Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials

Comparing internet-delivered cognitive therapy and behavior therapy with telephone support for insomnia disorder: a randomized controlled trial

STUDY OBJECTIVES

Our aim was to compare the effects of Internet-delivered cognitive therapy (CT) and behavior therapy (BT) against a waitlist (WL) condition to better understand their unique contribution in the treatment of insomnia.

METHODS

Two hundred and nineteen participants with insomnia disorder were randomized to CT (n = 72), BT (n = 73), or WL (n = 74). The treatment arms consisted of 10 weekly internet-delivered modules with 15 min of telephone support per week. At pre, post, and follow-up, participants completed measures of insomnia severity, sleep diaries, functional impairment, anxiety, depression, quality of life, adverse events, satisfaction and perception of content, workload, and activity in treatment. Measures of completed exercises, modules, therapist support, and platform logins were also measured at posttreatment.

RESULTS

Moderate to large effect sizes for both CT and BT outperformed the WL on the majority of outcomes, with significant differences in favor of both therapy groups. Both treatment groups had significantly larger proportion of treatment remitters (CT: 35.8%, BT: 40%, WL: 2.7%) and responders (CT: 74.6%, BT 58.6%, WL: 10.8%) compared to the WL at posttreatment. There were no significant differences between the two therapy groups in terms of outcomes, except for sleep onset latency in favor of BT (6 min difference at posttreatment) and adverse events in favor of CT (CT 14.1% vs BT 43.2%).

CONCLUSIONS

This study indicates that both Internet-delivered CT and BT are effective as stand-alone therapies for insomnia disorder. Results highlight the need for examining which therapy and subcomponents that are necessary for change.

CLINICALTRIALS.GOV IDENTIFIER

NCT02984670.

Intraindividual variability in sleep schedule: effects of an internet-based cognitive-behavioral therapy for insomnia program and its relation with symptom remission

STUDY OBJECTIVES

Sleep schedule consistency is fundamental to cognitive-behavioral therapy for insomnia (CBT-I), although there is limited evidence suggesting whether it predicts treatment response. This analysis tested whether: (1) an Internet-based CBT-I program affects intraindividual variability (IIV) in sleep schedule and (2) sleep schedule IIV predicts insomnia symptom remission.

METHODS

This secondary analysis compares participants (N = 303) randomized to an Internet-based CBT-I program (SHUTi-Sleep Healthy Using the Internet) or Internet-based patient education (PE). Participants reported daily bedtimes and rising times on 10 online sleep diaries collected over 2 weeks at baseline and 9-week post-intervention assessment. Participants completed the Insomnia Severity Index (ISI) at post-assessment and 6-month follow-up; symptom remission was defined by ISI < 8. Mixed effects location scale modeling was used to examine the effect of SHUTi on bedtime and rising time IIV; a novel two-staged analysis examined the effect of bedtime and rising time IIV on insomnia symptom remission.

RESULTS

At post-assessment, SHUTi participants reported about 30% less bedtime and 32% less rising time variability compared to PE (ps < 0.03). Bedtime and rising time IIV was not independently associated with likelihood of insomnia symptom remission at the subsequent time point (ps > 0.18), nor did sleep schedule IIV moderate treatment response (ps > 0.12).

CONCLUSIONS

Findings demonstrate that an Internet-delivered CBT-I program can effectively increase users' sleep schedule consistency relative to an educational control. This consistency, however, was not related to treatment outcome when defined by insomnia symptom remission, suggesting that enforcing rigid sleep schedules for patients may not be necessary for treatment success.

CLINICAL TRIAL REGISTRATION

NCT00328250.

Prevalence of post-traumatic stress symptoms among people influenced by coronavirus disease 2019 outbreak: A meta-analysis

BACKGROUND

As one of the most widely researched consequence of traumatic events, the prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from coronavirus disease 2019 (COVID-19) outbreak varies greatly across studies. This review aimed at examining the pooled prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from COVID-19 outbreak.

METHODS

Systematic searches of databases were conducted for literature published on PubMed, EMBASE, Web of Science, the Cochrane Library, PsycArticle, and Chinese National Knowledge Infrastructure until October 14, 2020. Statistical analyses were performed using R software (PROSPERO registration number: CRD42020180309).

RESULTS

A total of 106,713 people exposed to the trauma resulting from the COVID-19 outbreak were identified in the 76 articles, of which 33,810 were reported with post-traumatic stress symptoms. The pooled prevalence of post-traumatic stress symptoms among people exposed to the trauma resulting from COVID-19 outbreak was 28.34%, with a 95% confidence interval of 23.03-34.32%. Subgroup analysis indicated that older age, male and bigger sample size were associated with higher prevalence of post-traumatic stress symptoms. After controlling for other factors, the results of meta-regression showed that the influence of gender and sample size on prevalence is no longer significant.

CONCLUSIONS

Symptoms of post-traumatic stress disorder (PTSD) were very common among people exposed to the trauma resulting from COVID-19 outbreak. Further research is needed to explore more possible risk factors for post-traumatic stress symptoms and identify effective strategies for preventing PTSD-related symptoms among people exposed to the trauma resulting from COVID-19 outbreak.

How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change

Insomnia is prevalent and debilitating, comprising sustained difficulties initiating or maintaining sleep. Cognitive-behavioural therapy for insomnia (CBT-I) is a multicomponent intervention recommended as the first-line treatment, but the mediators of change remain unclear. This systematic review and meta-analysis aimed to synthesise and evaluate the evidence for potential mediators of CBT-I. Searches were performed for studies published until February 2021, reporting on mediation analyses with CBT-I. Seventeen unique samples of adults with insomnia (20 studies, N = 3125) were included. Two-stage structural equation modelling was applied to the available data, where 7 studies examined the cognitive mediator, 'dysfunctional beliefs about sleep', 5 studies examined a hyperarousal mediator, and 3 studies examined the behavioural mediator, 'time in bed'. There was evidence in support of changes in dysfunctional beliefs as a cognitive mediator of insomnia symptom improvement following CBT-I. There was more limited evidence in support of changes in hyperarousal-related mediators, and no significant effect of time in bed as a mediator. Numerous studies recorded diary-based measures of potential behavioural mediators, but analyses of these variables were not typically conducted. The most serious limitation of the evidence base is that the temporal precedence of mediator changes cannot be established. Future studies should consider: i) using mid-treatment measurements of mediator changes; ii) reporting on mediator psychometric properties; and iii) explicitly stating analyses as pre-specified or exploratory.

Feasibility of a video-based cognitive behavioral therapy for insomnia in French adult cancer outpatients: results from the Sleep-4-All-1 study

BACKGROUND

Insomnia affects up to 63% of patients with cancer. Cognitive behavioral therapy for insomnia (CBT-I) is considered to be the non-pharmacological gold standard treatment, but it remains underutilized in France. Self-administered interventions offer new ways to overcome some of the barriers that restrict access to efficacious supportive care.

OBJECTIVE

To assess the feasibility, among French adult cancer outpatients, of a validated Quebec video-based, self-administered, cognitive behavioral therapy for insomnia (VCBT-I).

METHODS

A pre-post design with quantitative measures (Insomnia Severity Index, Edmonton Symptom Assessment System, Treatment Perception Questionnaire) and qualitative measures (semi-structured interviews) was used.

