Thomas Roth

Henry Ford Health System · Center for Sleep Medicine

Introduction Methods for quantifying emotional dream content have been developed. These approaches have yielded significant insights into dream content, their relation to waking cognition, and mental health. The current dream rating scale was developed to improve upon previous approaches by conceptualizing the scale based on the known fundamental a...

Polysomnographic sleep architecture parameters are commonly used to diagnose or evaluate treatment of sleep disorders. Polysomnography (PSG) having practical constraints, the development of wearable devices and algorithms to monitor and stage sleep is rising. Beside pure validation studies, it is necessary for a clinician to ensure that the conclus...

Treating insomnia during pregnancy improves sleep and depressed mood. However, given well-established links between poor sleep and a broad spectrum of adverse maternal outcomes, the benefits of insomnia care may reach beyond sleep and depression. The present study evaluated the preliminary efficacy of 'Perinatal Understanding of Mindful Awareness f...

Objectives Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depressi...

Objectives. Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness...

Introduction Cognitive behavioral therapy for insomnia (CBTI) improves sleep in pregnancy, but its therapeutic benefits may be diminished in pregnancy due to undertreatment of cognitive arousal (i.e., heightened cognitive activity, especially at night). Growing evidence indicates that mindfulness-based interventions produce large reductions in cogn...

Introduction Cognitive behavioral therapy for insomnia (CBTI) improves sleep in pregnancy, but its therapeutic benefits may be diminished in pregnancy due to undertreatment of cognitive arousal (i.e., heightened cognitive activity, especially at night). A recent proof-of-concept, single-arm trial suggested that combining behavioral sleep strategies...

Introduction A number of studies have evaluated epoch-by-epoch agreement between 2 technologists in scoring individual sleep stage. Scoring for the specific sleep stages average agreement ranged from 20% to 90% in different studies. The goal of this study is to evaluate the validity of the Somno-Art analyses against a pool of scorers including vali...

Introduction Cognitive behavioral therapy for insomnia (CBTI) is gold standard for insomnia care. However, recent data suggest Black CBTI patients may complete fewer sessions and experience poorer outcomes relative to white CBTI patients. The present study examined whether racial disparities in CBTI engagement mediated group differences in treatmen...

Introduction Clinicians prescribing hypnotics remain concerned regarding the inability to discontinue hypnotics after chronic use. In a controlled prospective study using self-administration choice procedures we tested whether BZRA hypnotic receptor specificity is predictive of discontinuation difficulty in a clinical trial in which insomnia subjec...

Introduction High cognitive arousal—i.e., heightened cognitive activity often in the form of perseverative thinking—is a central feature insomnia. Emerging evidence from randomized controlled trials (RCTs) support alleviating cognitive arousal as a mechanism by which cognitive behavioral therapy for insomnia (CBTI) reduces symptoms of insomnia and...

Introduction Cognitive-behavioral therapy for insomnia (CBTI) is first-line treatment for insomnia, but a provider shortage limits access. eHealth technology can increase access to behavioral interventions, and digital CBTI (fully automated programs) are effective. However, >50% of digital CBTI patients do not remit, and non-remission is linked to...

Background Sleep disruption is common in pregnancy, manifesting as insomnia in half of pregnant women as well as increasing objective nocturnal wakefulness across gestation. Despite potential overlap between insomnia and objective sleep disturbances in pregnancy, objective nocturnal wakefulness and its potential contributing factors remain uncharac...

Study Objectives: Vulnerability to stress-related sleep disturbances (sleep reactivity) is an established heritable risk factor for insomnia disorder with unclear biological underpinnings. Preliminary research points to a blunted cortisol response to stress as a biological predisposition to familial risk for insomnia, but the role of cortisol respo...

Background Prevention of major depressive disorder (MDD) is a public health priority. Strategies targeting individuals at elevated risk for MDD may guide effective preventive care. Insomnia is a reliable precursor to depression, preceding half of all incident and relapse cases. Thus, insomnia may serve as a useful entry point for preventing MDD. Co...

The COVID-19 pandemic is a rare stressor that has precipitated an accompanying mental health crisis. Prospective studies traversing the pandemic’s onset can elucidate how pre-existing disease vulnerabilities augured risk for later stress-related morbidity. We examined how pre-pandemic sleep reactivity predicted maladaptive stress reactions and depr...

