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Zhou ES, Revette A, Ritterband LM, Bethea TN, Delp L, Simmons PD, Rosenberg L. Developing a culturally tailored digital health intervention for insomnia in Black women. Transl Behav Med 2024; 14:117-126. [PMID: 37715959 DOI: 10.1093/tbm/ibad056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
Insomnia disorder is highly prevalent among Black women. Cognitive-behavioral therapy for insomnia (CBT-I) is considered the optimal treatment, but very little efficacy research has been conducted in minority populations. Culturally tailoring intervention content may increase participant engagement and improve treatment outcomes. We culturally tailored an Internet-delivered CBT-I program (Sleep Healthy Using the Internet; SHUTi) for Black women. First, relevant stakeholders were identified. Semi-structured interviews were conducted after stakeholders completed each of the six SHUTi intervention sessions. Questions focused on improving program relatability and engagement for Black women. Key themes pertinent to peripheral, evidential, and sociocultural strategies for cultural adaptation were identified using thematic content analysis, and adaptation recommendations were developed. A total of 50 interviews, across 9 stakeholders, were conducted. Two overarching themes were identified: (i) there was limited visual African American representation, and (ii) there was a lack of diversity in the environments and lifestyles of the patient vignettes. Respondents provided peripheral, evidential, and sociocultural recommendations for program modifications, emphasizing the importance of race-concordant visual content and didactic content exploring the diverse cultural and social contexts in which insomnia occurs for Black women. As more diverse patients seek evidence-based insomnia treatment, digital health interventions must consider whether it is therapeutically important to address and tailor for cultural differences. Here, stakeholders made clear recommendations for taking cultural contexts into account to improve patient engagement with the program. Further research should work to understand the extent to which culturally tailored interventions are beneficial for health outcomes among minority populations.
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Affiliation(s)
- Eric S Zhou
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anna Revette
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lee M Ritterband
- Psychiatry and Neurobehavioral Sciences, University of Virginia Health System, Charlottesville, VA, USA
| | - Traci N Bethea
- Office of Minority Health and Health Disparities Research, Georgetown Lombardi Comprehensive Cancer Center, Washington DC, USA
| | - Lauren Delp
- Slone Epidemiology Center at Boston University, Boston, MA, USA
| | | | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, MA, USA
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2
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Lee Y, Kim I, Lee S, Yu S. Information and Communication Technology-Based Application for Cognitive Behavioral Therapy among Community-Dwelling Older Adults with Insomnia: Development and Validation Study. Healthcare (Basel) 2024; 12:106. [PMID: 38201011 PMCID: PMC10778576 DOI: 10.3390/healthcare12010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
This study developed an information and communication technology-based mobile application to administer cognitive behavioral therapy to community-dwelling older adults with insomnia. First, the content of the application was determined through a systematic review and preference survey. Preference data on the perception, needs, and preference for non-face-to-face service content were collected from 15 July 2021 to 31 August 2021 from 100 community-dwelling older adults aged 65 years and older. In the design stage, the structure and function of the application were determined, and an interface was designed. The application was developed in conjunction with design experts and programmers using Android Studio software (Android 9). Usability tests were conducted during the implementation stage, followed by an evaluation stage. The evaluation revealed that the application's structure and functions should comprise sleep information, sleep-habit improvement, sleep assistance, video, real-time counseling, and exercise services. These elements were finalized after receiving the results of a preference analysis and advice from an advisory panel of experts in different fields. The developed application was rated with a score of four or higher in all areas. This study successfully developed, implemented, and evaluated a new mobile application called Smart Sleep for community-dwelling older adults with insomnia.
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Affiliation(s)
- Yeonhee Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon 21936, Republic of Korea;
| | - Inseong Kim
- Health Insurance Review & Assessment Service, Wonju-si 26465, Republic of Korea;
| | - Seonheui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon 21936, Republic of Korea;
| | - Soyoung Yu
- College of Nursing, CHA University, Pocheon 11160, Republic of Korea
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3
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Altena E, Ellis J, Camart N, Guichard K, Bastien C. Mechanisms of cognitive behavioural therapy for insomnia. J Sleep Res 2023; 32:e13860. [PMID: 36866434 DOI: 10.1111/jsr.13860] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 03/04/2023]
Abstract
Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.
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Affiliation(s)
| | - Jason Ellis
- Northumbria Centre for Sleep Research, Northumbria University, Newcastle, UK
| | - Nathalie Camart
- UR CLIPSYD, UFR SPSE, Département de psychologie, Université Paris Nanterre, Nanterre, France
- Cabinet Pôle Psy République, Bordeaux, France
- Nouvelle Clinique Bel Air- PEAS, Bordeaux, France
| | - Kelly Guichard
- Nouvelle Clinique Bel Air- PEAS, Bordeaux, France
- CHU Bordeaux, Centre Hypersomnies Rares, Bordeaux, France
| | - Célyne Bastien
- Ecole de Psychologie, Université Laval, Québec, Québec, Canada
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Drager LF, Assis M, Bacelar AFR, Poyares DLR, Conway SG, Pires GN, de Azevedo AP, Carissimi A, Eckeli AL, Pentagna Á, Almeida CMO, Franco CMR, Sobreira EST, Stelzer FG, Mendes GM, Minhoto GR, Linares IMP, Sousa KMM, Gitaí LLG, Sukys-Claudino L, Sobreira-Neto MA, Zanini MA, Margis R, Martinez SCG. 2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association. Sleep Sci 2023; 16:507-549. [PMID: 38370879 PMCID: PMC10869237 DOI: 10.1055/s-0043-1776281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.
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Affiliation(s)
- Luciano Ferreira Drager
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Unidades de HipertenSão, Instituto do Coração (InCor) e Disciplina de Nefrologia, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Márcia Assis
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Clínica do Sono de Curitiba, Hospital São Lucas, Curitiba, Brazil.
| | - Andrea Frota Rego Bacelar
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Clínica Bacelar - Neuro e Sono, Rio de Janeiro, RJ, Brazil.
| | - Dalva Lucia Rollemberg Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- Instituto do Sono, São Paulo, SP, Brazil.
| | - Silvia Gonçalves Conway
- Instituto de Psiquiatria (IPq), Universidade de São Paulo, São Paulo, SP, Brazil.
- Departamento de Otoneurologia, Universidade de São Paulo, São Paulo, SP, Brazil.
