title: A community-based study on the association between insomnia and hypothalamic-pituitary-adrenal axis: sex and pubertal influences.
abstract: BACKGROUND
  The association between insomnia disorder and the hypothalamic-pituitary-adrenal (HPA) axis needs to be explored in both adults and adolescents.
  
  
  OBJECTIVE
  Our objective was to investigate the associations of the HPA axis (via serial salivary cortisol) with insomnia disorder and subjective and objective sleep quality in a community-based study.
  
  
  METHODS
  This was a community-based case-control family study.
  
  
  METHODS
  Participants included 205 adolescents (14.2 ± 2.8 years old, 51.7% females, and 57 with insomnia) and 244 adults (46.4 ± 4.1 years old, 52.8% females, and 69 with insomnia).
  
  
  METHODS
  Outcome measures included a diagnostic interview for assessment of insomnia disorder, 3-day actigraphy and sleep diary, and serial salivary cortisol measurement.
  
  
  RESULTS
  Adults with insomnia had a significantly greater cortisol awakening response (CAR) reference to increase (CARi) but a comparable CAR reference to ground and a comparable cortisol level during afternoon and evening when compared with noninsomniac adults. The association between insomnia disorder and larger CARi was also found in adolescents at late/post puberty but not in pre/early pubertal adolescents. There was an interaction effect between sex and insomnia disorder on CARi level with adult females having larger CARi than adult males. Among subjects with insomnia disorder, those with lower subjective sleep efficiency had higher cortisol levels in the late evening (10:00 pm) in both adults and adolescents.
  
  
  CONCLUSIONS
  Our study suggests that a series of insomniac indices at both syndromal and symptomatic levels including clinical diagnosis and poor sleep quality are associated with dysfunction of the HPA axis. The association between insomnia and increased CARi emerges at late puberty, and the sex difference in this association occurs in adulthood but not in adolescence.
authors.affiliation: Departments of Psychiatry (J.Z., S.-P.L., S.X.L., Y.-K.W.), Medicine and Therapeutics (R.C.W.M., A.P.S.K.), Chemical Pathology (M.H.M.C., C.-S.H.), and Paediatrics (A.M.L.), Li Ka Shing Institute of Health Sciences (R.C.W.M., A.P.S.K.), The Chinese University of Hong Kong, Hong Kong SAR, China.
authors.forename: Jihui
authors.initials: J
authors.lastname: Zhang
authors.forename: Siu-Ping
authors.initials: SP
authors.lastname: Lam
authors.forename: Shirley Xin
authors.initials: SX
authors.lastname: Li
authors.forename: Ronald C W
authors.initials: RC
authors.lastname: Ma
authors.forename: Alice P S
authors.initials: AP
authors.lastname: Kong
authors.forename: Michael H M
authors.initials: MH
authors.lastname: Chan
authors.forename: Chung-Shun
authors.initials: CS
authors.lastname: Ho
authors.forename: Albert M
authors.initials: AM
authors.lastname: Li
authors.forename: Yun-Kwok
authors.initials: YK
authors.lastname: Wing
mesh_terms: D056044:Actigraphy; D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002648:Child; D002940:Circadian Rhythm; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D007030:Hypothalamo-Hypophyseal System / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D010913:Pituitary-Adrenal System / Q000502:physiology*; D011627:Puberty / Q000502:physiology*; D012111:Residence Characteristics; D012737:Sex Factors; D012890:Sleep / Q000502:physiology; D007319:Sleep Initiation and Maintenance Disorders / Q000453:epidemiology* / Q000378:metabolism
chemical_list: D006854:Hydrocortisone