Treatment agreement, adherence, and outcome in cognitive behavioral treatments for insomnia

Optimizing the Time and Dose of Melatonin as a Sleep-Promoting Drug: A Systematic Review of Randomized Controlled Trials and Dose-Response Meta-Analysis

Previous studies have reported inconsistent results about exogenous melatonin's sleep-promoting effects. A possible explanation relies on the heterogeneity in administration schedule and dose, which might be accountable for differences in treatment efficacy. In this paper, we undertook a systematic review and meta-analysis of double-blind, randomized controlled trials performed on patients with insomnia and healthy volunteers, evaluating the effect of melatonin administration on sleep-related parameters. The standardized mean difference between treatment and placebo groups in terms of sleep onset latency and total sleep time were used as outcomes. Dose-response and meta-regression models were estimated to explore how time of administration, dose, and other treatment-related parameters might affect exogenous melatonin's efficacy. We included 26 randomized controlled trials published between 1987 and 2020, for a total of 1689 observations. Dose-response meta-analysis showed that melatonin gradually reduces sleep onset latency and increases total sleep time, peaking at 4 mg/day. Meta-regression models showed that insomnia status (β = 0.50, p < 0.001) and time between treatment administration and the sleep episode (β = -0.16, p = 0.023) were significant predictors of sleep onset latency, while the time of day (β = -0.086, p < 0.01) was the only significant predictor of total sleep time. Our results suggest that advancing the timing of administration (3 h before the desired bedtime) and increasing the administered dose (4 mg/day), as compared to the exogenous melatonin schedule most used in clinical practice (2 mg 30 min before the desired bedtime), might optimize the efficacy of exogenous melatonin in promoting sleep.

Factors influencing the effectiveness of digital cognitive behavioural therapy for chronic insomnia in clinical practice

Digital cognitive behavioural therapy for chronic insomnia (D-CBT-I) has been shown to be as efficacious as traditional CBT-I. However, not all patients achieve insomnia remission after treatment. We explored the factors influencing the effectiveness of D-CBT-I in a clinical practice. A total of 414 Asian chronic insomniacs were studied during a 6 week D-CBT-I intervention. All patients were assessed at baseline and posttreatment and were determined to be remitters or non-remitters, responders or non-responders by posttreatment criteria; Insomnia Severity Index (ISI <8) or ISI reduction ≥8, to examine whether remission and response status were associated with patient baseline characteristics. The average baseline ISI score in all subjects was 16.29 points. At posttreatment, 192 (46.4%) patients achieved ISI remission and 218 (52.7%) patients demonstrated an ISI response. An increased baseline early morning awakening time and ISI score were independently associated with a lower odds for remission (OR, 0.995 and 0.991, respectively). Increased baseline Patients Health Questionnaire-9 score was independently associated with higher odds for response (OR, 1.114). Our results suggest that D-CBT-I can be recommended as the first-line treatment for chronic insomnia, particularly in insomniacs with milder insomnia symptoms and more severe depressive symptoms. Meanwhile, the effectiveness of D-CBT-I was adversely affected by longer early morning awakening time and higher insomnia severity at pretreatment, which may be improved by more intense intervention and greater therapeutic support or by traditional CBT-I.

Experience with the use of a digital sleep diary in symptom management by individuals with insomnia -a pilot mixed method study

Background

Insomnia is the most common sleep disorder. The recommended treatment is cognitive behavioural therapy for insomnia (CBTi). A sleep diary is a core tool in CBTi. We have developed a digital sleep diary with a standardised feedback function.

Aim

To study feasibility of the digital sleep diary in participants of the Akershus Sleep Apnea (ASAP) cohorts with difficulties falling asleep or maintaining sleep. To describe sleep diary engagement and explore experiences with the digital sleep diary with potential influences in insomnia symptom management.

Material and methods

Twenty participants were recruited from the ASAP. All filled out a digital sleep diary up to 12 weeks. Treatment options provided were a self-help book (N = 11) or electroencephalography neurofeedback (N = 9) in addition to the sleep diary standardised feedback function. We collected quantitative data from the sleep diary reports and we sub-divided insomnia by sleep onset insomnia and non-sleep onset insomnia. Finally, we performed qualitative interviews.

Results

The median number of entries to the sleep diary was 81 (25th quartile: 26, 75th quartile 84). In the qualitative analysis, we identified two main themes; "structure and overview" and "usability and digital features".

Conclusion

The sleep diary was found to be feasible when distributed in combination with a self-help book or electroencephalography neurofeedback. The qualitative results emphasised the importance of a timely graphical overview and visualisations of self-recorded sleep.

Adherence to sleep restriction therapy - An evaluation of existing measures

Sleep restriction, a key element of cognitive behavioural therapy for insomnia, involves considerable behavioural changes in patients' lives, leading to side-effects like increased daytime sleepiness. Studies on sleep restriction rarely report adherence, and when assessed it is often limited to the average number of therapy sessions attended. This study aims to systematically evaluate different measures of adherence to cognitive behavioural therapy for insomnia and their relationship with treatment outcome. This is a secondary analysis of data from a randomized controlled trial investigating cognitive behavioural therapy for insomnia (Johann et al. (2020) Journal of Sleep Research, 29, e13102). The sample included 23 patients diagnosed with insomnia according to DSM-5 criteria who underwent 8 weeks of cognitive behavioural therapy for insomnia. The following adherence measures based on sleep diary data were used: number of sessions completed; deviations from agreed time in bed; average percentage of patients deviating from bedtime by 15, 30 or 60 min; variability of bedtime and wake-up time; change in time in bed from pre- to post-assessment. Treatment outcome was assessed using the Insomnia Severity Index. Multiple regression models were employed, and insomnia severity was controlled for. Results showed that none of the adherence measures predict insomnia severity. Baseline insomnia severity, dysfunctional thoughts and attitudes about sleep, depression or perfectionism did not predict adherence. The limited variance in the outcome parameter due to most patients benefiting from treatment and the small sample size may explain these findings. Additionally, using objective measures like actigraphy could provide a better understanding of adherence behaviour. Lastly, the presence of perfectionism in patients with insomnia may have mitigated adherence problems in this study.

