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The morbidity of insomnia uncomplicated by psychiatric disorders
Open accessAbstract
The morbidity of sleep problems has been well documented; however, they are frequently associated with and are symptomatic of several psychiatric disorders. It is unclear how much of the morbidity can be accounted for by the associated psychiatric and substance abuse disorders and medical problems, and how much by the sleep problems per se. Sleep problems may also be an early sign of a psychiatric problem. This paper reports data from an epidemiologic community survey of over 10,000 adults living in three U.S. communities. A structured diagnostic assessment of psychiatric disorders as well as assessment of the presence of insomnia not due to medical conditions, medication, drug or alcohol abuse, and a 1-year follow-up were completed. Persons with insomnia in the past year without any psychiatric disorders ever (uncomplicated insomnia); with a psychiatric disorder in the past year (complicated insomnia); and with neither insomnia nor psychiatric disorders ever were compared on treatment utilization and the first onset of a psychiatric disorder in the subsequent year. Eight percent of those with uncomplicated as compared with 14.9% with complicated insomnia and 2.5% with neither had sought treatment from the general medical sector for emotional problems in the 6 months prior to the interview. The rates of treatment sought from the psychiatric specialty sector were 3.8%, 9.4%, and 1.2%, respectively. These differences were significant after controlling for sociodemographic characteristics and were sustained when the persons were interviewed 1 year later. Uncomplicated insomnia was also associated with an increase in risk for first onset of major depression, panic disorder, and alcohol abuse over the following year. Insomnia, even in the absence of psychiatric disorders, is associated with increased use of general medical and mental health treatment for emotional problems and for the subsequent first onset in the following year of some psychiatric disorders. Early diagnosis and treatment of uncomplicated insomnia may be useful.
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“In addition, it also demonstrates that insomnia can be a risk factor for the development of depression [51].”
From Non-Pharmacological Treatment of Insomnia (2012) · cites this paper as [51]
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Insomnia in the Context of Cancer: A Review of a Neglected Problem
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Primary insomnia: a risk factor to develop depression?
Riemann, D. (2003) · Journal of Affective Disorders · doi:10.1016/s0165-0327(02)00072-1 · Cited by 641
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“Similar findings have been reported by other investigators (Breslau et al., 1996; Dryman and Eaton, 1991; Livingston et al., 1993; Weissman et al., 1997).”
ResultInsomnia and the risk of depression: a meta-analysis of prospective cohort studies
Li, L., Wu, C., Gan, Y., Qu, X., & Lu, Z. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-1075-3 · Cited by 626
“In the present study, 11 studies [9, 10, 19–21, 32–34, 36, 38, 42, 46, 48, 52, 56] diagnosed insomnia on the basis of all DSM- IV criteria [57]: sleep difficulties, duration and daytime consequence (sd, dur and day), 10 studies [10, 23, 33, 34, 36, 47, 50, 51, 53, 54] based the diagnosis only on sleep difficulties and…”
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Healthy Older Adults’ Sleep Predicts All-Cause Mortality at 4 to 19 Years of Follow-Up
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Kobayashi, I., Boarts, J. M., & Delahanty, D. L. (2007) · Psychophysiology · doi:10.1111/j.1469-8986.2007.537.x · Cited by 435
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“Several longitudinal studies suggest that those with insomnia are at increased risk for the development of subsequent problems related to alcohol use in comparison with those without disturbed sleep.(81,89,90) Several studies suggest that those with alcoholism often use alcohol as a means to treat sleep difficulties.”
BackgroundOrexin Receptors: Pharmacology and Therapeutic Opportunities
Scammell, T. E., & Winrow, C. J. (2011) · The Annual Review of Pharmacology and Toxicology · doi:10.1146/annurev-pharmtox-010510-100528 · Cited by 391
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An American Academy of Sleep Medicine Review
Sateia, M. J., Doghramji, K., Hauri, P., & Morin, C. M. (2000) · Cited by 369
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“The association between substance use and sleep problems appears to be bidirectional [105, 110], with sleep problems increasing risk for developing substance use disorders [31, 89, 210], and acute and chronic substance use leading to acute and chronic problems with sleep [44, 47, 89, 97, 104, 138, 156, 168].”
