3.3; Comb vs Med, -3.7), and led to higher percentages of responders (dCBT-I vs Med, 54.8 % vs 16.0 %, OR = 6.38; Comb vs Med, 53.6 % vs 16.0 %, OR = 6.07) and remitters (dCBT-I vs Med, 65.8 % vs 9.4 %, OR = 18.61; Comb vs Med, 67.5 % vs 9.4 %, OR = 20.13). Adding FtFCBT-I as second-step treatment offered an added value for non-remitters after the first-step treatment. Improvements achieved at post-treatment were sustained through the 6-month follow-up for most of the treatment sequences.nnCONCLUSIONS: These findings demonstrated the feasibility and efficiency of implementing digital and in-person CBT-I within a stepped-care model in primary care practice.nnTRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03633305.},

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pubstate = {published},

tppubtype = {article}

}

@article{pmid40627924,

title = {Estimation of the global prevalence and burden of insomnia: a systematic literature review-based analysis},

author = {Adam V Benjafield and Fatima H Sert Kuniyoshi and Atul Malhotra and Jennifer L Martin and Charles M Morin and Leonie F Maurer and Peter A Cistulli and Jean-Louis Pépin and Emerson M Wickwire and },

doi = {10.1016/j.smrv.2025.102121},

issn = {1532-2955},

year  = {2025},

date = {2025-08-01},

journal = {Sleep Med Rev},

volume = {82},

pages = {102121},

abstract = {Insomnia is common, is associated with major adverse medical and mental health outcomes, has a negative impact on quality of life, and has significant economic consequences. However, little is known about the global insomnia burden. This systematic review estimated the global prevalence of insomnia in adults. PubMed and Embase were searched (terms "insomnia," "prevalence," and "general population") to identify relevant peer-reviewed studies (final search 2-3 Sep 2024). Included studies had the highest data quality and lowest risk of bias, and reported clinically relevant insomnia prevalence in the general population. Insomnia prevalence estimates were applied to United Nations (UN) population data using a country-specific study (if available) or the highest-quality study (if no country-specific study). Of 1651 potential records, 18 studies (262,582 participants) were included. Thirty-one of 237 UN/World Bank-recognized countries/territories had a suitable nation-specific adult insomnia prevalence estimate. 852,325,091 adults (95 % confidence interval 830,354,161-874,309,252) were estimated to have insomnia (global prevalence: 16.2 %) and 414,967,941 were estimated to have severe insomnia (7.9 %). Insomnia and severe insomnia were more prevalent in females versus males across all age groups. The high global prevalence of insomnia disorder reinforces the need for comprehensive public health and clinical sleep health initiatives worldwide. REGISTRATION: PROSPERO: CRD42024581410.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40188800,

title = {Are trajectories of insomnia symptoms associated with clinically significant depressive symptoms or vice versa? Evidence from a 5-year longitudinal study},

author = {Si-Jing Chen and Hans Ivers and Josée Savard and Mélanie LeBlanc and Charles M Morin},

doi = {10.1016/j.sleep.2025.106489},

issn = {1878-5506},

year  = {2025},

date = {2025-07-01},

journal = {Sleep Med},

volume = {131},

pages = {106489},

abstract = {OBJECTIVES: To examine the association between different insomnia symptom trajectories and subsequent depressive symptoms, as well as the reverse.nnMETHODS: This was a secondary analysis of a population-based study on the natural course of insomnia in Canada, and 3030 participants (18-94 years) with valid data were included. Two separate analyses were conducted for the distinct objectives of the current study, which required different samples. Participants who exhibited the designated outcomes at baseline were excluded from each analysis. Growth mixture modeling was used to identify insomnia and depressive symptom trajectories over five years, measured by Insomnia Severity Index (ISI) and Beck Depression Inventory-II (BDI-II), respectively. Cases with clinically significant depressive symptoms at follow-ups were defined as reporting at least moderate depressive symptoms (BDI-II ≥ 20) and one core symptom of depression, while insomnia disorder at follow-ups was identified according to a validated algorithm using a combination of criteria from DSM-4 and ICSD-3 and self-reported use of sleep medication.nnRESULTS: Five insomnia symptom trajectories were identified over five years: stable good sleepers (24 %), stable low insomnia severity (35 %), gradual improvements in symptoms (6 %), persistent insomnia symptoms (31 %), and progressive worsening of symptoms (5 %). Compared with good sleepers, the other insomnia trajectory groups all had higher risks of clinically significant depressive symptoms at follow-ups, especially those with progressive symptoms (harzad ratio [HR]: 19.77 [10.30 to 37.93]). In a parallel analysis, four depression trajectories emerged: noncases (49 %), stable low depressive severity (38 %), moderate symptoms improving over time (7 %), and progressive worsening of symptoms (6 %). Compared with noncases, the other depression trajectory groups all showed elevated risks of insomnia disorder, especially those with progressive worsening of symptoms (HR: 6.85 [5.26 to 8.93]).nnCONCLUSIONS: Our findings support a close relationship between insomnia and depressive symptoms, especially when both symptoms become progressive or persistent.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40713469,

