Effect of Light Flashes vs Sham Therapy During Sleep With Adjunct Cognitive Behavioral Therapy on Sleep Quality Among Adolescents: A Randomized Clinical Trial | Adolescent Medicine | JAMA Network Open | JAMA Network
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1.
Keyes  KM, Maslowsky  J, Hamilton  A, Schulenberg  J.  The great sleep recession: changes in sleep duration among US adolescents, 1991-2012.  Pediatrics. 2015;135(3):460-468. doi:10.1542/peds.2014-2707PubMedGoogle ScholarCrossref
2.
Carskadon  MA, Mindell  JA, Drake  C.  Sleep in America Poll. Washington, DC: The National Sleep Foundation; 2006.
3.
Calamaro  CJ, Mason  TB, Ratcliffe  SJ.  Adolescents living the 24/7 lifestyle: effects of caffeine and technology on sleep duration and daytime functioning.  Pediatrics. 2009;123(6):e1005-e1010. doi:10.1542/peds.2008-3641PubMedGoogle ScholarCrossref
4.
Wolfson  AR, Carskadon  MA.  Understanding adolescents’ sleep patterns and school performance: a critical appraisal.  Sleep Med Rev. 2003;7(6):491-506. doi:10.1016/S1087-0792(03)90003-7PubMedGoogle ScholarCrossref
5.
Wolfson  AR, Carskadon  MA.  Sleep schedules and daytime functioning in adolescents.  Child Dev. 1998;69(4):875-887. doi:10.1111/j.1467-8624.1998.tb06149.xPubMedGoogle ScholarCrossref
6.
Knutson  KL, Spiegel  K, Penev  P, Van Cauter  E.  The metabolic consequences of sleep deprivation.  Sleep Med Rev. 2007;11(3):163-178. doi:10.1016/j.smrv.2007.01.002PubMedGoogle ScholarCrossref
7.
Weiss  A, Xu  F, Storfer-Isser  A, Thomas  A, Ievers-Landis  CE, Redline  S.  The association of sleep duration with adolescents’ fat and carbohydrate consumption.  Sleep. 2010;33(9):1201-1209. doi:10.1093/sleep/33.9.1201PubMedGoogle ScholarCrossref
8.
McGlinchey  EL, Harvey  AG.  Risk behaviors and negative health outcomes for adolescents with late bedtimes.  J Youth Adolesc. 2015;44(2):478-488. doi:10.1007/s10964-014-0110-2PubMedGoogle ScholarCrossref
9.
Killgore  WD.  Effects of sleep deprivation and morningness-eveningness traits on risk-taking.  Psychol Rep. 2007;100(2):613-626. doi:10.2466/pr0.100.2.613-626PubMedGoogle ScholarCrossref
10.
Talbot  LS, McGlinchey  EL, Kaplan  KA, Dahl  RE, Harvey  AG.  Sleep deprivation in adolescents and adults: changes in affect.  Emotion. 2010;10(6):831-841. doi:10.1037/a0020138PubMedGoogle ScholarCrossref
11.
McGlinchey  EL, Talbot  LS, Chang  KH, Kaplan  KA, Dahl  RE, Harvey  AG.  The effect of sleep deprivation on vocal expression of emotion in adolescents and adults.  Sleep. 2011;34(9):1233-1241. doi:10.5665/SLEEP.1246PubMedGoogle ScholarCrossref
12.
Dagys  N, McGlinchey  EL, Talbot  LS, Kaplan  KA, Dahl  RE, Harvey  AG.  Double trouble? the effects of sleep deprivation and chronotype on adolescent affect.  J Child Psychol Psychiatry. 2012;53(6):660-667. doi:10.1111/j.1469-7610.2011.02502.xPubMedGoogle ScholarCrossref
13.
Iglowstein  I, Jenni  OG, Molinari  L, Largo  RH.  Sleep duration from infancy to adolescence: reference values and generational trends.  Pediatrics. 2003;111(2):302-307. doi:10.1542/peds.111.2.302PubMedGoogle ScholarCrossref
14.
Breslau  N, Roth  T, Rosenthal  L, Andreski  P.  Daytime sleepiness: an epidemiological study of young adults.  Am J Public Health. 1997;87(10):1649-1653. doi:10.2105/AJPH.87.10.1649PubMedGoogle ScholarCrossref
15.
Mercer  PW, Merritt  SL, Cowell  JM.  Differences in reported sleep need among adolescents.  J Adolesc Health. 1998;23(5):259-263. doi:10.1016/S1054-139X(98)00037-8PubMedGoogle ScholarCrossref