Restorative sleep is a commonly used term but a poorly defined construct. Few studies have assessed restorative sleep in nationally representative samples. We convened a panel of 7 expert physicians and researchers to evaluate and enhance available measures of restorative sleep. We then developed the revised Restorative Sleep Questionnaire (REST-Q)...

Introduction Inability to discontinue chronic hypnotic use by people with insomnia remains a clinical problem. Sleep was recorded by actigraphy during a two-week discontinuation in an on-going “blinded” clinical trial in which people with insomnia were instructed to discontinue their study medication after 6 months of nightly use. Methods DSM-V di...

Introduction Clinicians prescribing hypnotics remain concerned regarding the inability to discontinue hypnotics after chronic use, which has never been directly tested in a controlled prospective study using self-administration choice methodology. This study reports on difficulty discontinuing medication as a function of basal sleep disturbance in...

The visual scoring of gold standard polysomnography is known to present inter- and intra-scorer variability. Previously, Somno-Art Software, a cardiac based sleep scoring algorithm, has been validated in comparison to 2expert visual PSG scorers. The goal of this research is to evaluate the performances of the algorithm against a pool of scorers. Si...

Study objectives The study had three primary goals. First, we estimated survey-assessed DSM-5 insomnia disorder rates in pregnancy, and described associated sociodemographics, and sleep-wake and mental health symptoms. Second, we derived cutoffs for detecting DSM-5 insomnia disorder using common self-report measures of sleep symptoms. Third, we ide...

Integrated analysis of heart rate (electrocardiogram [ECG]) and body movements (actimetry) during sleep in healthy subjects has previously been shown to generate similar evaluation of sleep architecture and continuity with Somno-Art Software compared to polysomnography (PSG), the gold standard. However, the performance of this new approach of sleep...

Objective: Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a pe...

The majority of the literature describing the relation of sleep/alertness disturbance and substance use disorders (SUD) has focused on the disruptive effects of substances with abuse liability on sleep and alertness. Rarely have studies or literature reviews assessed or discussed how sleep/alertness disturbance affects substance use. This paper foc...

The overall concept and aim of this chapter is to provide a basic sleep medicine “crash course” with a specific goal of describing a practical approach to treating the patient population afflicted with substance dependence and concomitant sleep complaints.

Research and clinical practice have demonstrated that patients with insomnia are a heterogeneous population. As such, it is important to understand and differentiate the potential sub-groups among insomnia patients as well as individuals at risk for insomnia. Questionnaires completed by 291 students of both sexes and at risk for insomnia (FIRST sca...

Study objectives: A critical barrier to successful treatment of circadian misalignment in shift workers is determining circadian phase in a clinical or field setting. Light and movement data collected passively from wrist actigraphy can generate predictions of circadian phase via mathematical models; however, these models have largely been tested...

Introduction Over half of pregnant women experience clinical insomnia, which is linked to perinatal depression and cognitive-emotional dysregulation. Despite high rates of prenatal insomnia and known maternal consequences, efficacious insomnia treatment options for this population are woefully scant. Early evidence from randomized controlled trials...

Introduction Despite a growing need for nighttime work, few studies have characterized the causes of sleep disturbance in night shift workers beyond circadian misalignment. Recent research suggest that high sleep reactivity to stress (a predisposition for sleep disturbance due to stress) may also lead to sleep difficulties in shift workers. This st...

Introduction Physicians prescribing hypnotics remain concerned regarding patient’s inability to discontinue hypnotics after chronic use. That concern has never been directly tested in a controlled prospective study using self-administration choice procedures. This is an update on results from an on-going “blinded” clinical trial in which insomnia s...

Introduction Rebound insomnia refers to worsened sleep relative to baseline on 1-2 nights after discontinuation of active hypnotic medication. Rebound is typically assessed using a placebo substitution. We assessed rebound in an on-going “blinded” clinical trial in which people with insomnia are instructed to discontinue their study medication (i.e...

Introduction Circadian misalignment is commonly cited as a culprit of daytime sleep disturbances in night shift workers; however, the specific impact and magnitude that circadian misalignment has on daytime sleep has not been well-characterized in larger samples of night shift workers. Methods Participants included fixed-night shift workers (n=52,...

Introduction Drowsy driving is a common occupational hazard for night shift workers (NSWs). While sleep loss is commonly identified as the primary culprit of drowsy driving, another critical factor to consider is circadian phase. However, the role of circadian phase in driving safety has not been well characterized in NSWs. This study examined if d...