- AkasA - Formação e Conhecimento, São Paulo, SP, Brazil.
| | - Gabriel Natan Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- Instituto do Sono, São Paulo, SP, Brazil.
| | | | - Alicia Carissimi
- Faculdade Dom Bosco, Porto Alegre, RS, Brazil.
- Cronosul Clínica de Psicologia do Sono, Psicoterapia e Neuropsicologia, Porto Alegre, RS, Brazil.
| | - Allan Luiz Eckeli
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Álvaro Pentagna
- Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | | | | | - Emmanuelle Silva Tavares Sobreira
- AkasA - Formação e Conhecimento, São Paulo, SP, Brazil.
- Universidade Federal do Ceará, Fortaleza, CE, Brazil.
- Clínica Sinapse Diagnóstico, Fortaleza, CE, Brazil.
| | - Fernando Gustavo Stelzer
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | | | | | - Ila Marques Porto Linares
- Instituto de Psiquiatria (IPq), Universidade de São Paulo, São Paulo, SP, Brazil.
- Instituto da Criança, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | - Ksdy Maiara Moura Sousa
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- SleepUp Tecnologia e Saúde LTDA, São Paulo, SP, Brazil.
| | | | - Lucia Sukys-Claudino
- Disciplina de Neurologia, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil.
| | | | - Marcio Andrei Zanini
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMPSE), São Paulo, SP, Brazil.
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Li X, Bao T, Garland SN, Li SQ, Yu J, Li Y, Mao JJ. Does expectancy affect insomnia treatment response in cancer survivors receiving acupuncture and cognitive behavioral therapy? J Cancer Surviv 2023; 17:826-835. [PMID: 36462115 PMCID: PMC11223715 DOI: 10.1007/s11764-022-01272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 10/07/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Insomnia negatively affects quality of life in cancer survivors. Expectations of insomnia treatment efficacy may influence response to intervention. We sought to determine whether pre-treatment outcome expectancy predicts response to two non-pharmacological interventions for insomnia among cancer survivors. METHODS We analyzed data from a randomized clinical trial that compared acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) in cancer survivors. Patient expectancy was measured by the Mao Treatment Expectancy Scale (MTES) at baseline. Insomnia severity was assessed using the Insomnia Severity Index (ISI) at treatment completion (week 8). Multivariate linear regression was used to evaluate the associations between pre-treatment expectancy and ISI score at week, 8 adjusting for co-variates. RESULTS Expectancy for acupuncture and CBT-I were similar at baseline (acupuncture: 13.3 ± 4.0; CBT-I: 13.2 ± 2.9, p = 0.17). Greater baseline expectancy scores were associated with a greater and statistically significant insomnia severity reduction at week 8 in the acupuncture group (beta coefficients [Coef.] = - 0.35, 95% confidence interval [CI] = - 0.6 to - 0.1, p = 0.016) adjusted for co-variates. Baseline expectancy was not statistically associated with insomnia severity reduction in the CBT-I group (Coef. = - 0.2, 95% CI = - 0.7 to 0.2, p = 0.31). High expectancy was significantly associated with greater proportion of treatment responders at week 8 in the acupuncture group (76% vs. 38%, p = 0.001) but not in the CBT-I group (83% vs. 70%, p = 0.21). CONCLUSIONS Higher pre-treatment outcome expectancy predicted significantly greater insomnia improvement in patients receiving acupuncture but not in those receiving CBT-I. IMPLICATIONS FOR CANCER SURVIVORS Aligning treatment provision with expected outcomes may lead to personalized non-pharmacological insomnia management for cancer survivors.
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Affiliation(s)
- Xiaotong Li
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, 4th Floor, New York, NY 10065, USA
| | - Ting Bao
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, 4th Floor, New York, NY 10065, USA
| | - Sheila N. Garland
- Departments of Psychology and Oncology, Memorial University of Newfoundland, 232 Elizabeth Avenue, St. John’s, St. John’s, Newfoundland and Labrador A1B 3X9, Canada
| | - Susan Q. Li
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, 4th Floor, New York, NY 10065, USA
| | - Jennifer Yu
- Clinical Tinking, Nucleus Global, 300 American Metro Boulevard, Suite 140, Hamilton, New Jersey, NY 08619, USA
| | - Yuelin Li
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jun J. Mao
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 321 East 61st Street, 4th Floor, New York, NY 10065, USA
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Carpi M, Vestri A. The Mediating Role of Sleep Quality in the Relationship between Negative Emotional States and Health-Related Quality of Life among Italian Medical Students. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:26. [PMID: 36612348 PMCID: PMC9819068 DOI: 10.3390/ijerph20010026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
Sleep problems have been shown to be related to adverse outcomes concerning physical and mental well-being. Furthermore, mental health issues and sleep problems were reported to be highly prevalent among medical students and physicians, and were found to be associated with worse academic and clinical performance in these populations. This study aims to investigate the prevalence of poor sleep to examine the associations between sleep quality and health-related quality of life (HRQoL), and to explore the possible mediating role of sleep in the relationship between psychological distress and HRQoL itself in a sample of medical and dental students attending a large Italian university. Participants (n = 407, mean age: 24.2 ± 2.4) answered an online questionnaire comprising the 21-item Depression Anxiety Stress Scale, the Pittsburgh Sleep Quality Index, and the Short Form-12 health survey. Up to 62% of the participants reported poor sleep quality. Controlling for psychological distress, sleep quality components were found to be associated with physical and mental HRQoL. Mediation analysis showed that overall sleep quality mediated all the single associations between anxiety, depression, and stress and HRQoL. These preliminary findings suggest that the quality of sleep is important for the well-being of medical students and that targeting sleep issues in this academic population may be beneficial.