RESULTS

One hundred and seventy-three cancer outpatients were self-screened for insomnia, and 57% (n=99) reported significant symptoms. Among them, 80% (n=79) agreed to participate in the VCBT-I. The download rate of the VCBT-I was 78% (n=62/79). Several technical and contextual barriers to the delivery and the applicability of the VCBT-I emerged. However, participants reported a high level of satisfaction, and some valuable benefits at post-immediate intervention (increased knowledge about sleep, better quality of sleep, and higher acceptance of the burden of insomnia), regardless of whether or not they still had insomnia.

DISCUSSION

This study confirms that there is a demand for a VCBT-I, which was perceived as appropriate by a sample of French cancer outpatients with insomnia, but it also highlights some limitations in terms of implementation and practicality. Remote professional support appears to be a core need in order to address these issues and personalize the guidance process.

Gender Differences in Adolescent Sleep Disturbance and Treatment Response to Smartphone App-Delivered Cognitive Behavioral Therapy for Insomnia: Exploratory Study

BACKGROUND

Insomnia and sleep disturbance are pervasive and debilitating conditions affecting up to 40% of adolescents. Women and girls are at greater risk of insomnia, yet differences in treatment responsiveness between genders have not been adequately investigated. Additionally, while women report greater symptom severity and burden of illness than men, this discrepancy requires further examination in adolescents.

OBJECTIVE

The purpose of this study was to examine gender differences in sleep symptom profiles and treatment response in adolescents.

METHODS

Digital cognitive behavioral therapy for insomnia (CBT-I) treatment responsiveness, as indexed by changes in Insomnia Severity Index (ISI) and Global Pittsburgh Sleep Quality Index (PSQI) scores, was compared in boys and girls (aged 12-16 years; N=49) who participated in a pilot evaluation of the Sleep Ninja smartphone app. Gender differences in self-reported baseline insomnia symptom severity (ISI), sleep quality (PSQI), and sleep characteristics derived from sleep diaries were also examined.

RESULTS

Compared with boys, we found that girls reported greater symptom severity (P=.04) and nighttime wakefulness (P=.01 and P=.04) and reduced sleep duration (P=.02) and efficiency (P=.03), but not poorer sleep quality (P=.07), more nighttime awakenings (P=.16), or longer time to get to sleep (P=.21). However, gender differences in symptom severity and sleep duration were accounted for by boys being marginally younger in age. Treatment response to CBT-I was equivalent between boys and girls when comparing reductions in symptom severity (P=.32); there was a trend showing gender differences in improvements in sleep quality, but this was not statistically significant (P=.07).

CONCLUSIONS

These results demonstrate the presence of gender differences in insomnia symptoms and severity in adolescents and suggest further research is required to understand gender differences in insomnia symptom profiles to inform the development of gender-specific digital interventions delivered to adolescents.

A Review of Digital Cognitive Behavioral Therapy for Insomnia (CBT-I Apps): Are They Designed for Engagement?

There are different ways to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), of which in-person (face to face) is the traditional delivery method. However, the scalability of in-person therapy is low. Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) is an alternative and there are tools on the market that are validated in clinical studies. In this paper, we provide a review of the existing evidence-based CBT-I apps and a summary of the published usability-oriented studies of these apps. The goal is to explore the range of interaction methods commonly applied in dCBT-I platforms, the potential impact for the users, and the design elements applied to achieve engagement. Six commercially available CBT-I apps tested by scientifically valid methods were accessed and reviewed. Commonalities were identified and categorized into interactive elements, CBT-I-related components, managerial features, and supportive motivational features. The dCBT-I apps were effectively assisting the users, and the type of interactions promoted engagement. The apps' features were based on design principles from interactive product design, experience design, online social media, and serious gaming. This study contributes to the field by providing a critical summary of the existing dCBT-I apps that could guide future developers in the field to achieve a high engagement.

Nurse-Guided Internet-Delivered Cognitive Behavioral Therapy for Insomnia in General Practice: Results from a Pragmatic Randomized Clinical Trial

INTRODUCTION

Guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as the first line of treatment for insomnia in general practice, but CBT-I is rarely available. Nurse-guided Internet-delivered CBT-I might be a solution to improve access to care.

OBJECTIVE

We aimed to determine the effectiveness of nurse-guided Internet-delivered CBT-I (I-CBT-I) on insomnia severity experienced by patients in general practice.

METHODS

Nurse-guided I-CBT-I ("i-Sleep") was compared to care-as-usual (and I-CBT-I after 6 months) in 15 participating general practices among 134 patients (≥18 years old) with clinical insomnia symptoms. Assessments took place at 8, 26 and 52 weeks. Primary outcome was self-reported insomnia severity (Insomnia Severity Index) at 8 weeks. Secondary outcomes were sleep diary indices, depression and anxiety symptoms (Hospital Anxiety and Depression Scale), fatigue, daytime consequences of insomnia, sleep medication and adverse events.

RESULTS

Two thirds of the 69 intervention patients (n = 47; 68%) completed the whole intervention. At the posttest examination, there were large significant effects for insomnia severity (Cohen's d =1.66), several sleep diary variables (wake after sleep onset, number of awakenings, terminal wakefulness, sleep efficiency, sleep quality) and depression. At 26 weeks there were still significant effects on insomnia severity (d = 1.02) and on total sleep time and sleep efficiency. No significant effects were observed for anxiety, fatigue, daily functioning or sleep medication. No adverse events were reported.

CONCLUSIONS

Nurse-guided I-CBT-I effectively reduces insomnia severity among general practice patients. I-CBT-I enables general practitioners to offer effective insomnia care in accordance with the clinical guidelines.

Protocol for Digital Real-world Evidence trial for Adults with insomnia treated via Mobile (DREAM): an open-label trial of a prescription digital therapeutic for treating patients with chronic insomnia

Background: Cognitive behavioral therapy for insomnia (CBT-I) is underused in healthcare settings and is challenging for people with insomnia to access because of uneven geographical distribution of behavioral sleep medicine providers. Prescription digital therapeutics can overcome these barriers. This study evaluates the effectiveness of a specific digital CBT-I therapeutic. Materials & methods: Digital Real-world Evidence trial for Adults with insomnia treated via Mobile (DREAM) is a 9-week, open-label, decentralized clinical trial to collect real-world evidence for a digital therapeutic (Somryst™) delivering CBT-I to patients with chronic insomnia. The primary objective is to examine the effectiveness of Somryst to reduce self-reported insomnia symptoms and severity in a real-world population (n = 350). Conclusion: This pragmatic study seeks to assess the potential benefits of treating insomnia with an asynchronous, mobile, tailored prescription digital therapeutic. Clinical trial registration: NCT04325464 (ClinicalTrials.gov).

Specific aspects of sleep disturbance associated with suicidal thoughts and attempts

OBJECTIVE

Previous research suggests that sleep disturbance is associated with suicidal ideation and suicide attempt. However, few studies have accounted for the presence of multiple mental disorders and interpersonal factors associated with suicide risk. Furthermore, limited research has examined which aspects of sleep disturbance are most strongly associated with suicidal thoughts and attempts.