title = {The complex association between bedtime screen use and adult sleep health},

author = {Lydi-Anne Vézina-Im and Charles M Morin and Sijing Chen and Hans Ivers and Colleen E Carney and Jean-Philippe Chaput and Thien Thanh Dang-Vu and Judith R Davidson and Rébecca Robillard and Canadian Sleep Research Consortium},

doi = {10.1016/j.sleh.2025.06.010},

issn = {2352-7226},

year  = {2025},

date = {2025-07-01},

urldate = {2025-07-01},

journal = {Sleep Health},

abstract = {OBJECTIVES: To evaluate whether bedtime screen use is associated with sleep health and if this association varies by biological sex, age, and income among adults in Canada.nnMETHODS: Data were collected through a national stratified random population-based phone interview on sleep health among adults (≥18 years) from Canada. Self-reported bedtime screen use (in bed or within 1 hour of bedtime) of the past month was used to classify participants into three groups: occasional (<once/week), moderate (1-4 times/week), and regular (≥5 times/week) bedtime screen users. Sleep health (regularity, satisfaction, alertness, timing, efficiency, duration) was measured using the RU-SATED questionnaire. Post-stratified survey weights were computed from the 2021 Canadian census to ensure representativeness of the adult population in terms of geography, biological sex, age, and ethnicity.nnRESULTS: The sample included 1342 adults (51.5% females; 41.7% between 40-64 years) and 45.3% reported bedtime screen use every day. After accounting for biological sex, age, and income, both occasional and regular screen users reported the best overall sleep health. Results varied by sleep health dimension and biological sex was a moderator of the bedtime screen use and sleep regularity association. Bedtime screen use frequency was significantly associated (p = .01) with sleep regularity only among males.nnCONCLUSIONS: The association between bedtime screen use and sleep health appears complex as bedtime screen use frequency, the sleep health dimension measured, and biological sex can all influence this relationship. More research is needed to understand the sleep health and bedtime screen use association and moderators of this relationship in adults.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40681664,

title = {A randomized controlled trial of a digital cognitive behavioral therapy for insomnia for older adults},

author = {Lee M Ritterband and Kelly M Shaffer and Frances P Thorndike and Philip I Chow and Linda Gonder-Frederick and Karen S Ingersoll and Wendy F Cohn and Christina Frederick and Kirsten MacDonnell and Jillian V Glazer and Meghan K Mattos and Michelle M Hilgart and Mark S Quigg and Mudhasir Bashir and Charles M Morin},

doi = {10.1038/s41746-025-01847-0},

issn = {2398-6352},

year  = {2025},

date = {2025-07-01},

journal = {NPJ Digit Med},

volume = {8},

number = {1},

pages = {458},

abstract = {Older adults with insomnia face considerable challenges accessing treatment given limited availability to first-line therapy (Cognitive-Behavioral Therapy for Insomnia, CBT-I). This study evaluated the efficacy of Sleep Healthy Using the Internet for Older Adults Suffering with Insomnia and Sleeplessness (SHUTi OASIS), a tailored CBT-I internet intervention for older adults with insomnia, in a 3-arm randomized controlled trial (SHUTi OASIS alone, SHUTi OASIS + stepped support, online patient education [PE]). 311 participants (ages 55-95) were randomized to receive SHUTi OASIS (alone n = 105; with stepped support n = 102), with both conditions reporting significant improvements across post, 6-month, and 12-month follow-ups in insomnia severity compared to those receiving PE (n = 104). Clinically meaningful indices of insomnia response and remission were also higher among those receiving SHUTi OASIS. Those who received SHUTi OASIS also significantly outperformed those receiving PE on secondary outcomes, including sleep onset latency, wake after sleep onset, sleep efficiency, number of awakenings, sleep quality, and fatigue, across most timepoints. Results indicate that digital CBT-I provides important benefits for older adults, offering strong potential to expand access to insomnia treatment for this underserved population.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40518315,