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Affiliation(s)
- Matteo Carpi
- Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy
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7
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Sleep Quality and Insomnia Severity among Italian University Students: A Latent Profile Analysis. J Clin Med 2022; 11:jcm11144069. [PMID: 35887833 PMCID: PMC9318221 DOI: 10.3390/jcm11144069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 02/04/2023] Open
Abstract
Insomnia is a widespread sleep disorder associated with physical and mental health conditions. Although the heterogeneity of insomnia presentations has been acknowledged, research investigating clinically meaningful insomnia subtypes is still ongoing. This study aimed at exploring insomnia subtypes according to widely-used measures of symptoms severity and sleep quality among Italian university students using a latent profile analysis. Data were collected from 490 students reporting relevant insomnia symptoms through an online cross-sectional survey comprising the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, the 21-item Depression Anxiety Stress Scale, and the Short Form-12. Latent profile analysis identified five insomnia subtypes. The severe insomnia (8.8%) group showed the highest insomnia severity, with diverse complaints concerning sleep quality and daytime functioning. Moderate insomnia with sleep duration complaints (8.4%) and moderate insomnia with medication use (15.9%) subgroups were characterized by middle range insomnia severity, with problems of sleep continuity and sleep medication use, respectively. Subthreshold insomnia with sleep latency complaints (20.4%) and subthreshold insomnia (46.5%) groups showed attenuated insomnia symptoms. Higher psychological complaints and worse quality of life were associated with greater sleep complaints. Overall, these findings highlight the relevance of sleep quality domains in identifying insomnia subtypes and might help optimize insomnia treatments.
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8
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Zhou ES, Ritterband LM, Bethea TN, Robles YP, Heeren TC, Rosenberg L. Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial. JAMA Psychiatry 2022; 79:538-549. [PMID: 35442432 PMCID: PMC9021979 DOI: 10.1001/jamapsychiatry.2022.0653] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Black women are at risk for insomnia disorder. Despite interest in addressing sleep health disparities, there is limited research investigating the efficacy of criterion-standard treatment (cognitive behavioral therapy for insomnia [CBT-I]) among this racial minority population. OBJECTIVE To compare the efficacy of a standard version of an internet-delivered CBT-I program, a culturally tailored version, and a sleep education control at improving insomnia symptoms. DESIGN, SETTING, AND PARTICIPANTS In this single-blind, 3-arm randomized clinical trial, participants in a national, longitudinal cohort (Black Women's Health Study [BWHS]) were recruited between October 2019 and June 2020. BWHS participants with elevated insomnia symptoms were enrolled and randomized in the current study. INTERVENTIONS Participants were randomized to receive (1) an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education (PE) about sleep. MAIN OUTCOMES AND MEASURES The primary outcome was insomnia severity (Insomnia Severity Index [ISI]). Index score ranged from 0 to 28 points, with those scoring less than 8 points considered to not have clinically significant insomnia symptoms and a score of 15 points or higher suggesting insomnia disorder. An ISI score reduction of more than 7 points was considered a clinically significant improvement in insomnia symptoms. The SHUTi-BWHS program was hypothesized to be more effective at significantly decreasing insomnia severity compared with the SHUTi program and PE. RESULTS A total of 333 Black women were included in this trial, and their mean (SD) age was 59.5 (8.0) years. Those randomized to receive either SHUTi or SHUTi-BWHS reported significantly greater reductions in ISI score at 6-month follow-up (SHUTi: -10.0 points; 95% CI, -11.2 to -8.7; SHUTi-BWHS: -9.3 points; 95% CI, -10.4 to -8.2) than those randomized to receive PE (-3.6 points; 95% CI, -4.5 to -2.1) (P < .001). Significantly more participants randomized to SHUTi-BWHS completed the intervention compared with those randomized to SHUTi (86 of 110 [78.2%] vs 70 of 108 [64.8%]; P = .008). Participants who completed either intervention showed greater reductions in insomnia severity compared with noncompleters (-10.4 points [95% CI, -11.4 to -9.4] vs -6.2 points [95% CI, -8.6 to -3.7]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, both the SHUTi and SHUTi-BWHS programs decreased insomnia severity and improved sleep outcomes more than PE. The culturally tailored SHUTi-BWHS program was more effective at engaging participants with the program, as a greater proportion completed the full intervention. Program completion was associated with greater improvements in sleep. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03613519.
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Affiliation(s)
- Eric S. Zhou
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts,Perini Family Survivors’ Center, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lee M. Ritterband
- Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia Health System, Charlottesville
| | - Traci N. Bethea
- Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC
| | - Yvonne P. Robles
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
| | | | - Lynn Rosenberg
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
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9
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Brownlow JA, Miller KE, Gehrman PR. Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2021; 7:301-316. [PMID: 33552844 DOI: 10.1007/s40501-020-00222-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of the review Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD. Recent Findings Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities. Summary Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.
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Affiliation(s)
- Janeese A Brownlow
- Department of Psychology, College of Health & Behavioral Sciences, Delaware State University, Dover, Delaware, USA.,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine E Miller
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Philip R Gehrman
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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10
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Kim HG. Effects and mechanisms of a mindfulness-based intervention on insomnia. Yeungnam Univ J Med 2021; 38:282-288. [PMID: 33440465 PMCID: PMC8688792 DOI: 10.12701/yujm.2020.00850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 01/07/2023] Open
Abstract
Medication alone is not sufficient to treat insomnia. In addition, the side effects of sleep medications themselves cannot be ignored during treatment. Insomnia begins with poor sleep quality and discomfort, but as it continues, patients fall into a vicious circle of insomnia with negative thoughts and dysfunctional and distorted perceptions related to sleep. Mindfulness-based intervention for insomnia corrects these sequential cognitive and behavioral processes. The mindfulness technique basically recognizes all the thoughts, feelings, and experiences that occur to us as they are, nonjudgmentally, and then trains them to return to the senses of our body. In this way, while noticing all the processes of the sequential vicious cycle and training them to return to our bodies (e.g., breathing), mindfulness determines whether we are really sleepy or just fatigued. This mindfulness-based intervention can be a useful nonpharmaceutical intervention for insomnia, and its stability and efficacy has been proven by many studies.
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Affiliation(s)
- Hye-Geum Kim
- Department of Psychiatry, Yeungnam University College of Medicine, Daegu, Korea
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11
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Zalta AK, Pinkerton LM, Valdespino-Hayden Z, Smith DL, Burgess HJ, Held P, Boley RA, Karnik NS, Pollack MH. Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes? J Trauma Stress 2020; 33:521-527. [PMID: 32216141 PMCID: PMC7529651 DOI: 10.1002/jts.22505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 10/17/2019] [Accepted: 10/22/2019] [Indexed: 01/30/2023]
Abstract
Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.