METHOD

A large community-based sample of Australian adults (n = 3,618; 81% female; 37% reporting ideation) completed a comprehensive survey assessing suicidal thoughts and behaviours, sleep disturbance, common mental disorders and interpersonal risk factors. Sleep disturbance was assessed using the 6-item PROMIS sleep disturbance scale and suicidality was measured using the Psychiatric Symptom Frequency Scale. Analyses were adjusted for age, sex, perceived burdensomeness, thwarted belongingness, and clinical caseness for six mental disorders, including major depression.

RESULTS

After accounting for mental health, demographic and interpersonal characteristics, increasing sleep disturbance was significantly associated with higher odds of both suicidal ideation (OR=1.17 for one-SD increase in PROMIS-SD), and suicide attempt (OR=1.33 for one-SD increase in PROMIS-SD). Of the specific indicators of sleep disturbance, only sleep onset (difficulties falling asleep) had a significant independent association with both suicidal ideation (p < 0.001) and suicide attempt (p = 0.047).

CONCLUSIONS

Sleep disturbance is independently associated with greater risk of suicidal thoughts and behaviours. Sleep disturbance is highly modifiable, so sleep interventions for people with suicide risk and sleep problems may provide an effective and efficient approach to suicide prevention in the community.

Modularized iCBT‑I self-learn training for university staff-prevention and early intervention in the SARS-CoV-2 crisis: A pilot study

Background

Insomnia is a widespread disease in adults and has a high prevalence rate. As sleep disturbances are a risk factor concerning mental and physical health, prevention and early intervention are necessary. Thus, the aim of this study was to implement a self-learning prevention and early intervention training for university staff members. We adapted an established cognitive behavioral therapy for insomnia (CBT-I) intervention as an online version for use during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) crisis.

Methods

Development and adaptation procedure of the internet-based CBT‑I (iCBT-I) prevention and early intervention training is described. Sessions and topics are shown in detail. The Online Sleep Prevention and Treatment Acceptance questionnaire (OSTA) and the Online Sleep Prevention and Treatment Feedback questionnaire (OSTF) were used to assess acceptance. Sleep problems of university staff members were assessed using the Pittsburgh Sleep Questionnaire (PSQI).

Results

The online-adapted version consisted of seven modules. Contents of sessions and topics were implemented based on video clips. Drawings were added to information regarding sleep and sleep hygiene as well as addressing stress and cognitions. In all, 15 individuals participated in this pilot study. The new iCBT‑I self-learning prevention training was well accepted. In addition, participants scored the online version as helpful based on the OSTA. Prior to online training, 89% of the participants reported impaired sleep quality or insomnia symptoms, and 56% had a PSQI score over 10. After training 78% of participants showed reduced sleep problems according to PSQI and 56% reached clinically significant enhancement. In addition, after training 44% were healthy sleepers.

Discussion

This is the first iCBT‑I prevention and early intervention training for university staff members. The training by participants was very well accepted and they scored the videos as very helpful. Sleep problems decreased after online training. However, further studies with larger samples and more sleep-related assessment strategies, e.g., actigraphy and sleep log, are necessary.

The Early Impact of COVID-19 on Chronic Pain: A Cross-Sectional Investigation of a Large Online Sample of Individuals with Chronic Pain in the United States, April to May, 2020

OBJECTIVE

Individuals with chronic pain are uniquely challenged by the COVID-19 pandemic, as increased stress may exacerbate chronic pain, and there are new barriers to receiving chronic pain treatment. In light of this, using a large online sample in the United States, we examined 1) the early impact of COVID-19 on pain severity, pain interference, and chronic pain management; and 2) variables associated with perceived changes in pain severity and pain interference.

DESIGN

A cross-sectional study.

METHODS

Online survey data for 1,453 adults with chronic pain were collected via Amazon's Mechanical Turk platform.

RESULTS

Although a large proportion of participants reported no perceived changes in their pain severity and pain interference since the outbreak, approximately 25-30% of individuals reported exacerbation in these domains. Individuals identifying as Black and of non-Hispanic origin, who experienced greater disruptions in their mood and sleep quality, were more likely to report worsened pain interference. The majority of participants reported engaging in self-management strategies as usual. However, most appointments for chronic pain treatment were either postponed or canceled, with no future session scheduled. Furthermore, a notable proportion of participants had concerns about or difficulty accessing prescription opioids due to COVID-19.

CONCLUSIONS

We may expect to see a long-term exacerbation of chronic pain and related interference in functioning and chronic pain management among individuals most impacted by the pandemic. These individuals may benefit from remotely delivered intervention to effectively mitigate COVID-19-related exacerbations in chronic pain and interruptions in face-to-face treatment.

Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies

BACKGROUND

Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments.

OBJECTIVE

To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment.

METHODS

We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients' perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges.

RESULTS

Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality-based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks.

CONCLUSIONS

The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders.

Framework for the Design Engineering and Clinical Implementation and Evaluation of mHealth Apps for Sleep Disturbance: Systematic Review

BACKGROUND

Mobile health (mHealth) apps offer a scalable option for treating sleep disturbances at a population level. However, there is a lack of clarity about the development and evaluation of evidence-based mHealth apps.

OBJECTIVE

The aim of this systematic review was to provide evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance.

METHODS

A systematic search of studies published from the inception of databases through February 2020 was conducted using 5 databases (MEDLINE, Embase, Cochrane Library, PsycINFO, and CINAHL).

RESULTS

A total of 6015 papers were identified using the search strategy. After screening, 15 papers were identified that examined the design engineering and clinical implementation and evaluation of 8 different mHealth apps for sleep disturbance. Most of these apps delivered cognitive behavioral therapy for insomnia (CBT-I, n=4) or modified CBT-I (n=2). Half of the apps (n=4) identified adopting user-centered design or multidisciplinary teams in their design approach. Only 3 papers described user and data privacy. End-user acceptability and engagement were the most frequently assessed implementation metrics. Only 1 app had available evidence assessing all 4 implementation metrics (ie, acceptability, engagement, usability, and adherence). Most apps were prototype versions (n=5), with few matured apps. A total of 6 apps had supporting papers that provided a quantitative evaluation of clinical outcomes, but only 1 app had a supporting, adequately powered randomized controlled trial.

CONCLUSIONS

This is the first systematic review to synthesize and examine evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. The minimal number of apps with published evidence for design engineering and clinical implementation and evaluation contrasts starkly with the number of commercial sleep apps available. Moreover, there appears to be no standardization and consistency in the use of best practice design approaches and implementation assessments, along with very few rigorous efficacy evaluations. To facilitate the development of successful and evidence-based apps for sleep disturbance, we developed a high-level framework to guide researchers and app developers in the end-to-end process of app development and evaluation.