BackgroundInsomnia, alcoholism and relapse
Brower, K. J. (2003) · Sleep Medicine Reviews · doi:10.1016/s1087-0792(03)90005-0 · Cited by 360
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“…prospective studies found that PWI were 2.35 times more likely to develop alcohol abuse or dependence disorders (d = .02–.05), and 7.18 times more likely to develop drug abuse or dependence disorders (d = .07) than PNI (Breslau et al., 1996; Ford & Kamerow, 1989; Weissman et al., 1997).”
BackgroundInfluentialInsomnia as a Risk Factor for Onset of Depression in the Elderly
Perlis, M. L., Smith, L. J., Lyness, J. M., Matteson, S. R., Pigeon, W. R., Jungquist, C. R., & Tu, X. M. (2006) · Behavioral Sleep Medicine · doi:10.1207/s15402010bsm0402_3 · Cited by 353
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ResultCognitive-behavioral therapy for primary insomnia
Edinger, J. D., & Means, M. K. (2005) · Clinical Psychology Review · doi:10.1016/j.cpr.2005.04.003 · Cited by 344
“However, epidemiologic evidence suggests insomnia, uncomplicated by co-morbid psychiatric, substance abuse, or medical disorders, substantially increases health care utilization/costs and accounts for as many as 3.5 disability days per month among affected individuals (Hajak, 2001; Simon & VonKorff, 1997; Weissman, Gr…”
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S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen
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The Bidirectional Association Between Depression and Insomnia
Sivertsen, B., Salo, P., Mykletun, A., Hysing, M., Pallesen, S., Krokstad, S., Nordhus, I. H., & Øverland, S. N. (2012) · Psychosomatic Medicine · doi:10.1097/psy.0b013e3182648619 · Cited by 327
Is Insomnia a Perpetuating Factor for Late-Life Depression in the IMPACT Cohort?
Pigeon, W. R., Hegel, M. T., Unützer, J., Fan, M., Sateia, M. J., Lyness, J. M., Phillips, C., & Perlis, M. L. (2008) · SLEEP · doi:10.1093/sleep/31.4.481 · Cited by 324
Alcohol's effects on sleep in alcoholics.
Brower, K. J. (2001) · PubMed Central · Cited by 316
Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation
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Sex Differences in Insomnia: from Epidemiology and Etiology to Intervention
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Alcohol use disorder and sleep disturbances: a feed-forward allostatic framework
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INSOMNIA: SYMPTOM OR DIAGNOSIS?
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Sleep problems in early childhood and early onset of alcohol and other drug use in adolescence
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MethodInsomnia as predictor versus outcome of PTSD and depression among Iraq combat veterans
Wright, K. M., Britt, T. W., Bliese, P. D., Adler, A. B., Picchioni, D., & Moore, D. (2011) · Journal of Clinical Psychology · doi:10.1002/jclp.20845 · Cited by 264
Insomnia in Men—A 10-Year Prospective Population Based Study
Janson, C., Lindberg, E., Gíslason, Þ., Elmasry, A., & Boman, G. (2001) · SLEEP · doi:10.1093/sleep/24.4.425 · Cited by 264
Gender differences in insomnia—a study in the Hong Kong Chinese population
Li, R. H. Y., Wing, Y. K., Ho, S. C., & Fong, S. (2002) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(02)00437-3 · Cited by 262
“Interestingly, although tea or coffee drinking had been suggested as a risk factor for insomnia [21,22], we observed that in women, frequent tea or coffee drinking had a paradoxically lower risk of insomnia.”
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Sleep problems and substance use in adolescence
Johnson, E. O., & Breslau, N. (2001) · Drug and Alcohol Dependence · doi:10.1016/s0376-8716(00)00222-2 · Cited by 254
“Sleep problems may be early indicators of increased risk for psychiatric problems and substance use/abuse among adolescents, a possibility suggested in studies of adults (Breslau et al., 1996; Weissman et al., 1997; Eaton et al., 1995) and in studies of adolescents (Price et al.”