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Affiliation(s)
- Alyson K. Zalta
- Department of Psychological Science, University of California, Irvine, Irvine, California, USA,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Linzy M. Pinkerton
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA,Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Dale L. Smith
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA,Department of Psychology, Olivet Nazarene University, Bourbonnais, Illinois, USA
| | - Helen J. Burgess
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Randy A. Boley
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Niranjan S. Karnik
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Mark H. Pollack
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
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Heenan A, Pipe A, Lemay K, Davidson JR, Tulloch H. Cognitive-Behavioral Therapy for Insomnia Tailored to Patients With Cardiovascular Disease: A Pre-Post Study. Behav Sleep Med 2020; 18:372-385. [PMID: 31007057 DOI: 10.1080/15402002.2019.1594815] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: There is little research assessing the use of cognitive-behavioral therapy for insomnia (CBT-I) among patients with cardiovascular disease (CVD), even less on the effects of CBT-I on CVD risk factors such as anxiety and depression, and to our knowledge, only limited studies of the efficacy of CBT-I protocols with cardiac disease-specific modifications. The objective of this study is to evaluate a group-based CBT-I intervention tailored to patients with CVD on sleep quality, duration, and mental health. Participants: A sample of 47 participants (25 men) diagnosed with primary insomnia were included in this study. Methods: This study used a pre-post design comparing outcomes before and after a group intervention. Clinicians in a cardiac center referred CVD patients with self-reported sleep disturbance to the intervention group. Following screening and confirmation of insomnia disorder, participants completed a six-week CBT-I group-based intervention tailored for patients with CVD. Participants completed sleep diaries and questionnaires, including the Insomnia Severity Index, Beck Depression Inventory-II, and Beck Anxiety Inventory, pre- and postintervention. Results: Participants' sleep outcomes (sleep duration, maintenance, efficiency, latency, and quality) were significantly improved and patients reported significantly fewer symptoms of anxiety, depression, and insomnia following the CBT-I intervention (p values < .05). Conclusions: After participating in a CBT-I group intervention tailored for cardiac patients, patients reported improved sleep and significantly lower levels of anxiety and depression. Randomized trials of this intervention are warranted.
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Affiliation(s)
- Adam Heenan
- Division of cardiac prevention and rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Andrew Pipe
- Division of cardiac prevention and rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Department of Medicine, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Kyle Lemay
- Division of cardiac prevention and rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Heather Tulloch
- Division of cardiac prevention and rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada
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Short NA, Schmidt NB. Developing and Testing a Novel, Computerized Insomnia and Anxiety Intervention to Reduce Safety Aids Among an at-Risk Student Sample: A Randomized Controlled Trial. Behav Ther 2020; 51:149-161. [PMID: 32005332 DOI: 10.1016/j.beth.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 11/16/2022]
Abstract
Anxiety and insomnia disorders are two of the most common and costly mental health conditions. They are frequently comorbid, but current treatments do not target both. To streamline treatment, we developed a computerized intervention targeting a transdiagnostic factor, safety aids (cognitive or behavioral strategies used to cope with distress that paradoxically exacerbate symptoms). We conducted a randomized controlled trial to determine the acceptability and efficacy of this brief one-session intervention. Young adult undergraduates (N = 61) with elevated subclinical anxiety and insomnia were randomized to receive the anxiety-insomnia intervention or a physical health control condition. Participants were followed for 1 month and completed self-report measures. Analyses indicated that participants found the intervention acceptable, credible, and engaging. Analyses revealed the active intervention reduced sleep- and anxiety-related safety aids, with medium to large effect sizes. Findings suggest that targeting safety aids for anxiety and insomnia is acceptable and effective in reducing the target mechanism, safety aids, as well as worry. Future research should replicate these findings within a clinical sample and with a longer-term follow-up.
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Affiliation(s)
- Nicole A Short
- Florida State University; Medical University of South Carolina
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Miller KE, Brownlow JA, Gehrman PR. Sleep in PTSD: treatment approaches and outcomes. Curr Opin Psychol 2019; 34:12-17. [PMID: 31541965 DOI: 10.1016/j.copsyc.2019.08.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/12/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
The high incidence of sleep disturbance associated with trauma exposure and posttraumatic stress disorder (PTSD) points to the need for effective sleep interventions for trauma survivors. The present review focuses on recent psychotherapeutic, pharmacological, and sleep medicine treatment approaches for sleep disturbances in PTSD. Findings highlight that targeted sleep interventions can ameliorate sleep symptoms and mitigate daytime PTSD symptoms. Attention has turned to the role of multidisciplinary and integrative approaches, as comprehensive treatment for sleep disturbances in PTSD is likely to require innovative assessment modalities and multiple interventions. A method for compressing these components into a treatment plan acceptable to most PTSD-diagnosed patients remains to be developed.
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Affiliation(s)
- Katherine E Miller
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Janeese A Brownlow
- Department of Psychology, College of Health and Behavioral Sciences at Delaware State University, Dover, DE, USA
| | - Philip R Gehrman
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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15
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Shallcross AJ, Visvanathan PD, Sperber SH, Duberstein ZT. Waking up to the problem of sleep: can mindfulness help? A review of theory and evidence for the effects of mindfulness for sleep. Curr Opin Psychol 2019; 28:37-41. [PMID: 30390479 PMCID: PMC6459734 DOI: 10.1016/j.copsyc.2018.10.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/02/2018] [Accepted: 10/05/2018] [Indexed: 12/14/2022]
Abstract
The high incidence of poor sleep and associated negative health consequences substantiates the need for effective behavioral sleep interventions. We offer an integrative model of sleep disturbance whereby key risk factors for compromised sleep quality and quantity are targeted through mindfulness practice-namely, experiential awareness, attentional control, and acceptance. Theoretical considerations and burgeoning evidence suggest that mindfulness-based interventions (MBIs) may be promising treatments for improving sleep outcomes. However, evidence is mixed due to heterogeneity in design and methods across studies. More rigorous RCTs are needed to determine the efficacy and underlying mechanisms of MBI's for sleep. MBIs that are affordable, accessible, and scalable are needed to improve sleep outcomes at the population level.