16.
Carskadon  MA, Acebo  C, Jenni  OG.  Regulation of adolescent sleep: implications for behavior.  Ann N Y Acad Sci. 2004;1021:276-291. doi:10.1196/annals.1308.032PubMedGoogle ScholarCrossref
17.
Van den Bulck  J.  Television viewing, computer game playing, and Internet use and self-reported time to bed and time out of bed in secondary-school children.  Sleep. 2004;27(1):101-104. doi:10.1093/sleep/27.1.101PubMedGoogle ScholarCrossref
18.
Moseley  L, Gradisar  M.  Evaluation of a school-based intervention for adolescent sleep problems.  Sleep. 2009;32(3):334-341. doi:10.1093/sleep/32.3.334PubMedGoogle ScholarCrossref
19.
Kira  G, Maddison  R, Hull  M, Blunden  S, Olds  T.  Sleep education improves the sleep duration of adolescents: a randomized controlled pilot study.  J Clin Sleep Med. 2014;10(7):787-792.PubMedGoogle Scholar
20.
Hansen  M, Janssen  I, Schiff  A, Zee  PC, Dubocovich  ML.  The impact of school daily schedule on adolescent sleep.  Pediatrics. 2005;115(6):1555-1561. doi:10.1542/peds.2004-1649PubMedGoogle ScholarCrossref
21.
Gradisar  M, Dohnt  H, Gardner  G,  et al.  A randomized controlled trial of cognitive-behavior therapy plus bright light therapy for adolescent delayed sleep phase disorder.  Sleep. 2011;34(12):1671-1680. doi:10.5665/sleep.1432PubMedGoogle ScholarCrossref
22.
Qaseem  A, Kansagara  D, Forciea  MA, Cooke  M, Denberg  TD; Clinical Guidelines Committee of the American College of Physicians.  Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.  Ann Intern Med. 2016;165(2):125-133. doi:10.7326/M15-2175PubMedGoogle ScholarCrossref
23.
Flynn-Evans  EE, Shekleton  JA, Miller  B,  et al.  Circadian phase and phase angle disorders in primary insomnia.  Sleep. 2017;40(12):zsx163. doi:10.1093/sleep/zsx163PubMedGoogle ScholarCrossref
24.
Crowley  SJ, Eastman  CI.  Human adolescent phase response curves to bright white light.  J Biol Rhythms. 2017;32(4):334-344. doi:10.1177/0748730417713423PubMedGoogle ScholarCrossref
25.
Khalsa  SBS, Jewett  ME, Cajochen  C, Czeisler  CA.  A phase response curve to single bright light pulses in human subjects.  J Physiol. 2003;549(pt 3):945-952. doi:10.1113/jphysiol.2003.040477PubMedGoogle ScholarCrossref
26.
Zeitzer  JM, Ruby  NF, Fisicaro  RA, Heller  HC.  Response of the human circadian system to millisecond flashes of light.  PLoS One. 2011;6(7):e22078. doi:10.1371/journal.pone.0022078PubMedGoogle ScholarCrossref
27.
Berson  DM, Dunn  FA, Takao  M.  Phototransduction by retinal ganglion cells that set the circadian clock.  Science. 2002;295(5557):1070-1073. doi:10.1126/science.1067262PubMedGoogle ScholarCrossref
28.
Najjar  RP, Zeitzer  JM.  Temporal integration of light flashes by the human circadian system.  J Clin Invest. 2016;126(3):938-947. doi:10.1172/JCI82306PubMedGoogle ScholarCrossref
29.
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.  JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053PubMedGoogle ScholarCrossref
30.
Carskadon  MA, Vieira  C, Acebo  C.  Association between puberty and delayed phase preference.  Sleep. 1993;16(3):258-262. doi:10.1093/sleep/16.3.258PubMedGoogle ScholarCrossref
31.
LeBourgeois  MK, Giannotti  F, Cortesi  F, Wolfson  AR, Harsh  J.  The relationship between reported sleep quality and sleep hygiene in Italian and American adolescents.  Pediatrics. 2005;115(1)(suppl):257-265. doi:10.1542/peds.2004-0815HPubMedGoogle ScholarCrossref
32.