Acceptance and Commitment Therapy (ACT) Improves Sleep Quality, Experiential Avoidance, and Emotion Regulation in Individuals with Insomnia-Results from a Randomized Interventional Study

Insomnia is a common problem in the general population. To treat insomnia, medication therapies and insomnia-related cognitive-behavioral interventions are often applied. The aim of the present study was to investigate the influence of acceptance and commitment therapy (ACT) on sleep quality, dysfunctional sleep beliefs and attitudes, experiential avoidance, and acceptance of sleep problems in individuals with insomnia, compared to a control condition. A total of 35 participants with diagnosed insomnia (mean age: 41.46 years old; 62.9% females) were randomly assigned to the ACT intervention (weekly group therapy for 60-70 min) or to the active control condition (weekly group meetings for 60-70 min without interventional and psychotherapeutic character). At baseline and after eight weeks (end of the study), and again 12 weeks later at follow-up, participants completed self-rating questionnaires on sleep quality, dysfunctional beliefs and attitudes about sleep, emotion regulation, and experiential avoidance. Furthermore, participants in the intervention condition kept a weekly sleep log for eight consecutive weeks (micro-analysis). Every morning, participants completed the daily sleep log, which consisted of items regarding subjective sleep duration, sleep quality, and the feeling of being restored. Sleep quality, dysfunctional beliefs and attitudes towards sleep, emotion regulation, and experiential avoidance improved over time, but only in the ACT condition compared to the control condition. Improvements remained stable until follow-up. Improvements in experiential avoidance were related to a favorable change in sleep and cognitive-emotional processing. Micro-analyses showed that improvements occurred within the first three weeks of treatment. The pattern of results suggests that ACT appeared to have improved experiential avoidance, which in turn improved both sleep quality and sleep-related cognitive-emotional processes at longer-term in adults with insomnia.

Effectiveness comparisons of Chinese patent medicine on insomnia: A protocol for systematic review and Bayesian network meta-analysis

BACKGROUND

In recent years, the incidence of insomnia is increasing. However, the existing therapy methods for cannot fundamentally treat the disease. Meanwhile, Chinese patent medicine (CPM) plays an active role in the treatment of insomnia. However, there is no comparison and ranking of the efficacy of every CPM. Therefore, our study will use network meta-analysis to compare the efficacy of different CPM on insomnia, in order to provide evidence-based medical evidence for clinical treatment.

METHODS

We will search CNKI, Wanfang, VIP, CBM, Pubmed, Cochrane Library, Embase for the randomized controlled trials of CPM in the treatment of insomnia (up to December 31, 2020). We will use RevMan5.3, Stata15.1 and ADDIS software for statistical analysis. We will draw the surface under cumulative ranking area to predict the order of efficacy.

RESULTS

We aim to rank the efficacy and safety of different CPM for the treatment of insomnia.

CONCLUSION

CPM plays a positive role in the treatment of insomnia and can provide evidence support for clinicians and patients.

INPLASY REGISTRATION NUMBER

INPLASY2020120121.

Cognitive behavioral therapy for insomnia in patients with chronic pain - A systematic review and meta-analysis of randomized controlled trials

Several randomized controlled trials have implemented cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid insomnia and chronic pain. This systematic review and meta-analysis investigated the effectiveness of CBT-I on patient-reported sleep, pain, and other health outcomes (depressive symptoms, anxiety symptoms, and fatigue) in patients with comorbid insomnia and chronic non-cancer pain. A systematic literature search was conducted using eight electronic databases. Upon duplicate removal, 6374 records were screened against the inclusion criteria. Fourteen randomized controlled trials were selected for the review, with twelve (N = 762 participants) included in the meta-analysis. At post-treatment, significant treatment effects were found on global measures of sleep (standardized mean difference = 0.89), pain (0.20), and depressive symptoms (0.44). At follow-up (up to 12 mo), CBT-I significantly improved sleep (0.56). Using global measures of sleep, we found a probability of 81% and 71% for having better sleep after CBT-I at post-treatment and final follow-up, respectively. The probability of having less pain after CBT-I at post-treatment and final follow-up was 58% and 57%, respectively. There were no statistically significant effects on anxiety symptoms and fatigue at either assessment point. Future trials with sufficient power, longer follow-up periods, and inclusion of CBT for pain components are warranted.

Efficacy of cognitive behavioral therapy for insomnia in breast cancer: A meta-analysis

Insomnia is highly prevalent among patients with breast cancer (BC). Although cognitive behavioral therapy for insomnia (CBT-I) is available in integrative oncology settings, it poses unique challenges for BC survivors. Our review aimed to assess the evidence for the therapeutic effects of CBT-I on insomnia in BC. Randomized controlled trials (RCTs) that included patients/survivors with BC and insomnia, and at least one validated self-report measure of sleep quality were included in the review. Of the 14 included RCTs (total N = 1363), the most common components incorporated in CBT-I interventions were sleep hygiene, stimulus control and sleep restriction. Pooled effect sizes favored CBT-I at post-intervention (Hedges' g = -0.779, 95% CI = -0.949, -0.609), short-term follow-up (within six months, Hedges' g = -0.653, 95% CI = -0.808, -0.498), and long-term follow-up (12 mo, Hedges' g = -0.335, 95% CI = -0.532, -0.139). In sub-analyses, CBT-I had similar effect sizes regardless of potential modifiers (comparison design, delivery formats, etc.). As an integrative oncology intervention, CBT-I is efficacious for reducing insomnia and improving sleep quality in women treated for BC, with medium-to-large effect sizes that persist after intervention delivery ends. Given the variability in the CBT-I components tested in RCTs, future studies should investigate the optimal integration of CBT-I components for managing insomnia during BC survivorship.

Maintaining musculoskeletal health using a behavioural therapy approach: a population-based randomised controlled trial (the MAmMOTH Study)

Objective

Cognitive–behavioural therapy (CBT) has been shown to be effective in the management of chronic widespread pain (CWP); we now test whether it can prevent onset among adults at high risk.

Methods

A population-based randomised controlled prevention trial, with recruitment through UK general practices. A mailed screening questionnaire identified adults at high risk of CWP. Participants received either usual care (UC) or a short course of telephone CBT (tCBT). The primary outcome was CWP onset at 12 months assessed by mailed questionnaire. There were seven secondary outcomes including quality of life (EuroQol Questionnaire-five dimensions-five levels/EQ-5D-5L) used as part of a health economic assessment.

Results

996 participants were randomised and included in the intention-to-treat analysis of which 825 provided primary outcome data. The median age of participants was 59 years; 59% were women. At 12 months there was no difference in the onset of CWP (tCBT: 18.0% vs UC: 17.5%; OR 1.05; 95% CI 0.75 to 1.48). Participants who received tCBT were more likely to report better quality of life (EQ-5D-5L utility score mean difference 0.024 (95% CI 0.009 to 0.040)); and had 0.023 (95% CI 0.007 to 0.039) more quality-adjusted life-years at an additional cost of £42.30 (95% CI −£451.19 to £597.90), yielding an incremental cost-effectiveness ratio of £1828. Most secondary outcomes showed significant benefit for the intervention.

Conclusions

A short course of tCBT did not prevent onset of CWP in adults at high risk, but improved quality of life and was cost-effective. A low-cost, short-duration intervention benefits persons at risk of CWP.

Trial registration number

ClinicalTrials.gov Registry (NCT02668003).

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Cognitive behavioural therapy for insomnia for patients with co-morbid generalized anxiety disorder: an open trial on clinical outcomes and putative mechanisms

BACKGROUND

Very little is known concerning the efficacy of psychosocial treatments for patients with insomnia disorder co-morbid with generalized anxiety disorder (GAD).

AIM

The aim was to examine the efficacy of cognitive behavioral therapy for insomnia (CBT-I) for patients with insomnia disorder co-morbid with GAD.