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Birling Y, Wang J, Li G, Wu E, Yu Z, Feng Y, Wu Y. Culturally Adapted CBTI for Chinese Insomnia Patients: a One-Arm Pilot Trial. Int J Behav Med 2019. [PMID: 29536428 DOI: 10.1007/s12529-017-9710-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Insomnia is a common mental disorder with severe consequences. Cognitive-behavioral therapy for insomnia (CBTI) has been proved effective against insomnia, but most of the research is limited to Western countries. This trial objective is to develop a Chinese culture-adapted CBTI program and assess its efficacy. METHOD An 8-week culturally adapted CBTI program was developed that included mixed group and individual session and culturally adapted relaxation and cognitive restructuring treatment components. A one-arm clinical trial was conducted at a public hospital between March 2016 and January 2017. Seventy-two Chinese adults (15 males, 57 females; mean age, 50 years) with insomnia disorder underwent the culturally adapted CBTI program. Sleep diaries and self-report scales, as well as polysomnography (PSG, for a subgroup only), were used to assess qualitative and quantitative measures of sleep, mental health status, and quality of life at baseline, post-treatment, and 4-month follow-up. RESULTS Pre-post analyses showed significant changes in sleep diary sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time of respectively - 37.03 min (CI, - 48.90 to - 25.16), - 28.16 min (CI, - 40.22 to - 16.10), and + 27.49 min (CI, 10.51 to 44.47). Self-reported sleep quality, mental health, and quality of life improved compared to baseline. The self-reported outcomes were mainly stable at follow-up. PSG outcomes globally failed to show improvement. CONCLUSION The design of a CBTI program adapted to Chinese population was achieved. Culturally adapted CBTI showed promising results. More rigorously designed studies are needed to ensure efficacy.
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Affiliation(s)
| | - Jian Wang
- Guang'an Men Hospital, Beijing, 100053, China.
| | - Guixia Li
- Guang'an Men Hospital, Beijing, 100053, China
| | - Enlai Wu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhidan Yu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
| | - Yunshu Feng
- Guang'an Men Hospital, Beijing, 100053, China
| | - Yuting Wu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
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Oftedal S, Kolt GS, Holliday EG, Stamatakis E, Vandelanotte C, Brown WJ, Duncan MJ. Associations of health-behavior patterns, mental health and self-rated health. Prev Med 2019; 118:295-303. [PMID: 30476503 DOI: 10.1016/j.ypmed.2018.11.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 11/19/2018] [Accepted: 11/22/2018] [Indexed: 12/31/2022]
Abstract
Diet quality, physical activity, alcohol use, smoking, sleep and sitting-time are behaviors known to influence health. The aims of this study were to identify how these behaviors co-occur to form distinct health-behavior patterns, and to investigate the relationship between these patterns, and mental and self-rated health. Members of the Australian 10,000 Steps project were invited to participate in an online survey in November-December 2011. The participants self-reported demographic and behavioral characteristics (fruit and vegetable intake, fast food, soft drink and alcohol consumption, smoking, physical activity, sitting-time and sleep), frequency of mental distress and self-rated health. Latent Class Analysis was used to identify health-behavior patterns. Latent class regression was used to examine relationships between behavior patterns, mental and self-rated health, and socio-demographic and economic factors. Data were analyzed in October 2017. Complete datasets were obtained from 10,638 participants. Four latent classes were identified, characterized by 'Low-Risk Behavior', 'Poor Sleep, Low-Risk Daytime Behavior', 'Sound Sleep, High-Risk Daytime Behavior' and 'High-Risk Behavior'. The latter two classes, both characterized by high-risk daytime behaviors, were associated with poor self-rated health. Participants in classes with high-risk daytime behaviors were more likely to be younger, non-partnered, non-university educated, from lower income households and work longer hours. Classes characterized by poor sleep quality were associated with higher frequency of mental distress. Findings suggest that experiencing poor sleep is partly independent of daytime behaviors, demographic and socioeconomic factors, but has a strong association with mental health.
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Affiliation(s)
- Stina Oftedal
- School of Medicine & Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
| | - Gregory S Kolt
- School of Science and Health, Western Sydney University, Penrith, NSW 2751, Australia
| | | | - Emmanuel Stamatakis
- Epidemiology Unit, Charles Perkins Centre, University of Sydney, Australia; Prevention Research Collaboration, School of Public Health, University of Sydney, Australia
| | - Corneel Vandelanotte
- Physical Activity Research Group, Appleton Institute, Central Queensland University, Rockhampton, QLD 4700, Australia
| | - Wendy J Brown
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD 4072, Australia
| | - Mitch J Duncan
- School of Medicine & Public Health, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
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Jansson-Fröjmark M, Norell-Clarke A. The cognitive treatment components and therapies of cognitive behavioral therapy for insomnia: A systematic review. Sleep Med Rev 2018; 42:19-36. [DOI: 10.1016/j.smrv.2018.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/05/2018] [Accepted: 05/01/2018] [Indexed: 12/21/2022]
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Vargas I, Vgontzas AN, Abelson JL, Faghih RT, Morales KH, Perlis ML. Altered ultradian cortisol rhythmicity as a potential neurobiologic substrate for chronic insomnia. Sleep Med Rev 2018; 41:234-243. [PMID: 29678398 PMCID: PMC6524148 DOI: 10.1016/j.smrv.2018.03.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/11/2018] [Accepted: 03/20/2018] [Indexed: 11/19/2022]
Abstract
Chronic insomnia is highly prevalent and associated with significant morbidity (i.e., confers risk for multiple psychiatric and medical disorders, such as depression and hypertension). Therefore, it is essential to identify factors that perpetuate this disorder. One candidate factor in the neurobiology of chronic insomnia is hypothalamic-pituitary-adrenal-axis dysregulation, and in particular, alterations in circadian cortisol rhythmicity. Cortisol secretory patterns, however, fluctuate with both a circadian and an ultradian rhythm (i.e., pulses every 60-120 min). Ultradian cortisol pulses are thought to be involved in the maintenance of wakefulness during the day and their relative absence at night may allow for the consolidation of sleep and/or shorter nocturnal awakenings. It is possible that the wakefulness that occurs in chronic insomnia may be associated with the aberrant occurrence of cortisol pulses at night. While cortisol pulses naturally occur with transient awakenings, it may also be the case that cortisol pulsatility becomes a conditioned phenomenon that predisposes one to awaken and/or experience prolonged nocturnal awakenings. The current review summarizes the literature on cortisol rhythmicity in subjects with chronic insomnia, and proffers the suggestion that it may be abnormalities in the ultradian rather than circadian cortisol that is associated with the pathophysiology of insomnia.