Introduction Physical and sexual abuse are common and have demonstrated associations with insomnia. A common factor predisposing individuals to the development of insomnia is sleep reactivity, yet no studies have determined the relationship between sleep reactivity and physical and/or sexual abuse. Methods Patients with DSM-5 insomnia disorder (N...

Introduction Inability to discontinue chronic hypnotic use by people with insomnia remains a clinical concern. Sleep and hyperarousal was examined in an on-going “blinded” clinical trial in which people with insomnia are instructed to discontinue their study medication after 6 months of nightly use. Methods DSM-V diagnosed people with insomnia (n=...

Introduction Inability to discontinue chronic hypnotic use by people with insomnia remains a clinical concern. Self-reported sleep in an on-going “blinded” clinical trial in which people with insomnia are instructed to discontinue their study medication after 6 months of nightly use was examined and compared to objective actigraphic recordings of t...

Study objectives To determine whether insomnia patients with objective sleep disturbance are less responsive to cognitive and behavioral treatments than those without objective sleep disturbance, characterize effects of insomnia therapy on objective sleep, and determine whether reductions in nocturnal cognitive arousal correspond to changes in obje...

Background Insomnia and depression are highly prevalent perinatal complications. Ruminating on stress is etiologically implicated in both disorders, and ruminating while trying to fall asleep has been linked to insomnia and depression during pregnancy. Incompatible with rumination is everyday mindfulness, i.e., living with intentional and nonjudgme...

Objective Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven...

Objectives: The chronic pain disorder, fibromyalgia, is associated with sleep disturbance, typically sleep maintenance. No studies have evaluated the effect of sleep medication on pain sensitivity in this population. Suvorexant, an orexin antagonist, approved for treatment of insomnia was evaluated for effects on both the sleep and pain of fibromy...

None: The prevalence of shift work in the United States is nearly 20%, but recognition of shift work disorder (SWD) among shift workers is still a challenge. The health care sector is no exception. While a substantial portion of shift workers are physicians and nurses, expertise in identifying SWD is lacking. Shift work adjustment occurs spontaneo...

Objectives Irritable bowel syndrome (IBS) and insomnia symptoms are often found to occur together. The aim of this study was to investigate the relationship between sleep and IBS complaints, and their impact on reported health and daytime functioning. Methods An online advertisement invited people with difficulty initiating and/or maintaining slee...

Objective To characterize sleep habits and parameters among women in mid-to-late pregnancy and to identify disparities associated with poverty, race, and obesity. Design Cross-sectional. Setting Large multi-site health system in Metro Detroit. Participants A total of 267 pregnant women (27.3% non-Hispanic black; gestational age: 27.99±1.20 weeks...

Background. Cognitive arousal is central to models of sleep disturbance and insomnia, but findings are mixed regarding whether cognitive arousal is associated with objective sleep disturbance and physiologic hyperarousal. This study explored associations of objective nocturnal wakefulness and indicators of physiologic hyperarousal with cognitive ar...

None: The prevalence of shift work in the United States is nearly 20%, but recognition of shift work disorder (SWD) among shift workers is still a challenge. The health care sector is no exception. While a substantial portion of shift workers are physicians and nurses, expertise in identifying SWD is lacking. Shift work adjustment occurs spontaneo...

Objective: The determinants of sleep quality (sQUAL) are poorly understood. We evaluated how well a large number of objective polysomnography (PSG) parameters can predict sQUAL in insomnia patients participating in trials of sleep medications or placebo. Methods: PSG recordings over multiple nights from two clinical drug development programs inv...

Objective Menopause triggers changes in sexual function and many women develop sexual problems. Insomnia is common in postmenopausal women, and disturbed sleep has been linked to poor sexual health. Thus, postmenopausal women with insomnia may be especially vulnerable to developing sexual difficulties. This study estimated rates of sexual distress...

Study objectives: The safety profile of the dual orexin receptor antagonists (DORAs) are currently unknown with regard to nocturnal responsivity among people with insomnia. We compared the auditory awakening thresholds (AATs) of the DORA suvorexant (10 and 20 mg) versus placebo in 12 individuals with DSM-5 insomnia. Methods: The study used a dou...

Background Sleep problems and depression are highly prevalent in pregnancy. Nocturnal rumination has been linked to insomnia and depression in non-pregnant samples, but remains poorly characterized in pregnancy. This study explored relationships of depression and suicidal ideation with insomnia, short sleep, and nocturnal rumination in mid-to-lat...