METHOD

Given the limited, previous research on therapies for patients with insomnia disorder co-morbid with GAD, an open trial design was used. Twenty-four patients with insomnia disorder and GAD were administered CBT-I across 10 weeks. Across the study period to 6 months follow-up, the participants completed measures indexing insomnia, anxiety, worry, depression, functional impairment, quality of life, treatment perception (credibility, expectancy and satisfaction), adverse events and putative mechanisms.

RESULTS

Moderate to large effect sizes for CBT-I were observed for insomnia symptoms. In terms of insomnia severity, approximately 61% of the patients responded to CBT-I and 26-48% remitted. Moderate to large effect sizes were also demonstrated for GAD symptoms, depression, functional impairment and quality of life. Roughly one-third of the participants reported an adverse event during CBT-I. Five of the seven putative mechanisms were significantly reversed in the expected direction, i.e. all four cognitive process measures and time in bed.

CONCLUSIONS

This open trial indicates that CBT-I is an efficacious intervention for patients with insomnia disorder co-morbid with GAD. The results highlight the need for further research using a randomized controlled trial design with analyses of mechanisms of change.

Contribution of sleep disturbances to the heterogeneity of cognitive and brain alterations in alcohol use disorder

Cognitive and brain alterations are common in alcohol use disorder and vary importantly from one patient to another. Sleep disturbances are also very frequent in these patients and remain largely neglected even though they can persist after drinking cessation. Sleep disturbances may be the consequence of specific brain alterations, resulting in cognitive impairments. But sleep disruption may also exacerbate alcohol-related brain abnormalities and cognitive deficits through common pathophysiological mechanisms. Besides, sleep disturbances seem a vulnerability factor for the development of alcohol use disorder. From a clinical perspective, sleep disturbances are known to affect treatment outcome and to increase the risk of relapse. In this article, we conducted a narrative review to provide a better understanding of the relationships between sleep disturbances, brain and cognition in alcohol use disorder. We suggest that the heterogeneity of brain and cognitive alterations observed in patients with alcohol use disorder could at least partially be explained by associated sleep disturbances. We also believe that sleep disruption could indirectly favor relapse by exacerbating neuropsychological impairments required in psychosocial treatment and for the maintenance of abstinence. Implications for clinical practice as well as perspectives for future research are proposed.

Enhancing behavioral sleep care with digital technology: study protocol for a hybrid type 3 implementation-effectiveness randomized trial

BACKGROUND

Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment.

METHODS

This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group.

DISCUSSION

Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.

Non-pharmacological Approaches for Management of Insomnia

Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.

Feasibility of an online cognitive behavioral therapy program to improve insomnia, mood, and quality of life in bereaved adults ages 55 and older

The aim of the current study was to assess the feasibility and preliminary efficacy of utilizing an online Cognitive Behavioral Therapy for Insomnia (CBT-I) program in bereaved older adults (ages 55 and older). Participants were randomized to receive either a 6-week online CBT-I program or six weeks of online psychoeducational modules on insomnia and grief. The sample included 30 adults with mild to severe symptoms of insomnia. Results suggest that the study was feasible to conduct, as evidenced by the brief 5-week recruitment time, 87% retention rate, and 100% completion rate of the intervention modules. There were no treatment effects by time difference shown in the study and no significant differences in study outcomes were found between the CBT-I and control groups, as both demonstrated similar improvements in insomnia. However, this study suggests that it is feasible to recruit bereaved older adults for an online educational program and successfully administer an online protocol targeting insomnia and well-being.

Acceptance and commitment therapy-based behavioral intervention for insomnia: a pilot randomized controlled trial

Objective:

To evaluate a protocol for acceptance and commitment therapy-based behavioral intervention for insomnia (ACT-BBI-I) in adults compared to cognitive behavioral therapy for insomnia (CBT-I).

Methods:

Forty-five adults with chronic insomnia were randomized to ACT-BBI-I or CBT-I. Both interventions were performed in six weekly group sessions. The common treatment elements in both protocols included stimulus control and sleep restriction. CBT-I is focused on the cognitive restructuring of maladaptive beliefs about sleep and the daytime effects of insomnia. ACT-BBI-I focuses on therapeutic processes of acceptance, availability, values, defusion, and commitment. The results were evaluated through the following instruments: a sleep diary, the Insomnia Severity Index, the Epworth Sleepiness Scale, the Hospital Anxiety and Depression Scale, the Acceptance and Action Questionnaire-II, and the Dysfunctional Beliefs and Attitudes about Sleep scale.

Results:

Both interventions had a significant positive impact on sleep patterns, insomnia, anxiety, beliefs about sleep, and psychological flexibility. All improvement was maintained at the 6-month follow-up.

Conclusion:

The results suggest that integrating principles of ACT with behavioral techniques may be useful for treating insomnia. Further research should identify whether the principles of ACT result in added effectiveness compared to behavioral components alone.

Clinical trial registration:

RBR-7nc5wq

Smartphone-Based Virtual Agents to Help Individuals With Sleep Concerns During COVID-19 Confinement: Feasibility Study

BACKGROUND

The COVID-19 crisis and consequent confinement restrictions have caused significant psychosocial stress and reports of sleep complaints, which require early management, have increased during recent months. To help individuals concerned about their sleep, we developed a smartphone-based app called KANOPEE that allows users to interact with a virtual agent dedicated to autonomous screening and delivering digital behavioral interventions.

OBJECTIVE

Our objective was to assess the feasibility of this app, in terms of inclusion rate, follow-up rate, perceived trust and acceptance of the virtual agent, and effects of the intervention program, in the context of COVID-19 confinement in France.

METHODS

The virtual agent is an artificial intelligence program using decision tree architecture and interacting through natural body motion and natural voice. A total of 2069 users aged 18 years and above downloaded the free app during the study period (April 22 to May 5, 2020). These users first completed a screening interview based on the Insomnia Severity Index (ISI) conducted by the virtual agent. If the users were positive for insomnia complaints (ISI score >14), they were eligible to join the 2-stage intervention program: (1) complete an electronic sleep diary for 1 week and (2) follow personalized sleep recommendations for 10 days. We collected and analyzed the following measures: sociodemographic information, ISI scores and sleep/wake schedules, and acceptance and trust of the agent.

RESULTS

Approximately 76% (1574/2069) of the app users completed the screening interview with the virtual agent. The virtual agent was well accepted by 27.4% (431/1574) of the users who answered the acceptance and trust questionnaires on its usability, satisfaction, benevolence, and credibility. Of the 773 screened users who reported sleep complaints (ISI score >14), 166 (21.5%) followed Step 1 of the intervention, and only 47 of those (28.3%) followed Step 2. Users who completed Step 1 found that their insomnia complaints (baseline mean ISI score 18.56, mean ISI score after Step 1 15.99; P<.001) and nocturnal sleep quality improved significantly after 1 week. Users who completed Step 2 also showed an improvement compared to the initial measures (baseline mean ISI score 18.87, mean ISI score after Step 2 14.68; P<.001). Users that were most severely affected (ISI score >21) did not respond to either intervention.

CONCLUSIONS

These preliminary results suggest that the KANOPEE app is a promising solution to screen populations for sleep complaints and that it provides acceptable and practical behavioral advice for individuals reporting moderately severe insomnia.