Spilsbury  JC, Drotar  D, Rosen  CL, Redline  S.  The Cleveland Adolescent Sleepiness Questionnaire: a new measure to assess excessive daytime sleepiness in adolescents.  J Clin Sleep Med. 2007;3(6):603-612.PubMedGoogle Scholar
33.
Borkovec  TD, Nau  SD.  Credibility of analog therapy rationales.  J Behav Ther Exp Psychiatry. 1972;3:257-260. doi:10.1016/0005-7916(72)90045-6Google ScholarCrossref
34.
Carney  CE, Buysse  DJ, Ancoli-Israel  S,  et al.  The consensus sleep diary: standardizing prospective sleep self-monitoring.  Sleep. 2012;35(2):287-302. doi:10.5665/sleep.1642PubMedGoogle ScholarCrossref
35.
Buysse  DJ, Thompson  W, Scott  J,  et al.  Daytime symptoms in primary insomnia: a prospective analysis using ecological momentary assessment.  Sleep Med. 2007;8(3):198-208. doi:10.1016/j.sleep.2006.10.006PubMedGoogle ScholarCrossref
36.
Oka  Y, Horiuchi  F, Tanigawa  T.  Development and validation of a child sleep screening questionnaire: Child and Adolescent Sleep Checklist (CASC).  Jap J Sleep Med. 2009;3(2):404-408.Google Scholar
37.
Gayes  LA, Steele  RG.  A meta-analysis of motivational interviewing interventions for pediatric health behavior change.  J Consult Clin Psychol. 2014;82(3):521-535. doi:10.1037/a0035917PubMedGoogle ScholarCrossref
38.
Emmons  RA.  Personal strivings, daily life events, and psychological and physical well-being.  J Pers. 1991;59(3):453-472. doi:10.1111/j.1467-6494.1991.tb00256.xPubMedGoogle ScholarCrossref
39.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
40.
Feingold  A.  A regression framework for effect size assessments in longitudinal modeling of group differences.  Rev Gen Psychol. 2013;17(1):111-121. doi:10.1037/a0030048PubMedGoogle ScholarCrossref
41.
Package ‘lmerTest.’ https://cran.r-project.org/web/packages/lmerTest/lmerTest.pdf. Published February 11, 2019. Accessed August 28, 2019.
42.
Zeitzer  JM, Fisicaro  RA, Ruby  NF, Heller  HC.  Millisecond flashes of light phase delay the human circadian clock during sleep.  J Biol Rhythms. 2014;29(5):370-376. doi:10.1177/0748730414546532PubMedGoogle ScholarCrossref
43.
Dijk  D-J, Czeisler  CA.  Paradoxical timing of the circadian rhythm of sleep propensity serves to consolidate sleep and wakefulness in humans.  Neurosci Lett. 1994;166(1):63-68. doi:10.1016/0304-3940(94)90841-9PubMedGoogle ScholarCrossref
44.
Crowley  SJ, Acebo  C, Carskadon  MA.  Sleep, circadian rhythms, and delayed phase in adolescence.  Sleep Med. 2007;8(6):602-612. doi:10.1016/j.sleep.2006.12.002PubMedGoogle ScholarCrossref
45.
Kaplan  KA, Hardas  PP, Redline  S, Zeitzer  JM; Sleep Heart Health Study Research Group.  Correlates of sleep quality in midlife and beyond: a machine learning analysis.  Sleep Med. 2017;34:162-167. doi:10.1016/j.sleep.2017.03.004PubMedGoogle ScholarCrossref
46.
Kaplan  KA, Hirshman  J, Hernandez  B,  et al; Osteoporotic Fractures in Men (MrOS), Study of Osteoporotic Fractures SOF Research Groups.  When a gold standard isn’t so golden: lack of prediction of subjective sleep quality from sleep polysomnography.  Biol Psychol. 2017;123:37-46. doi:10.1016/j.biopsycho.2016.11.010PubMedGoogle ScholarCrossref
47.
Short  MA, Gradisar  M, Lack  LC, Wright  H, Carskadon  MA.  The discrepancy between actigraphic and sleep diary measures of sleep in adolescents.  Sleep Med. 2012;13(4):378-384. doi:10.1016/j.sleep.2011.11.005PubMedGoogle ScholarCrossref
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    Original Investigation
    Psychiatry
    September 25, 2019