title = {Is Objective Short Sleep a Proxy for Frequent Insomnia?},

author = {Hannah Scott and Janet M Y Cheung and Alexandria Muench and Hans Ivers and Charles M Morin and Michael L Perlis},

doi = {10.1111/jsr.70122},

issn = {1365-2869},

year  = {2025},

date = {2025-06-01},

journal = {J Sleep Res},

pages = {e70122},

abstract = {This study investigated the relationship between insomnia frequency and objective short sleep, a phenotype of insomnia. The hypothesis is that individuals with objective short sleep simply have more nights of insomnia per week. Data from a randomised controlled trial of Cognitive Behavioural Therapy for Insomnia combined with zolpidem and/or additional maintenance sessions were analysed. Insomnia frequency was derived from pre-treatment sleep diaries, using two definitions: nights with self-reported sleep latency (SL) or wake after sleep onset (WASO) > 30 min, and nights with self-reported sleep duration < 6 h. Objective short sleep was assessed via PSG sleep study, using < 6 h as the threshold. Results showed that objective short sleep was associated with more frequent insomnia when defined as nights with sleep duration < 6 h (8.1 ± 4.2 vs. 5.9 ± 3.7 nights/fortnight for short sleepers vs. normal sleepers, respectively), but not for nights with SL or WASO > 30 min. While insomnia frequency may partially explain objective short sleep, other factors likely influence this phenotype. Further studies are needed to explore the mechanisms underlying objective short sleep insomnia.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40532597,

title = {The putative effects of orexin receptor antagonists on pain and sleep in humans: A systematic review},

author = {Alberto Herrero Babiloni and Linda Sangalli and F Javier Puertas-Cuesta and Charles M Morin and Gilles J Lavigne and Cibele Dal Fabbro},

doi = {10.1016/j.sleep.2025.106633},

issn = {1878-5506},

year  = {2025},

date = {2025-06-01},

journal = {Sleep Med},

volume = {133},

pages = {106633},

abstract = {OBJECTIVE: Orexin antagonists are newer medications for management of insomnia, a condition frequently associated to chronic pain. This systematic review evaluates the effects of orexin receptor antagonists on pain perception and pain-related outcomes in humans, considering their role in both sleep regulation and pain modulation.nnMETHODS: A search was conducted in PubMed, Web of Science, Scopus, CINAHL, PsycINFO, and ClinicalTrials.gov, following PRISMA guidelines. Eligible studies included human participants with acute or chronic pain who received orexin receptor antagonists (e.g., suvorexant, lemborexant, daridorexant, filorexant) with pain intensity, pain thresholds, sleep disturbances, and functional outcomes as primary measures. Risk of bias was assessed using RoB 2 for randomized controlled trials (RCTs) and ROBINS-E for observational studies, while the GRADE approach was applied to assess the overall certainty of evidence.nnRESULTS: Out of 488 identified records, four studies met the inclusion criteria (three RCTs, one observational study), totaling 331 participants. No significant improvements in pain intensity were found, though one study observed increased pain sensitivity thresholds in fibromyalgia patients. Conversely, orexin receptor antagonists consistently improved sleep parameters, including total sleep time and sleep onset latency. Evidence certainty was moderate for RCTs and low for the observational study, with imprecision and publication bias as key concerns.nnCONCLUSION: Orexin receptor antagonists improve sleep, but due to the very limited number of studies and small sample sizes, evidence regarding analgesic effects in humans remains inconclusive. The lack of receptor-selective interventions, short treatment durations, and pain condition variability may contribute to these findings. Future trials should investigate mechanistic analgesic effects, receptor-specific therapies, and explore orexin's role in pain phenotypes.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40570832,

title = {Stepped-Care Management of Insomnia: Treatment Choices Guided by a Patient Decision Aid in a Pragmatic Nonrandomized Clinical Trial Setting},