Alcohol consumption can negatively affect sleep quality. The current study examined the impact of an evening of alcohol consumption on sleep, and next day activity levels and alcohol hangover. n = 25 healthy social drinkers participated in a naturalistic study, consisting of an alcohol and alcohol-free test day. On both days, a GENEactiv watch reco...

Introduction Depression afflicts 13% of pregnant women. Insomnia complaints often increase across pregnancy. As insomnia often triggers depression, women with insomnia in late pregnancy may be at high depression-risk. Cognitive-emotional dysregulation is thought to underlie both insomnia and depression. We proposed nocturnal rumination (negative re...

Introduction The chronic widespread pain disorder, fibromyalgia, is known for its nociceptive hypersensitization and disturbed sleep. The relation of sleep and pain is bidirectional and data suggest that improving sleep in chronic pain disorders would attenuate daytime pain sensitivity. Here we report on suvorexant’s next-day pain effects following...

Introduction The chronic pain disorder, fibromyalgia, is associated with sleep disturbance, typically sleep maintenance. Pharmacological treatment studies have either focused on the pain or the sleep disturbance with equivocal results in that few studies have improved both sleep and pain. No studies have evaluated the effect of sleep medication on...

Introduction Ability to awaken to external or internal stimuli (arousability) has significant clinical implications in patients with a variety of medical disorders (e.g., sleep related breathing disorders, GERD) and life circumstances (e.g. caregiver responsibility, environmental threat). Arousability with an orexin antagonist has been demonstrated...

Introduction A concern among physicians prescribing hypnotics is the inability to discontinue hypnotics after chronic use. This concern has never been directly tested in a controlled prospective study. This is a report of results from an on-going “blinded” trial in which insomnia subjects are instructed to stop taking study medication after 6 month...

Introduction Insomnia increases across the prenatal period. This study characterizes insomnia phenotypes in late pregnancy, and identifies factors related to prenatal insomnia. Methods A cross-sectional analysis of pregnant women (29.6±4.7 years, gestational weeks 26-33) receiving prenatal OB care at a large Midwestern health system completed onli...

Introduction A recent meta-analysis compared polysomnograms (PSGs) of people with insomnia to healthy controls; results showed short sleep time and reduced slow-wave and REM sleep in insomnia. Among people with insomnia, studies have shown morbidity associated with insomnia is found primarily in people with PSG short sleep. Here we characterize the...

Actigraphy is increasingly used in practice and research studies because of its relative low cost and decreased subject burden. How multiple nights of at‐home actigraphy compare to one independent night of in‐laboratory polysomnography (PSG) has not been examined in people with insomnia. Using event markers (MARK) to set time in bed (TIB) compared...

Introduction: Depression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. Recent evidence supports the efficacy of cognitive-behavioral therapy for insomnia (CBTI) to treat menopausal...

In this review, we outline the role of orexin receptor antagonists in disorders of sleep/wake and other potential neuropsychiatric conditions, with a focus on suvorexant, which is currently the only approved agent in this class. The efficacy of suvorexant was established in Phase 2–3 trials with treatment durations ranging from 1 to 12 months in pa...

We report a case series of four patients where tachypnea was observed during positive airway titration studies, double the baseline breathing rate (tachypnea range 46-68 breaths/min). It happened mainly during non-rapid eye movement to rapid eye movement sleep transitions without significant changes in oxygen saturation or signs of autonomic hypera...

Background: Irritable bowel syndrome (IBS) can have a significant negative impact on quality of life, mood and wellbeing. The aim of this study was to investigate the association between experiencing IBS symptoms and insomnia, and perceived health status. Method: An online survey was conducted among n = 1950 Dutch university students (83.6% wome...

Randomized controlled trials (RCTs) have eligibility criteria for the inclusion of participants. Ideally, the RCT sample would be representative for the patient population that will use the drug under investigation. However, external validity may be at stake when applying too many or too restrictive eligibility criteria. The current two-part study...

Hyperarousal is a key component in all modern etiological models of insomnia disorder. Overall patterns in the literature suggest that over-active neurobiological and psychological systems contribute to difficulty sleeping. Even so, mixed results regarding the specific mechanisms linking hyperarousal to sleep disturbance limit current etiological c...

Background Insomnia and depression are highly comorbid and mutually exacerbate clinical trajectories and outcomes. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces both insomnia and depression severity, and can be delivered digitally. This could substantially increase the accessibility to CBT-I, which could reduce the health di...