Sleep Disturbances and Atopic Dermatitis: Relationships, Methods for Assessment, and Therapies

Atopic dermatitis is one of the most common chronic inflammatory skin conditions and is associated with sleep disturbances in 47% to 80% of children and 33% to 90% of adults. Herein, we review the literature on sleep disturbances experienced by patients with atopic dermatitis, as well as the mechanisms that may underlie this. We present subjective and objective methods for measuring sleep quantity and quality and discuss strategies for management. Unfortunately, the literature on this topic remains sparse, with most studies evaluating sleep as a secondary outcome using subjective measures. The development of portable, at-home methods for more objective measures offers new opportunities to better evaluate sleep disturbances in atopic dermatitis research studies and in clinical practice.

Profile of Somryst Prescription Digital Therapeutic for Chronic Insomnia: Overview of Safety and Efficacy

Introduction: Prescription digital therapeutics (PDTs) represent a new class of software-based medical devices authorized by the Food and Drug Administration (FDA) to treat disease. Somryst™, the first PDT for treating chronic insomnia, delivers cognitive behavioral therapy for insomnia (CBT-I) via a mobile application. CBT-I is the guideline-recommended, first-line treatment for chronic insomnia, but availability of CBT-I therapists is limited. Somryst addresses this need by providing asynchronous access to CBT-I treatment. As a contactless therapeutic medium, Somryst is also an ideal option when face-to-face therapy is not available or recommended for safety reasons (e.g. because of possible exposure to the SARS-CoV-2 virus). Areas covered: This review summarizes the mechanisms of action and technical features of Somryst, and describes safety and effectiveness data from the randomized trials on which FDA clearance was based. Expert opinion: Somryst demonstrates robust clinical efficacy with a favorable benefit-to-risk profile for treating adults with chronic insomnia. FDA clearance was based on data from 2 clinical trials of the first-generation web-based CBT-I platform Sleep Healthy Using the Internet (SHUTi). Somryst, and PDTs in general, are promising devices to address the need for greater accessibility to effective therapies.

An Evaluation of Cognitive Behavioral Therapy for Insomnia: A Systematic Review and Application of Tolin's Criteria for Empirically Supported Treatments

The American Psychological Association's Society of Clinical Psychology recently adopted the "Tolin Criteria" to evaluate empirically supported treatments. These criteria better account for strength and quality of rapidly accumulating evidence bases for various treatments. Here we apply this framework to cognitive behavioral therapy for insomnia (CBT-I). Following procedures outlined by Tolin, McKay, et al. (2015), Step 1 included an examination of quantitative systematic reviews; nine met inclusion criteria. Step 2 evaluated review quality and effect size data. We found high-quality evidence that CBT-I produces clinically and statistically significant effects on insomnia and other sleep-related outcomes. Based on the Tolin Criteria, the literature merits a "strong" recommendation for CBT-I. This report is a working model for subsequent applications of the Tolin Criteria.

A Preliminary Investigation of the Underlying Mechanism Associating Daily Sleep Continuity Disturbance and Prescription Opioid Use Among Individuals With Sickle Cell Disease

BACKGROUND

There are emerging data indicating that sleep disturbance may be linked with an increase in opioid use. The majority of sickle cell disease (SCD) patients experience sleep disturbances, which can elevate pain severity and pain catastrophizing, both of which are important predictors of opioid consumption.

PURPOSE

We conducted a preliminary investigation on the association between previous night sleep disturbance and short-acting opioid use, as well as the potential mediating roles of pain severity and pain catastrophizing. Because sex is associated with sleep disturbance, pain-related experiences, and opioid use, we also explored the potential moderating role of sex.

METHODS

Participants were 45 SCD patients who were prescribed opioids. For 3 months, sleep diaries were collected immediately upon participants' awakening. Daily pain severity, pain catastrophizing, and prescription opioid use measures were collected before bedtime.

RESULTS

Multilevel structural equation modeling revealed that wake time after sleep onset (WASO) during the previous night (Time 1) predicted greater short-acting opioid use during the next day (Time 2). Pain severity and pain catastrophizing measured during the next day (Time 2) also mediated the association between the two. Sex moderation analysis showed that the positive association between WASO and pain severity was largely driven by women.

CONCLUSION

These findings provide some preliminary evidence as to the mechanism linking sleep continuity disturbance and opioid requirement in SCD patients. Future studies should replicate and extend these findings with clearer temporal information and employing more refined measures of sleep continuity and prescription opioid use in a larger sample.

A Self-Administered Multicomponent Web-Based Mental Health Intervention for the Mexican Population During the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic has become a public health emergency of international concern; it has not only threatened people's physical health but has also affected their mental health and psychological well-being. It is necessary to develop and offer strategies to reduce the psychological impact of the outbreak and promote adaptive coping.

OBJECTIVE

This study protocol aims to describe a self-administered web-based intervention (Mental Health COVID-19) based on the principles of positive psychology supported by elements of cognitive behavioral therapy and behavioral activation therapy to reduce the symptoms of anxiety and depression and increase positive emotions and sleep quality during and after the COVID-19 outbreak through a telepsychology system.

METHODS

A randomized controlled clinical superiority trial with two independent groups will be performed, with intrasubject measures at four evaluation periods: pretest, posttest, 3-month follow-up, and 6-month follow-up. Participants will be randomly assigned to one of two groups: self-administered intervention with assistance via chat or self-administered intervention without assistance via chat. The total required sample size will be 166 participants (83 per group).

RESULTS

The clinical trial is ongoing. This protocol was approved by the Research Ethics Board of the Free School of Psychology-University of Behavioral Sciences (Escuela libre de Psicología-Universidad de Ciencias del Comportamiento). The aim is to publish the preliminary results in December 2020. A conservative approach will be adopted, and the size effect will be estimated using the Cohen d index with a significance level (α) of .05 (95% reliability) and a conventional 80% power statistic.

CONCLUSIONS

The central mechanism of action will be to investigate the effectiveness of an intervention based on positive psychology through a web platform that can be delivered through computers and tablets, with content that has been rigorously contextualized to the Mexican culture to provide functional strategies to help the target users cope with the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04468893; https://clinicaltrials.gov/ct2/show/NCT04468893.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23117.

Testing an app-based intervention to improve insomnia in patients with epilepsy: A randomized controlled trial

PURPOSE

Insomnia has adverse effects on people with epilepsy. We aimed to test a novel cognitive behavioral therapy for insomnia (CBT-I) app-based intervention on insomnia symptoms and social psychological factors in people with epilepsy and to examine the possible mechanisms among the factors.

METHODS

Participants were recruited from neurology clinics in Iran and comprised individuals diagnosed with epilepsy and having moderate to severe insomnia. A two-arm randomized controlled trial design was used, consisting of a treatment group (CBT-I; n = 160) and control group (patient education; n = 160). Primary outcomes were self-reported sleep quality, insomnia severity, and sleep hygiene behavior and objective sleep characteristics measured by actigraphy. Secondary outcomes were attitude, perceived behavioral control, intention, action planning, coping planning, behavioral automaticity, self-monitoring, anxiety, depression, and quality of life (QoL). All outcomes were measured at baseline, and at one, three, and six months postintervention, except objective sleep, which was assessed at baseline, and one and six months postintervention. Data were analyzed using linear mixed models.