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Affiliation(s)
- Ivan Vargas
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Behavioral Sleep Medicine Program, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Alexandros N Vgontzas
- Sleep Research and Treatment Center, Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - James L Abelson
- University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
| | - Rose T Faghih
- Computational Medicine Laboratory, Department of Electrical and Computer Engineering, University of Houston, Houston, TX, USA
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L Perlis
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Behavioral Sleep Medicine Program, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Randomized Controlled Trial to Test the Efficacy of an Unguided Online Intervention with Automated Feedback for the Treatment of Insomnia. Behav Cogn Psychother 2018; 47:287-302. [DOI: 10.1017/s1352465818000486] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background: Insomnia has become a major public health concern. Aims: The study examined the efficacy of a web-based unguided self-help programme with automated feedback. The programme was based on cognitive behaviour therapy for insomnia (CBT-I). The investigation particularly focused on factors that contribute to the maintenance of insomnia and tested whether treatment effects were stable over a period of 12 months. Method: Fifty-six participants were randomly assigned either to web-based CBT-I or to the waiting-list control group. Included measures assessed insomnia severity, sleep-related cognitions, safety behaviours, depression, anxiety and somatization. In the intervention group, a sleep diary was used to assess sleep continuity parameters, sleep quality and daytime performance. Results: Large between- and within-group effect sizes (d = 1.79, d = 1.59) for insomnia severity were found. The treatment group effect remained stable over the period of 12 months. Further, sleep-related cognitions, safety behaviours, depression and somatization significantly decreased in the treatment group compared with the control group. On all sleep diary parameters, medium to large effects were revealed within the treatment group. Anxiety did not decrease significantly from pre- to post-assessment. For all measures except somatization and anxiety significant within-group effects were found at 12-month follow-up assessment indicating long-lasting effects. Conclusions: This study adds evidence to the literature on unguided online interventions for insomnia, and indicates that online CBT-I can have substantial long-term effects on relevant sleep-related outcome parameters. Moreover, the results indicate that sleep-related cognitions and safety behaviour can be successfully altered with an unguided CBT-I intervention.
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The Explanatory Role of Insomnia in the Relationship between Pain Intensity and Posttraumatic Stress Symptom Severity among Trauma-Exposed Latinos in a Federally Qualified Health Center. J Racial Ethn Health Disparities 2018; 5:1389-1396. [PMID: 29633158 DOI: 10.1007/s40615-018-0489-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 01/18/2023]
Abstract
Latinos, one of the fastest growing populations in the United States, suffer from high rates of posttraumatic stress symptoms (PTS) and its clinical correlates (e.g., disability). Although research suggests the experience of pain is closely related to PTS among trauma-exposed groups, there has been little exploration of the processes that may link pain intensity to greater PTS among trauma-exposed Latinos. The current study explored insomnia, a common problem associated with both pain intensity and PTS, as a mechanism in the association between pain intensity and PTS among trauma-exposed Latinos (N = 208, Mage = 39.39 years, SD = 11.48) attending a Federally Qualified Health Center. Results indicated that insomnia partially explained the relationship between pain intensity and PTS total score (B = 0.25, 95% CI [0.12, 0.43]), as well as re-experiencing (B = 0.09, 95% CI [0.04, 0.17]), avoidance (B = 0.09, 95% CI [0.04, 0.17]), and arousal symptoms (B = 0.10, 95% CI [0.04, 0.17]). Future work is needed to explore the extent to which insomnia accounts for relations between pain and PTS using longitudinal designs to further clarify theoretical health disparity models involving these comorbid conditions.
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Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review. J Psychosom Res 2018; 106:1-12. [PMID: 29455893 DOI: 10.1016/j.jpsychores.2017.12.012] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Major depressive disorder is one of the most commonly diagnosed psychiatric illnesses, and it has a profound negative impact on an individual's ability to function. Up to 90% of individuals suffering from depression also report sleep and circadian disruptions. If these disruptions are not effectively resolved over the course of treatment, the likelihood of relapse into depression is greatly increased. Cognitive Behavioural Therapy for Insomnia (CBT-I) has shown promise in treating these sleep and circadian disturbances associated with depression, and may be effective as a stand-alone treatment for depression. This may be particularly relevant in cases where antidepressant medications are not ideal (e.g. due to contraindications, cost, or treatment resistance). METHODS A systematic literature review was conducted of trials investigating the use of CBT-I to treat depression in adults. Therapy included in-person CBT-I, as well as telehealth and group CBT-I. RESULTS AND CONCLUSIONS CBT-I presents a promising treatment for depression comorbid with insomnia. In-person therapy has the most supporting evidence for its efficacy, though treatment effects may not be additive with those of antidepressant medications. Insomnia improvement due to CBT-I may mediate the improvement in depressive symptoms. There is less evidence for the use of telehealth, though a stepped-care approach is indicated based on baseline depressive severity. More research on group therapy and telehealth modalities of delivering CBT-I are required before making recommendations.
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Sleep disturbance may impact treatment outcome in bipolar disorder: A preliminary investigation in the context of a large comparative effectiveness trial. J Affect Disord 2018; 225:563-568. [PMID: 28881294 DOI: 10.1016/j.jad.2017.08.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/25/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bipolar patients experience sleep disturbances during and between mood episodes. Yet the impact of sleep on treatment with different medications has not been fully explored. The purpose of this paper is to explore the potential impact of poor sleep at baseline on outcomes in a randomized effectiveness trial of quetiapine and lithium. METHODS The Bipolar CHOICE study was a 6-month, parallel group, multisite randomized controlled trial. Participants with bipolar disorder (N = 482; 59% female and age 18-70 years) received quetiapine or lithium. Patients were allowed to also receive adjunctive personalized treatments, which were guideline-informed, empirically-based medications added to treatment as needed. Medication changes were recorded as necessary clinical adjustments (NCA). Fisher's exact tests, mixed-regression models, and Mann-Whitney U tests were used to assess demographic and clinical characteristics as well as whether sleep disturbance would predict outcomes. RESULTS 63% of patients had baseline sleep disturbance. Individuals with sleep disturbance had worse bipolar illness severity, greater severity of depression, mania, anxiety, irritability, and psychosis, were less likely to have sustained response (17% vs. 29%; adjusted RR: 0.55, 95% CI: 0.38-0.78, p = 0.0006) and had more NCAs (median 0.71 vs. 0.59, p = 0.03). LIMITATIONS Our findings were limited by how we defined sleep disturbance, and by how severity of sleep disturbance was assessed with one item with a non-sleep specific measure. CONCLUSIONS Baseline sleep disturbance was associated with more severe bipolar symptoms and worse 6-month outcomes. Further research is warranted on improving sleep in bipolar disorder, especially the role of psychosocial interventions.