BackgroundSleep Disturbance Immediately Prior to Trauma Predicts Subsequent Psychiatric Disorder
Bryant, R. A., Creamer, M., O'Donnell, M., Silove, D., & McFarlane, A. C. (2010) · Sleep · doi:10.1093/sleep/33.1.69 · Cited by 243
Aging and Sleep: Physiology and Pathophysiology
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Searching for the daytime impairments of primary insomnia
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“7,8 Symptoms may be transient but are often stable and persistent,1 and when untreated are associated with increased morbidity.(9)”
BackgroundAlcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders
Chakravorty, S., Chaudhary, N. S., & Brower, K. J. (2016) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.13217 · Cited by 262
“Sleep disturbance has been shown to predict subsequent alcohol consumption in adolescents and adults (Breslau et al., 1996; Ford and Kamerow, 1989; Weissman et al., 1997; Wong et al., 2004, 2010, 2015).”
Walsh, J. K., Krystal, A. D., Amato, D. A., Rubens, R., Caron, J., Wessel, T. C., Schaefer, K., Roach, J., Wallenstein, G., & Roth, T. (2007) · Sleep · doi:10.1093/sleep/30.8.959 · Cited by 239
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Sleep and circadian functioning: critical mechanisms in the mood disorders?
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“Finally, Weissman et al. (1997) reported the results of a community survey conducted across three communities in the United States.”
ResultTrouble sleeping and anxiety/depression in childhood.
Johnson, E. O., Chilcoat, H., & Breslau, N. (2000) · Psychiatry Research · doi:10.1016/s0165-1781(00)00145-1 · Cited by 239
Currie, S. R., Clark, S., Hodgins, D. C., & El‐Guebaly, N. (2004) · Addiction · doi:10.1111/j.1360-0443.2004.00835.x · Cited by 220
Sleep Disturbance in Bipolar Disorder: Therapeutic Implications
Plante, D. T., & Winkelman, J. W. (2008) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2008.08010077 · Cited by 268
Sleep disturbances and mood disorders: An epidemiologic perspective
Ford, D. E., & Cooper-Patrick, L. (2001) · Depression and Anxiety · doi:10.1002/da.1041 · Cited by 202
Bidirectional relationship between sleep and depression
Yasugaki, S., Okamura, H., Kaneko, A., & Hayashi, Y. (2023) · Neuroscience Research · doi:10.1016/j.neures.2023.04.006 · Cited by 231
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Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers
Troxel, W., Shih, R. A., Pedersen, E. R., Geyer, L., Fisher, M., Griffin, B. A., Haas, A. C., Kurz, J., & Steinberg, P. S. (2015) · Rand health quarterly · doi:10.7249/rhq-05-02-19 · Cited by 195
“…health conditions, such as PTSD, depression, and traumatic brain injury (TBI), and that sleep difficulties can also precipitate the development of mental health conditions and disorders, including an increased risk of suicide (Breslau et al., 1996; Taylor et al., 2005; Weissman et al., 1997).”
BackgroundEpidemiology of sleep disorders
Partinen, M. (2010) · Handbook of clinical neurology · doi:10.1016/b978-0-444-52006-7.00018-6 · Cited by 199
Childhood sleep problems, early onset of substance use and behavioral problems in adolescence
Wong, M. M.-H., Brower, K. J., & Zucker, R. A. (2009) · Sleep Medicine · doi:10.1016/j.sleep.2008.06.015 · Cited by 199
Sateia, M. J., & Nowell, P. D. (2004) · The Lancet · doi:10.1016/s0140-6736(04)17480-1 · Cited by 194
Sleep disturbance in mental health problems and neurodegenerative disease
Anderson, K. N., & Bradley (2013) · Nature and Science of Sleep · doi:10.2147/nss.s34842 · Cited by 198
Book Review: Insomnia following Traumatic Brain Injury: A Review
Ouellet, M., Savard, J., & Morin, C. M. (2004) · Neurorehabilitation and neural repair · doi:10.1177/1545968304271405 · Cited by 173
Sleep problems and suicidality in the National Comorbidity Survey Replication
Wojnar, M., Ilgen, M. A., Wojnar, J., McCammon, R. J., Valenstein, M. M., & Brower, K. J. (2008) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2008.07.006 · Cited by 168
“Several general population surveys indicate that less than 4% of individuals with uncomplicated insomnia report having received any psychiatric treatment in the prior 6 months (Weissmann et al., 1997).”