Introduction The aim of this study was to investigate the association between insomnia symptoms, psychological health, mental resilience, and stress. Methods A survey was held among young Dutch adults, aged 18 to 30 years old. The insomnia subscale of the SLEEP-50 questionnaire was completed. In addition, prior night’s bedtime, time of sleep onset...

Study Objectives Insomnia is one of the most common disorders in the general population. Hypnotic medications are efficacious, but their use is limited by adverse events (AEs). This study evaluated the safety and efficacy of a novel forehead temperature-regulating device that delivers frontal cerebral thermal therapy (maintained at 14–16°C, equival...

Study objectives: Recent evidence indicates that daytime sleep disturbance associated with night shift work may arise from both circadian misalignment and sleep reactivity to stress. This presents an important clinical challenge because there are limited means of predicting and distinguishing between the two mechanisms, and the respective treatmen...

Purpose To examine whether consuming an energy drink while having a break is effective in reducing the number of lapses of attention during prolonged highway driving. Methods In a double-blind crossover study, N = 21 healthy volunteers performed a 4-h driving test in the STISIM driving simulator. After 2 h, a 15-min break was scheduled. During the...

Objectives: To examine the duration and frequency of wake bouts underlying the wakefulness-after-sleep-onset (WASO) reduction with suvorexant. Methods: We analyzed polysomnogram recordings from clinical trials involving 1518 insomnia patients receiving suvorexant (40/30mg, 20/15mg) or placebo to determine: 1) the number of, and time spent in, lo...

The primary outcome measure of the on-road driving test is the Standard Deviation of Lateral Position. However, other outcome measures, such as lapses and excursions out-of-lane, also need to be considered as they may be related to crash risk. The aim of this study was to determine the direction of lapses and excursions out-of-lane (i.e. towards/in...

Objective To assess the effects of three narcolepsy treatment modalities on sleep stage shifts associated with disrupted nighttime sleep (DNS) using data from a clinical trial. Methods Polysomnograms were reviewed from 155 patients (who had these data available at baseline and 8 weeks) of the 278 patients who were randomized to placebo, 9-g sodium...

Objectives Abnormalities in the stress system have been implicated in insomnia. However, studies examining physiological stress regulation in insomnia have not consistently detected differences in the hypothalamic–pituitary–adrenal (HPA)-axis response to stress. One explanation may be that deficits in the stress system are associated specifically w...

RationaleSex-related differences in the clinical profiles of some insomnia medications have been previously reported. Objective To evaluate the clinical profile of suvorexant, a novel orexin receptor antagonist approved for treating insomnia at doses up to 20 mg, by sex subgroups. Methods Efficacy analyses by sex were based on pooled data from two...

Study Objectives To examine and compare the arousability threshold and fall risk upon awakening of doxepin (6 mg) versus zolpidem (10 mg). Methods A total of 52 healthy adult males were included in a double-blind, placebo-controlled, 4-way crossover study. The experimental procedure included four nights with polysomnography in the lab (zolpidem, d...

Representative surveys of the populations of industrialized countries have found that between 11 and 32 % of respondents reported that sleepiness interferes with activities almost daily. Normal and pathologic variations in daytime sleepiness and alertness can now be directly assessed and quantified by the multiple sleep latency test (MSLT), a test...

Objective: Suvorexant is an orexin receptor antagonist approved for treating insomnia at doses of 10-20 mg. Previously reported phase III results showed that suvorexant was effective and well-tolerated in a combined-age population (elderly and nonelderly adults). The present analysis evaluated the clinical profile of suvorexant specifically in the...

This post hoc analysis evaluated the dose-related effects of sodium oxybate on sleep continuity and nocturnal sleep quality in patients with narcolepsy-cataplexy. Polysomnography data, including shifts to Stage N1/Wake, were from a randomized, placebo-controlled trial of sodium oxybate. Patients were ≥16 years old with a diagnosis of narcolepsy inc...

Study objectives: To examine the real-world effectiveness of benzodiazepine receptor agonists (BzRAs) by quantifying response and remission rates in a clinical sample receiving chronic BzRA treatment for insomnia. Methods: Participants were outpatients (N = 193; 72% female; 55.2 ± 11.1 yo) who had an insomnia diagnosis per medical records, and w...

Objective: Sleep laboratory study to determine the dose-related efficacy and safety of almorexant in elderly patients with primary chronic insomnia. Methods: Patients aged ≥65 years with primary insomnia were enrolled into a prospective, randomized, double-blind, placebo-controlled, multicenter dose-finding study with a five-period,