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The mediating role of sleep disturbances in the relationship between posttraumatic stress disorder and self-injurious behavior. J Anxiety Disord 2015; 35:68-74. [PMID: 26398304 DOI: 10.1016/j.janxdis.2015.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/07/2015] [Accepted: 09/09/2015] [Indexed: 12/21/2022]
Abstract
Although posttraumatic stress disorder (PTSD) is associated with self-injurious behavior, it is currently unclear what mechanisms may account for this relationship. Sleep disturbances may be relevant as they are common among those with PTSD and are associated with emotion regulation difficulties, which may increase vulnerability to self-injurious behavior. As such, we investigated the relationship between PTSD and self-injurious behaviors, and the mediating roles of nightmares and insomnia. Hypotheses were tested cross-sectionally in a sample of psychology clinic outpatients (N=255). Participants completed a structured clinical interview assessing PTSD and self-report questionnaires measuring insomnia, nightmares, and self-injurious behaviors (i.e., Have you ever cut, burned, or scratched yourself on purpose?). PTSD was associated with self-injurious behavior after covarying for depression, and nightmare severity mediated the relationship between PTSD and self-injurious behavior. Findings are consistent with research indicating that sleep disturbances, specifically nightmares, are important predictors of poor outcomes among those with PTSD, and extend this research to suggest their role in self-injurious behaviors as well.
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Jansson-Fröjmark M, Norell-Clarke A, Linton SJ. The role of emotion dysregulation in insomnia: Longitudinal findings from a large community sample. Br J Health Psychol 2015; 21:93-113. [DOI: 10.1111/bjhp.12147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 06/05/2015] [Indexed: 12/19/2022]
Affiliation(s)
- Markus Jansson-Fröjmark
- Center for Health and Medical Psychology (CHAMP); School of Law, Psychology and Social Work; Örebro University; Sweden
- Department of Psychology; Stockholm University; Sweden
| | - Annika Norell-Clarke
- Center for Health and Medical Psychology (CHAMP); School of Law, Psychology and Social Work; Örebro University; Sweden
- Centre for Research on Child and Adolescent Mental Health; Karlstad University; Sweden
| | - Steven J. Linton
- Center for Health and Medical Psychology (CHAMP); School of Law, Psychology and Social Work; Örebro University; Sweden
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Hsu HM, Chou KR, Lin KC, Chen KY, Su SF, Chung MH. Effects of cognitive behavioral therapy in patients with depressive disorder and comorbid insomnia: A propensity score-matched outcome study. Behav Res Ther 2015; 73:143-50. [PMID: 26313621 DOI: 10.1016/j.brat.2015.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 07/29/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We evaluated the effects of cognitive behavioral therapy for insomnia (CBT-I) in inpatients with a diagnosis of depression and comorbid insomnia. METHOD This study used a prospective, parallel-group design. The experimental group received CBT-I for no more than 90 min once weekly for 6 weeks and the control group only have health education manuals for insomnia. The following questionnaires were administered at baseline: the Hamilton Rating Scale for Depression (HAM-D), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), Presleep Arousal Scale (PSAS), Sleep Hygiene Practice (SHP), and Pittsburgh Sleep Quality Index. The questionnaires were readministered after the completion of the 6-wk CBT-I intervention and 1 month following the completion of CBT-I, to determine the effects of the CBT-I intervention over time. The analysis of Generalized Estimation Equations was identified the difference between the experimental group and the control group by controlling for the variables in BZD dose and propensity score of gender, age, and the scores for the DBAS-16, PSAS, SHPS, and HAM-D. RESULTS Consequently, the significant difference in the PSQI scores was observed at the 1-month follow-up assessment however, no significant intergroup difference in the PSQI scores was found at the completion of the CBT-I intervention between two groups. CONCLUSIONS As a conclusion, we found that overall sleep quality significantly improved in patients who received CBT-I after we controlled for the BZD dose and propensity score, which suggests that CBT-I may represent a useful clinical strategy for improving sleep quality in patients with depression and comorbid insomnia.
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Affiliation(s)
- Hui-Min Hsu
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Kuei-Ru Chou
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Nursing, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan; Graduate Institutes of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Chia Lin
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Kuan-Yu Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Shu-Fang Su
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Institution of Nursing and Health Science, National Taipei University, Taipei, Taiwan
| | - Min-Huey Chung
- Graduate Institutes of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.
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Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study. COGNITIVE THERAPY AND RESEARCH 2015. [DOI: 10.1007/s10608-015-9698-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OPINION STATEMENT Psychological and behavioral therapies should be considered the first line treatment for chronic insomnia. Although cognitive behavioral therapy for insomnia (CBT-I) is considered the standard of care [1], several monotherapies, including sleep restriction therapy, stimulus control therapy, and relaxation training are also recommended in the treatment of chronic insomnia [2]. CBT-I is a multimodal intervention comprised of a combination of behavioral (eg, sleep restriction, stimulus control) and cognitive therapy strategies, and psychoeducation delivered in 4 to 10 weekly or biweekly sessions [3]. Given that insomnia is thought to be maintained by an interaction between unhelpful sleep-related beliefs and behaviors, the goal of CBT-I is to modify the maladaptive cognitions (eg, worry about the consequences of poor sleep), behaviors (eg, extended time in bed), and arousal (ie, physiological and mental hyperarousal) perpetuating the insomnia. CBT-I is efficacious when implemented alone or in combination with a pharmacologic agent. However, because of the potential for relapse upon discontinuation, CBT-I should be extended throughout drug tapering [4]. Although the treatment options should be guided by the available evidence supporting both psychological therapies and short-term hypnotic treatment, as well as treatment feasibility and availability, treatment selection should ultimately be guided by patient preference [5]. Despite its widespread use among treatment providers [6], the use of sleep hygiene education as a primary intervention for insomnia should be avoided. Sleep hygiene may be a necessary, but insufficient condition for promoting good sleep and should be considered an adjunct to another empirically supported treatment.