Etiology and Pathophysiology of Insomnia
Perlis, M. L., Smith, M. T., & Pigeon, W. R. (2005) · Elsevier eBooks · doi:10.1016/b0-72-160797-7/50067-7 · Cited by 167
Etiologies of Associations Between Childhood Sleep and Behavioral Problems in a Large Twin Sample
Gregory, A. M., Eley, T. C., O’Connor, T. G., & Plomin, R. J. (2004) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/01.chi/0000122798.47863.a5 · Cited by 164
Effect of sleep apnea on cognition and mood
El-Ad, B., & Lavie, P. (2005) · International Review of Psychiatry · doi:10.1080/09540260500104508 · Cited by 166
Circadian rhythms and depression: Human psychopathology and animal models
Kronfeld-Schor, N., & Einat, H. (2012) · Neuropharmacology · doi:10.1016/j.neuropharm.2011.08.020 · Cited by 166
“Generalized sleep disturbances are demonstrated to be associated with the development of depression [e.g., (Breslau et al., 1996; Dryman and Eaton, 1991; Mallon et al., 2000; Weissman et al., 1997)].”
BackgroundSearching for perfect sleep: the continuing evolution of GABA A receptor modulators as hypnotics
Nutt, D. J., & Stahl, S. M. (2010) · Journal of Psychopharmacology · doi:10.1177/0269881109106927 · Cited by 163
“Insomnia in the presence of psychiatric disorders imposes a significant extra burden on patients, who make greater use of healthcare services than patients with either of these conditions alone (Weissman et al., 1997).”
BackgroundWong, M. M., Brower, K. J., Nigg, J. T., & Zucker, R. A. (2010) · Alcoholism Clinical and Experimental Research · doi:10.1111/j.1530-0277.2010.01178.x · Cited by 161
“This relationship holds even when the analyses were performed on adults without a psychiatric disorder at Time 1 (N = 5,340; Weissman et al., 1997).”
Plante, D. T., Jensen, J. E., Schoerning, L., & Winkelman, J. W. (2012) · Neuropsychopharmacology · doi:10.1038/npp.2012.4 · Cited by 161
Prospective Associations of Insomnia Markers and Symptoms With Depression
Szklo‐Coxe, M., Young, T. B., Peppard, P. E., Finn, L. A., & Benca, R. M. (2010) · American Journal of Epidemiology · doi:10.1093/aje/kwp454 · Cited by 151
Zhang, M.-M., Ma, Y., Du, L.-T., Wang, K., Li, Z., Zhu, W., Sun, Y.-H., Lü, L., Bao, Y., & Li, S. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104532 · Cited by 160
Cousins, J. C., Whalen, D. J., Dahl, R. E., Forbes, E. E., Olino, T. M., Ryan, N. D., & Silk, J. S. (2011) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsr036 · Cited by 147
Insomnia, depression and aging. Assessing sleep and mood interactions in older adults.