RESULTS

Current findings showed that sleep quality, insomnia severity, sleep hygiene behavior, and sleep onset latency were significantly improved in the CBT-I group compared with the patient education group at all measurement points. Also, the CBT-I group had significantly improved anxiety, depression, and QoL compared with the patient education group. Mediation analyses showed that attitude, intention, coping planning, self-monitoring, and behavioral automaticity significantly mediated the effect of the intervention on sleep outcomes.

CONCLUSION

Results support the use of the CBT-I app to improve sleep outcomes among people with epilepsy.

Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis

BACKGROUND

Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.

METHODS

This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.

DISCUSSION

This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.

TRIAL REGISTRATION

NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).

A blended eHealth intervention for insomnia following acquired brain injury: study protocol for a randomized controlled trial

Background

Up to a third of stroke patients and patients with traumatic brain injury suffer from insomnia, including problems to fall asleep or stay asleep at night. Insomnia may exacerbate other brain damage-related problems, for example regarding cognitive functioning and emotional well-being; may lead to poorer quality of life; and may complicate recovery processes. Cognitive behavioral therapy for insomnia, delivered face-to-face or online, is found to be effective in the general population. However, despite the high prevalence and serious consequences of insomnia following acquired brain injury, studies on the efficacy of face-to-face cognitive behavioral treatment in this population are scarce, and this applies even more for studies on online cognitive behavioral therapy. Therefore, this study aims to evaluate the efficacy of a newly developed guided online cognitive behavioral therapy for insomnia following acquired brain injury.

Methods

A multicenter, prospective, randomized, open-label, blinded end point study (PROBE) will be conducted, in which 48 patients diagnosed with stroke or traumatic brain injury and insomnia will be randomly allocated to the online cognitive behavioral therapy for insomnia treatment group or the treatment as usual group. The treatment consists of 6 online cognitive behavioral therapy sessions given on a weekly basis and personalized feedback after each session, combined with 2 face-to-face sessions. Outcomes will be assessed at baseline, immediately after the intervention period and at 6-week follow-up. The primary outcome is the insomnia severity assessed with the Insomnia Severity Index. Secondary outcome measures include sleep quality, sleep features derived from the sleep diary, fatigue, anxiety and depression, subjective cognitive functioning, and societal participation.

Discussion

This study will provide insight on the efficacy of online cognitive behavioral therapy for insomnia following stroke and traumatic brain injury.

Trial registration

Netherlands Trial Register NTR7082. Registered on 12 March 2018.

Depression alters the circadian pattern of online activity

Human sleep/wake cycles follow a stable circadian rhythm associated with hormonal, emotional, and cognitive changes. Changes of this cycle are implicated in many mental health concerns. In fact, the bidirectional relation between major depressive disorder and sleep has been well-documented. Despite a clear link between sleep disturbances and subsequent disturbances in mood, it is difficult to determine from self-reported data which specific changes of the sleep/wake cycle play the most important role in this association. Here we observe marked changes of activity cycles in millions of twitter posts of 688 subjects who explicitly stated in unequivocal terms that they had received a (clinical) diagnosis of depression as compared to the activity cycles of a large control group (n = 8791). Rather than a phase-shift, as reported in other work, we find significant changes of activity levels in the evening and before dawn. Compared to the control group, depressed subjects were significantly more active from 7 PM to midnight and less active from 3 to 6 AM. Content analysis of tweets revealed a steady rise in rumination and emotional content from midnight to dawn among depressed individuals. These results suggest that diagnosis and treatment of depression may focus on modifying the timing of activity, reducing rumination, and decreasing social media use at specific hours of the day.

Treating depression with a smartphone-delivered self-help cognitive behavioral therapy for insomnia: study protocol for a parallel group randomized controlled trial

Background

Depression is a major public health concern. Emerging research has shown that cognitive behavioral therapy for insomnia (CBT-I) is effective in treating individuals with comorbid insomnia and depression. Traditional face-to-face CBT-I encounters many obstacles related to feasibility, accessibility, and help-seeking stigma. CBT-I delivered via smartphone application could be a potential solution. This paper reports a protocol designed to evaluate the efficacy of a self-help smartphone-based CBT-I, using a waitlist group as control, for people with major depression and insomnia.

Methods

A two-arm parallel randomized controlled trial is conducted in a target sample of 285 non-suicidal Hong Kong Chinese older than 17 years of age with major depression and insomnia. Participants complete an online rapid screening, followed by a telephone diagnostic interview. Those who meet the eligibility criteria are randomized in a ratio of 1:1 to receive either CBT-I immediately or to a waitlist control condition. The CBT-I consists of six weekly modules and is delivered through a smartphone application proACT-S. This smartphone app has been pilot tested and revamped to improve user experience. An online randomized algorithm is used to perform randomization to ensure allocation concealment. The primary outcomes are changes over the measurement points in sleep quality, insomnia severity, and depression severity. The secondary outcomes include changes over the measurement points in anxiety, subjective health, treatment expectancy, and acceptability of treatment. Assessments are administered at baseline, post-intervention, and 6-week follow-up. The recruitment is completed. Important adverse events, if any, are documented. Multilevel linear mixed model based on intention-to-treat principle will be conducted to examine the efficacy of the CBT-I intervention.

Discussion

It is expected that proACT-S is an efficacious brief sleep-focused self-help treatment for people with major depression and insomnia. If proven efficacious, due to its self-help nature, proACT-S may be applicable as a community-based early intervention, thereby reducing the burden of the public healthcare system in Hong Kong.

Trial registration

ClinicalTrials.gov NCT04228146. Retrospectively registered on 14 January 2020.

Telehealth-delivered CBT-I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: A pilot randomized controlled trial

Cognitive behavioural therapy for insomnia is the recommended treatment for chronic insomnia. However, up to a quarter of patients dropout from cognitive behavioural therapy for insomnia programmes. Acceptance, mindfulness and values-based actions may constitute complementary therapeutic tools to cognitive behavioural therapy for insomnia. The current study sought to evaluate the efficacy of a remotely delivered programme combining the main components of cognitive behavioural therapy for insomnia (sleep restriction and stimulus control) with the third-wave cognitive behavioural therapy acceptance and commitment therapy in adults with chronic insomnia and hypnotic dependence on insomnia symptoms and quality of life. Thirty-two participants were enrolled in a pilot randomized controlled trial: half of them were assigned to a 3-month waiting list before receiving the four "acceptance and commitment therapy-enhanced cognitive behavioural therapy for insomnia" treatment sessions using videoconference. The primary outcome was sleep quality as measured by the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. All participants also filled out questionnaires about quality of life, use of hypnotics, depression and anxiety, acceptance, mindfulness, thought suppression, as well as a sleep diary at baseline, post-treatment and 6-month follow-up. A large effect size was found for Insomnia Severity Index and Pittsburgh Sleep Quality Index, but also daytime improvements, with increased quality of life and acceptance at post-treatment endpoint in acceptance and commitment therapy-enhanced cognitive behavioural therapy for insomnia participants. Improvement in Insomnia Severity Index and Pittsburgh Sleep Quality Index was maintained at the 6-month follow-up. Wait-list participants increased their use of hypnotics, whereas acceptance and commitment therapy-enhanced cognitive behavioural therapy for insomnia participants evidenced reduced use of them. This pilot study suggests that web-based cognitive behavioural therapy for insomnia incorporating acceptance and commitment therapy processes may be an efficient option to treat chronic insomnia and hypnotic dependence.