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Thorndike FP, Ritterband LM, Gonder-Frederick LA, Lord HR, Ingersoll KS, Morin CM. A randomized controlled trial of an internet intervention for adults with insomnia: effects on comorbid psychological and fatigue symptoms. J Clin Psychol 2013; 69:1078-93. [PMID: 24014057 DOI: 10.1002/jclp.22032] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Insomnia is frequently comorbid with other medical and psychological disorders. This secondary data analysis investigated whether an Internet-delivered cognitive behavioral therapy for insomnia (CBT-I) intervention could also reduce comorbid psychological and fatigue symptoms. METHOD Data from a pilot randomized controlled trial (RCT) testing the efficacy of Internet-delivered CBT-I relative to a waitlist control was used to examine changes in symptoms of depression, anxiety, mental health quality of life (QOL), and fatigue. RESULTS Group by time interactions from repeated measures analyses revealed significant post intervention improvements in Internet participants (n = 22) relative to control participants (n = 22) on all psychological symptoms, mental health QOL, and fatigue. A small post hoc subsample of Internet participants with mild or moderate depression also showed large effect size changes in these constructs (depression, anxiety, mental health QOL, and fatigue). CONCLUSION Internet-delivered CBT-I appears to not only improve sleep but also reduce comorbid psychological and fatigue symptoms.
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Babson KA, Boden MT, Harris AH, Stickle TR, Bonn-Miller MO. Poor sleep quality as a risk factor for lapse following a cannabis quit attempt. J Subst Abuse Treat 2013; 44:438-43. [PMID: 23098380 DOI: 10.1016/j.jsat.2012.08.224] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 08/15/2012] [Accepted: 08/30/2012] [Indexed: 11/25/2022]
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Ritterband LM, Bailey ET, Thorndike FP, Lord HR, Farrell-Carnahan L, Baum LD. Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. Psychooncology 2012; 21:695-705. [PMID: 21538678 PMCID: PMC3424270 DOI: 10.1002/pon.1969] [Citation(s) in RCA: 201] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 02/24/2011] [Accepted: 02/28/2011] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Insomnia is a common complaint among cancer survivors. Fortunately, cognitive-behavioral therapy for insomnia (CBT-I) has been shown to be an effective treatment in this population. However, it is rarely implemented given its limited availability. To address this barrier, we examined the ability of an easily accessible online CBT-I program to improve insomnia symptoms in cancer survivors. METHODS Twenty-eight cancer survivors with insomnia were randomly assigned to either an Internet insomnia intervention (n = 14) or to a waitlist control group (n = 14). The online program, Sleep Healthy Using The Internet, delivers the primary components of CBT-I (sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention). Pre- and post-assessment data were collected via online questionnaires and daily sleep diaries. RESULTS Participants in the Internet group showed significant improvements at post-assessment compared with those in the control group in overall insomnia severity (F(1,26) = 22.8; p<0.001), sleep efficiency (F(1,24) = 11.45; P = 0.002), sleep onset latency (F(1,24) = 5.18; P = 0.03), soundness of sleep (F(1,24) = 9.34; P = 0.005), restored feeling upon awakening (F(1,24) = 11.95; P = 0.002), and general fatigue (F(1,26) = 13.88; P = 0.001). Although other group × time interactions were not significant, overall adjusted effect sizes for all sleep variables as well as for fatigue, depression, anxiety, and quality of life ranged from small to large. CONCLUSIONS CBT-I delivered through an interactive, individually tailored Internet intervention may be a viable treatment option for cancer survivors experiencing insomnia.
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Affiliation(s)
- Lee M Ritterband
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Anxiety Sensitivity is Associated with Frequency of Sleep Medication Use Above and Beyond Self-Reported Sleep Quality. COGNITIVE THERAPY AND RESEARCH 2011. [DOI: 10.1007/s10608-011-9399-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Carney CE, Harris AL, Friedman J, Segal ZV. Residual sleep beliefs and sleep disturbance following Cognitive Behavioral Therapy for major depression. Depress Anxiety 2011; 28:464-70. [PMID: 21400641 DOI: 10.1002/da.20811] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 02/09/2011] [Accepted: 02/14/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Sleep disturbance is a commonly reported residual symptom after effective depression treatment. This residual sleep impairment, as well as the presence of problem levels of certain sleep beliefs, may be important for depressive relapse prevention, and as such should be addressed in treatment. The following study examined residual sleep disturbance and residual maladaptive sleep beliefs in those treated with Cognitive Behavior Therapy for depression. METHODS Participants (N = 24) were clinic patients seeking treatment for depression at a community clinic. Repeated measures analyses of variance tested pre- to posttreatment change on depression symptoms, general negative beliefs, sleep quality, and maladaptive sleep beliefs. RESULTS As expected, significant time effects were found for depressive symptoms and general negative beliefs. Sleep quality scores also decreased significantly at posttreatment; however, 92% of those no longer meeting depressive criteria continued to endorse residual sleep disturbance, according to an established clinical cutoff score of > 5 on a validated measure of sleep quality (the Pittsburgh Sleep Quality Index). There were no significant pre- to posttreatment changes for maladaptive sleep beliefs. CONCLUSIONS The results indicate that sleep disturbance and maladaptive sleep-related beliefs remain a problematic residual symptom of remitted depression. These findings are discussed with reference to improving cognitive behavioral treatments for depression in order to help reduce rates of residual sleep problems.
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Affiliation(s)
- Colleen E Carney
- Ryerson University, University of Toronto, Toronto, Ontario, Canada.
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Abstract
More than 70 million people in the United States experience primary insomnia (PI) at some point in their life, resulting in an estimated $65 billion in health care costs and lost productivity. PI is therefore one of the most common health care problems in the United States. To mollify the negative effects of PI, scholars have sought to evaluate and improve treatments of this costly health care problem. A breadth of research has demonstrated that cognitive behavioral therapy (CBT) is an effective intervention for PI. The goal of this article is to provide an overview of CBT for PI, including evidence regarding treatment efficacy, effectiveness, and practitioner considerations.
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Affiliation(s)
- Kimberly A Babson
- Department of Psychology, University of Arkansas, 216 Memorial Hall, Fayetteville, AR 72701, USA.
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