author = {Janet M Y Cheung and Lee M Ritterband and Si-Jing Chen and Hans Ivers and Charles M Morin},

doi = {10.1111/jsr.70127},

issn = {1365-2869},

year  = {2025},

date = {2025-06-01},

journal = {J Sleep Res},

pages = {e70127},

abstract = {Patients with insomnia face difficult decisions when choosing between treatment options with competing risk-benefit profiles. Patient treatment choices were evaluated as part of a pragmatic nonrandomized clinical trial for a two-step cognitive behavioural therapy for insomnia (CBT-I) intervention. Upon enrollment, participants were guided by a patient decision aid (PtDA), outlining the risk-benefit profiles of medication, face-to-face CBT-I (FtFCBT-I), and digital CBT-I (dCBT-I). In Step 1, participants chose between dCBT-I alone, combined dCBT-I plus medication or medication alone. Non-remitters who enrolled into Step 2 chose between FtFCBT-I, medication, or no additional treatment. A secondary analysis was conducted evaluating patient treatment choices, the presence of decisional conflict, and the acceptability of the PtDA. In Step 1, 47.4% (n = 73) of participants chose dCBT-I, followed by combined dCBT-I plus medication (42.3% n = 66) and medication alone (9.74%; n = 15). The dCBT-I group was less likely to use medications or used them less frequently compared to the other treatment groups. Men and individuals less motivated to change sleep habits were more likely to choose medication in Step 1. In Step 2, 60.9% (n = 42) of non-remitters chose FtFCBT-I, followed by no additional treatment (23.6%; n = 16) and medication (15.9%; n = 11). Non-remitters from the medication group in Step 1 were more likely to choose medication again in Step 2. Over 90% of participants across both treatment steps endorsed the PtDA as acceptable and facilitated their decision-making. This corroborated with the minimal decisional conflict observed, highlighting a potential role in further developing and integrating patient decision aids into practice. Trial Registration: NCT03633305.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pmid40346496,

title = {Efficacy of cognitive behavioral therapy for insomnia and lemborexant medication for different subtypes of chronic insomnia: study protocol for a randomized controlled trial},

author = {Si-Jing Chen and Hans Ivers and Thien Thanh Dang-Vu and Colin M Shapiro and Colleen E Carney and Rébecca Robillard and Charles M Morin},

doi = {10.1186/s12888-025-06878-1},

issn = {1471-244X},

year  = {2025},

date = {2025-05-01},

journal = {BMC Psychiatry},

volume = {25},

number = {1},

pages = {470},

abstract = {INTRODUCTION: Insomnia is a prevalent yet under-characterized disorder, particularly regarding the heterogeneity of patients and their associated responses to different treatment modalities. This often leads to suboptimal management. There is a need to consider personalized approaches tailored to the characteristics of insomnia phenotypes with regard to objective evidence of shortened sleep duration (< 6 h). This study will examine whether there is a differential treatment response to cognitive behavioral therapy for insomnia (CBT-I) versus pharmacotherapy (lemborexant) as a function of insomnia phenotypes (i.e., ± 6 h of sleep).nnMETHODS: This study is a three-arm pragmatic randomized clinical trial, which will enroll 90 adults with chronic insomnia disorder and anxiety/depressive symptoms. Eligible participants will be randomized to one of three conditions (1:1:1) involving CBT-I, lemborexant (Dual Orexin Receptor Antagonist) or placebo medication. Treatment outcomes will be assessed at post-treatment and 6-month follow-up. Insomnia symptom severity as measured by the Insomnia Severity Index will serve as the primary outcome for treatment comparisons. Secondary outcomes will include daily sleep/wake variables derived from the Consensus Sleep Diary, subjective measures of fatigue, mood, mental well-being, functional impairments, and sleep-related beliefs and attitudes. In addition, changes in cognitive performance will be examined as an exploratory outcome. Sleep reactivity and arousal level will be evaluated as potential mediators of treatment-related changes in CBT-I and pharmacotherapy.nnDISCUSSION: This study will contribute to the development of personalized medicine for managing different insomnia phenotypes and will have implication for knowledge mobilization of sleep research.nnTRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT06779149. Registered on 12 January 2025.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}