Buysse, D. J. (2004) · PubMed · Cited by 145
History of the Development of Sleep Medicine in the United States
Shepard, J., Buysse, D. J., Chesson, A. L., Dement, W. C., Goldberg, R., Guilleminault, C., Harris, C., Iber, C., Mignot, E. J.-M., Mitler, M. M., et al. (2005) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.26298 · Cited by 150
Edinger, J. D., Means, M. K., Carney, C. E., & Krystal, A. D. (2008) · Sleep · doi:10.1093/sleep/31.5.599 · Cited by 168
Mendelson, W. (2004) · Sleep Medicine Reviews · doi:10.1016/s1087-0792(03)00042-x · Cited by 142
Krystal, A. D., Thakur, M. E., & Roth, T. G. (2008) · Annals of Clinical Psychiatry · doi:10.1080/10401230701844661 · Cited by 141
Sleep Disturbance Influences Gastrointestinal Symptoms in Women with Irritable Bowel Syndrome
Jarrett, M. E., Heitkemper, M. M., Cain, K. C., Burr, R. L., & Hertig, V. L. (2000) · Digestive Diseases and Sciences · doi:10.1023/a:1005581226265 · Cited by 139
“A US national study (N 5 18,571) found that only 5% of people over 18 report insomnia, using a mental health definition (14).”
BackgroundInsomnia and depression: a multifaceted interplay
Manber, R., & Chambers, A. S. (2009) · Current Psychiatry Reports · doi:10.1007/s11920-009-0066-1 · Cited by 134
“The conclusion holds true in the absence of a psychiatric disorder at time 1 [ 33 ], across various age groups [34,35], and among pregnant women [36].”
BackgroundPrevalence, Correlates, and Predictors of Insomnia in the US Army prior to Deployment
Taylor, D. J., Pruiksma, K. E., Hale, W. J., Kelly, K., Maurer, D., Peterson, A. L., Mintz, J., Litz, B. T., & Williamson, D. E. (2016) · SLEEP · doi:10.5665/sleep.6156 · Cited by 134
Wong, M. M.-H., Robertson, G. C., & Dyson, R. B. (2015) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.12618 · Cited by 129
“Growing literature suggests that sleep difficulties and insomnia are important risk factors for substance use and abuse onset (Breslau et al., 1996; Weissman et al., 1997; Wong et al., 2009, 2010).”
InfluentialRondanelli, M., Opizzi, A., Monteferrario, F., Antoniello, N., Manni, R., & Klersy, C. (2011) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2010.03232.x · Cited by 126
“Poor sleep is correlated with morbidity and mortality in older adults.(9) In addition to daytime dysfunction, insomnia is associated with various adverse effects such as poorer quality of life in Address correspondence to Mariangela Rondanelli, Department of Applied Health Sciences, Section of Human Nutrition and Diet…”
BackgroundAnxiety and sleep problems: Emerging concepts and theoretical treatment implications
Uhde, T. W., Cortese, B. M., & Vedeniapin, A. B. (2009) · Current Psychiatry Reports · doi:10.1007/s11920-009-0039-4 · Cited by 129
“[4–6], as well as primary anxiety disorders developing later insomnia [7]).”
BackgroundComorbid Sleep Disorders in Neuropsychiatric Disorders Across the Life Cycle
Spiegelhalder, K., Regen, W., Nanovska, S., Baglioni, C., & Riemann, D. W. (2013) · Current Psychiatry Reports · doi:10.1007/s11920-013-0364-5 · Cited by 127
Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia
Backhaus, J., Hohagen, F., Voderholzer, U., & Riemann, D. W. (2001) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s004060170066 · Cited by 127
“This result is important because different studies [5, 7, 9, 13, 34 ] found that insomnia patients have a significantly higher risk of psychiatric disorders, especially depression, anxiety disorder, or alcoholism.”
ResultAmbulatory sleep-wake patterns and variability in young people with emerging mental disorders
Robillard, R., Hermens, D. F., Naismith, S. L., White, D., Rogers, N. L., Ip, T. K. C., Mullin, S. J., Alvares, G. A., Guastella, A. J., Smith, K. L., et al. (2015) · Journal of Psychiatry and Neuroscience · doi:10.1503/jpn.130247 · Cited by 119
Sleep in hospitalized medical patients, Part 1: Factors affecting sleep
Young, J. S., Bourgeois, J. A., Hilty, D. M., & Hardin, K. A. (2008) · Journal of Hospital Medicine · doi:10.1002/jhm.372 · Cited by 118
“Longitudinal studies have found that prior insomnia was associated with 2- to 5-fold increase in the odds of mood and anxiety disorders and suicide.(61,62) Examining prodromes and precursors to mental disorders, Eaton et al.”