    Effect of Light Flashes vs Sham Therapy During Sleep With Adjunct Cognitive Behavioral Therapy on Sleep Quality Among Adolescents: A Randomized Clinical Trial

    Author Affiliations
    • 1Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
    • 2Palo Alto University, Palo Alto, California
    JAMA Netw Open. 2019;2(9):e1911944. doi:10.1001/jamanetworkopen.2019.11944
    Key Points español 中文 (chinese)

    Question  Can adjustment of circadian timing through light flash therapy during sleep increase total sleep time in teenagers?

    Findings  In this double-blind, placebo-controlled, randomized clinical trial of 102 adolescents, light flash therapy alone was ineffective. When delivered in combination with a cognitive behavioral therapy meant to encourage an earlier bedtime, the combination of light flash therapy and cognitive behavioral therapy significantly and stably increased total sleep time by nearly 45 minutes per night.

    Meaning  Combination light flash therapy and cognitive behavioral therapy is an effective tool to increase sleep time and combat sleep loss in teenagers.

    Abstract

    Importance  Owing to biological, behavioral, and societal factors, sleep duration in teenagers is often severely truncated, leading to pervasive sleep deprivation.

    Objective  To determine whether a novel intervention, using both light exposure during sleep and cognitive behavioral therapy (CBT), would increase total sleep time in teenagers by enabling them to go to sleep earlier than usual.

    Design, Setting, and Participants  This double-blind, placebo-controlled, randomized clinical trial, conducted between November 1, 2013, and May 31, 2016, among 102 adolescents enrolled full-time in grades 9 to 12, who expressed difficulty going to bed earlier and waking up early enough, was composed of 2 phases. In phase 1, participants were assigned to receive either 3 weeks of light or sham therapy and were asked to try to go to sleep earlier. In phase 2, participants received 4 brief CBT sessions in addition to a modified light or sham therapy. All analyses were performed on an intent-to-treat basis.

    Interventions  Light therapy consisted of receiving a 3-millisecond light flash every 20 seconds during the final 3 hours of sleep (phase 1) or final 2 hours of sleep (phase 2). Sham therapy used an identical device, but delivered 1 minute of light pulses (appearing in 20-second intervals, for a total of 3 pulses) per hour during the final 3 hours of sleep (phase 1) or 2 hours of sleep (phase 2). Light therapy occurred every night during the 4-week intervention. Cognitive behavioral therapy consisted of four 50-minute in-person sessions once per week.

    Main Outcomes and Measures  Primary outcome measures included diary-based sleep times, momentary ratings of evening sleepiness, and subjective measures of sleepiness and sleep quality.

    Results  Among the 102 participants (54 female [52.9%]; mean [SD] age, 15.6 [1.1] years), 72 were enrolled in phase 1 and 30 were enrolled in phase 2. Mixed-effects models revealed that light therapy alone was inadequate in changing the timing of sleep. However, compared with sham therapy plus CBT alone, light therapy plus CBT significantly moved sleep onset a mean (SD) of 50.1 (27.5) minutes earlier and increased nightly total sleep time by a mean (SD) of 43.3 (35.0) minutes. Light therapy plus CBT also resulted in a 7-fold greater increase in bedtime compliance than that observed among participants receiving sham plus CBT (mean [SD], 2.21 [3.91] vs 0.29 [0.76]), as well as a mean 0.55-point increase in subjective evening sleepiness as compared with a mean 0.48-point decrease in participants receiving sham plus CBT as measured on a 7-point sleepiness scale.

    Conclusions and Relevance  This study found that light exposure during sleep, in combination with a brief, motivation-focused CBT intervention, was able to consistently move bedtimes earlier and increase total sleep time in teenagers. This type of passive light intervention in teenagers may lead to novel therapeutic applications.

    Trial Registration  ClinicalTrials.gov identifier: NCT01406691

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