Weekly Self-Ratings of Treatment Involvement and Their Relation to Symptom Reduction in Internet Cognitive Behavioral Therapy for Insomnia

Background

Treatment involvement, including involvement with written material as well as homework assignments, has previously been associated with better outcomes in cognitive behavioral therapy, but there is a lack of knowledge on which specific aspects of involvement that are the most promising for use as predictors of treatment effects.

Methods

The objective of this study was to use a battery of weekly self-rated questions regarding different aspects of participant involvement during 8 weeks of either guided internet cognitive behavioral therapy for insomnia (ICBT-i, n = 73), or an active internet-delivered control treatment also including homework (ICBT-ctrl, n = 75), to predict reductions in insomnia severity after treatment. The markers of involvement were single questions on amount of time spent on treatment, amount of text read, amount of subjective knowledge gained and index scores of homework quantity (based on ratings of how many times specific techniques were used) and homework quality (based on ratings of the understanding, used as intended, and helpfulness of each specific technique).

Results

While none of the markers predicted reductions in insomnia severity for participants in the ICBT-ctrl group, text read, subjective knowledge gain, and homework quality predicted larger reductions in insomnia severity for participants in ICBT-i. Amount of subjective knowledge gained was a particularly useful marker in the ICBT-i group, since weekly ratings from the first half of treatment sufficed to explain a rather large proportion of variance in insomnia severity post treatment (14%).

Conclusions

The results strengthen subjective knowledge gain as a candidate for use as a predictor of treatment effects in ICBT-i.

Video cognitive-behavioral therapy for insomnia in cancer patients: A cost-effective alternative

OBJECTIVE

Despite its high prevalence, cancer-related insomnia typically remains untreated because of a lack of access to cognitive-behavioral therapy for insomnia (CBT-I), the treatment of choice for this condition. While face-to-face CBT-I appears to be optimal in terms of efficacy, self-administered formats may be more cost-effective. The goal of this secondary analysis of a randomized clinical trial was to compare the cost-effectiveness of a professionally-based CBT-I (PCBT-I) to that of a video-based CBT-I (VCBT-I).

METHODS

A total of 161 women with breast cancer received six weekly, individual CBT-I sessions (PCBT-I; n = 81) or a 60-minutes animated video +6 short booklets (VCBT-I; n = 80). Participants completed the Insomnia Severity Index (ISI) and provided information to calculate treatment costs.

RESULTS

Total per patient treatment costs were 5.5 times greater for PCBT-I ($1298.90) than VCBT-I ($234.36; P < .0001). Both at posttreatment and 3-month follow-up, the ISI reduction was greater in PCBT-I than VCBT-I, but these differences were not significant (P = .09 and P = .24, respectively). In contrast, the cost-effectiveness ratio was significantly more advantageous for VCBT-I than PCBT-I. Compared to VCBT-I, each reduction of 1 unit on the ISI produced by PCBT-I was associated with a treatment cost that was significantly greater at posttreatment ($186.95 CAD vs $44.87 CAD; P = .001) and follow-up ($154.76 vs $24.97, P = .005).

CONCLUSIONS

Although CBT-I is slightly less efficacious when self-administered, it constitutes a much more cost-effective alternative than face-to-face CBT-I and represents an extremely valuable option in settings where monetary and human resources required to administer CBT-I are not available or sufficient.

Insomnia Interventions in the Workplace: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to identify and evaluate the impact of interventions to improve or reduce insomnia in the workforce through randomized clinical trials. Following the recommendations of the PRISMA and MARS statement, a systematic literature search was carried out on the PubMed, Web of Science, CINHAL, and PsycINFO databases, with no restrictions on the language or publication date. For the meta-analysis, a random-effects model and the Insomnia Severity Index were used as outcome measures. To assess the risk of bias and the quality of evidence, the Cochrane Collaboration tool and the GRADE method were used, respectively. Twenty-two studies were included in the systematic review and 12 studies in the meta-analysis, making a total of 14 intervention groups with a sample of 827 workers. Cognitive behavioral therapy was the most widely used intervention. According to the estimated difference between the means, a moderate effect for the reduction of insomnia symptoms after the intervention (MD -2.08, CI 95%: [-2.68, -1.47]) and a non-significant degree of heterogeneity were obtained (p = 0.64; I² = 0%). The quality of the evidence and the risk of bias were moderate. The results suggest that interventions on insomnia in the workplace are effective for improving workers' health, and that improvements in the quality of sleep and a decrease in the symptoms of insomnia are produced, thanks to an increase in weekly sleeping hours and a reduction in latency at sleep onset. As regards work, they also led to improvements in productivity, presenteeism, and job burnout.

Association between Sleep Problems and Sedentary Behaviors during Work among Korean Workers

Background

We aimed to identify the association between sleep problems and sedentary behaviors during work among Korean workers.

Methods

We employed a cross-sectional survey, and analyzed data from the 5^th Korean Working Conditions Survey, conducted in 2017. The participants were 50,205 workers aged 15 years and above. The data were analyzed using Pearson's correlation, chi-square distribution, and logistic regression.

Results

Sleep problems occurred more frequently among female participants with higher ages; those with low educational levels; skilled agricultural, forestry, and fishery workers; elementary workers; and service and sales workers. With general characteristics as control variables, it was found that the odds of sleep problems were 5.547 times higher if the duration of sedentary behavior was longer.

Conclusion

It is important to improving work environment and provide education on various physical activities for workers with a long duration of sedentary behaviors to reduce sleep problems among them.

Internet-delivered insomnia intervention improves sleep and quality of life for adolescent and young adult cancer survivors

BACKGROUND

Insomnia is common among adolescent and young adult (AYA) cancer survivors. Cognitive-behavioral therapy for insomnia (CBT-I) is considered the gold standard treatment. Standard CBT-I was designed for adults and not adapted to the unique medical, psychosocial, and developmental needs of AYA cancer survivors, which can exacerbate their insomnia. Further, the vast majority of cancer centers do not have a behavioral sleep medicine expert on staff. Our study objective was to examine the efficacy of an Internet-delivered CBT-I program that was tailored for AYA cancer survivors (NCT03279055).

PROCEDURE

Twenty-two AYA cancer survivors (mean age 20.4; range 14-25) with insomnia enrolled in an automated CBT-I program modified for AYA cancer survivors following stakeholder feedback. Participants were blood cancer (54.5%) and solid tumor (45.5%) survivors, an average of 9.7 years postdiagnosis. Sleep health, fatigue, and quality of life were assessed at baseline and at two follow up timepoints (8 and 16 weeks postbaseline).

RESULTS

Significant improvements in insomnia severity, daytime sleepiness, fatigue, and quality of life were reported at both follow up timepoints. However, most participants (72.7%) did not complete all of the six study sessions, with a mean completion rate of 3.2 sessions. Participants who completed at least two sessions reported better sleep (insomnia severity index total score) than those who did not.

CONCLUSIONS

An Internet-delivered insomnia intervention adapted for AYA cancer survivors was efficacious. This has important implications for access to evidence-based clinical care for this growing population. Future efforts should study stepped care models of care and ways to improve treatment adherence.