BackgroundOral Nonprescription Treatment for Insomnia: An Evaluation of Products With Limited Evidence
Meoli, A. L., Rosen, C., Kristo, D., Kohrman, M., Gooneratne, N., Aguillard, R. N., Fayle, R., Troell, R., Townsend, D., Claman, D., et al. (2005) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.26314 · Cited by 152
Neuroimaging in sleep medicine
Dang‐Vu, T. T., Desseilles, M., Petit, D., Mazza, S., Montplaisir, J. Y., & Maquet, P. (2007) · Sleep Medicine · doi:10.1016/j.sleep.2007.03.006 · Cited by 122
“[103] Weissman MM, Greenwald S, Nino-Murcia G, Dement WC.”
Dombrovski, A. Y., Cyranowski, J. M., Mulsant, B. H., Houck, P. R., Buysse, D. J., Andreescu, C., Thase, M. E., Mallinger, A. G., & Frank, E. (2008) · Depression and Anxiety · doi:10.1002/da.20467 · Cited by 116
“1997) and with findings of insomnia preceding incident depression in community samples [(Johnson et al., 2006; Neckelmann et al., 2007; Weissman et al. 1997), ing, older studies reviewed in (Riemann and Voderholzer 2003)], underscoring the clinical importance of restoring normal sleep in depression.”
ResultManagement of chronic insomnia in elderly persons
Bain, K. T. (2006) · The American Journal of Geriatric Pharmacotherapy · doi:10.1016/j.amjopharm.2006.06.006 · Cited by 119
Chronic Insomnia: Clinical and Research Challenges - An Agenda
Riemann, D. W., Spiegelhalder, K., Espie, C. A., Pollmächer, T., Léger, D., Bassetti, C. L., & Someren, E. J. W. V. (2010) · Pharmacopsychiatry · doi:10.1055/s-0030-1267978 · Cited by 114
Enhancing sleep quality and memory in insomnia using instrumental sensorimotor rhythm conditioning
Schabus, M., Heib, D. P. J., Lechinger, J., Griessenberger, H., Klimesch, W., Pawlizki, A., Kunz, A. B., Sterman, B. M., & Hoedlmoser, K. (2013) · Biological Psychology · doi:10.1016/j.biopsycho.2013.02.020 · Cited by 117
Metadata
- Authors
- Weissman, M. M., Greenwald, S., Niño-Murcia, G., & Dement, W. C.
- Affiliations
- New York State Psychiatric Institute (US)
- Stanford Medicine (US)
- Corresponding author
- Weissman, Myrna M.
- ORCID
- Weissman, Myrna M.
- Venue
- General Hospital Psychiatry
- Publisher
- Elsevier BV
- Published
- 1997-07
- Volume
- 19
- Issue
- 4
- Pages
- 245-250
- ISSN
- 0163-8343 (ISSN-L)
- OpenAlex
- W2077240469
- Cited by
- 415
- References
- 23
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 1 · 2023: 18 · 2022: 9 · 2021: 7 · 2020: 6 · 2019: 10 · 2018: 5 · 2017: 15 · 2016: 21 · 2015: 16 · 2014: 21 · 2013: 24 · 2012: 21
- FWCI
- 7.62
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- General Hospital Psychiatry (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (7r01mh040603-05)
- National Institute of Mental Health (NIMH 40603-01A1)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
- Keywords
- insomnia, mental illness, major depressive disorder, panic disorder, alcohol abuse, psychiatric treatment utilization, sleep disorders, community survey
- MeSH terms
- Adult, Mental Disorders, Female, Follow-Up Studies, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Patient Acceptance of Health Care, Population Surveillance, Risk Factors, Time Factors, United States, Comorbidity, Prevalence, Case-Control Studies
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