Development and preliminary validation of the treatment adherence rating scale

BACKGROUND AND OBJECTIVES

Patient adherence to treatment is an important barrier to the implementation of evidence-based psychological treatments (EBPTs). There is a need for simple and deployable measures of patient adherence to treatment for use across EBPTs. The Treatment Adherence Rating Scale (TARS) was developed and validated in two samples.

METHODS

This study includes two samples: adults with Major Depressive Disorder who received Cognitive Therapy for depression (Sample 1; N = 48, mean age = 44.27 years), and at-risk adolescents who received either the Transdiagnostic Sleep and Circadian Intervention or Psychoeducation (Sample 2; N = 176, mean age = 14.77 years). Factor structure of the TARS scores was examined via Exploratory Factor Analyses (EFA) in Sample 1 and Confirmatory Factor Analyses (CFA) in Sample 2. Internal consistency, predictive validity, and construct validity of the TARS scores were examined.

RESULTS

Results from EFA in Sample 1 supported a one-factor model. Results from CFA in Sample 2 suggested that a two-factor model (i.e., agreement and compliance) fit better than a one-factor model. TARS scores from both samples demonstrated adequate predictive validity with primary clinical outcomes and construct validity with treatment expectations.

LIMITATIONS

The sample was small with two specific populations. Future research should focus on other patient populations, a larger population, and other EBPTs. Future research examining patient ratings of these items are needed for further validation of the TARS.

CONCLUSIONS

Preliminary findings support the use of a two-factor model and highlight the potential utility of a simple measure of patient adherence to treatment across age and diagnostic groups.

Real, misreported, and backfilled adherence with paper sleep diaries

OBJECTIVE

Paper-based sleep diaries play an important role in the diagnosis and treatment of insomnia disorder. Accurate self-report data help to guide therapy and track progress, both in the clinic and during research trials. Previous research with paper diaries suggests that timely adherence with self-report diaries may be an issue, which can result in biased event recall.

PATIENTS/METHODS

University students (N = 31) were asked to track their bedtime and wake time within 30 min of these events on paper-based sleep diaries. Specially designed binders covertly timestamped when participants actually wrote on their sleep diary. We assessed adherence by comparing timestamped diary usage with what participants documented in their sleep diary.

RESULTS

Participants self-reported they were adherent with sleep diary instructions 97.9% of the time. However, timestamped data revealed that only 37.1% of diary entries were completed within the instructed timeframe. More than half of participants backfilled diary data, and three participants (9.7%) provided data that completely did not match their actual time of completion.

CONCLUSIONS

When naïve to the objective tracking of their sleep diary usage, participants greatly over-reported the extent of their adherence. Non-adherence with sleep diary protocols poses a challenge for researchers utilizing this tool as a study outcome in clinical trials and for clinicians attempting to implement behavioral therapies for insomnia.

Treatment Fidelity in a Randomized Controlled Trial of Cognitive Behavioral Therapy for Insomnia in Heart Failure

BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment for people with chronic insomnia, including those with heart failure (HF). Treatment fidelity evaluation is needed to ensure study validity and reliability.

OBJECTIVE

The aim of this study was to apply the National Institutes of Health Behavioral Change Consortium framework to ensure adequate treatment fidelity in a randomized controlled trial of CBT-I for people with stable HF.

METHODS

We describe strategies to ensure treatment fidelity in study design, provider training, and treatment delivery. We measured treatment receipt (observation and self-report) and enactment of CBT-I strategies (self-report and actigraphy). We used the Dysfunctional Beliefs and Attitudes About Sleep Scale and the Sleep Disturbance Questionnaire to indicate sleep-related beliefs and cognitions. We computed descriptive statistics for demographic characteristics, treatment receipt, and enactment variables. We compared baseline and post-intervention dichotomous sleep behaviors using the two-sided Wilcoxon rank-sum test. We calculated the root mean square of successive difference in time of sleep onset and midpoint (actigraphy) to indicate day-by-day variability in bed and wake times.

RESULTS

Most participants completed the CBT-I intervention and follow-up assessments and attended each group or make-up session. Most correctly computed their sleep efficiency and completed their homework. Most participants used the sleep tracker and reported using strategies to improve their sleep schedules. There was a significant decrease in actigraph-measured light intensity during the 30 minutes and 1 hour before bedtime between baseline and post-intervention and no statistically significant changes in light intensity after waking or in nap frequency. Most of those who woke during the night got out of bed, consistent with recommendations. There were significant improvements on all of the Dysfunctional Beliefs and Attitudes About Sleep items and total score and all but one item on the Sleep Disturbance Questionnaire.

DISCUSSION

Preserved treatment fidelity may explain the large and sustained effects in people with HF found in our trial. Further research is needed to evaluate CBT-I's effectiveness and implementation strategies among people with HF in real-world clinical settings.

Examining whether Changes in Sleep Habits Predict Long-Term Sustainment of Treatment Gains in Individual Remitted from Insomnia after CBT-I

OBJECTIVES

Providers of Cognitive-Behavioral Therapy for Insomnia (CBT-I) are often asked whether the behavioral recommendations (e.g., stimulus control, sleep restriction) must be adhered to ad infinitum. We examined whether changes in sleep habits/behaviors are a life sentence, or whether patients who remit can relax their adherence while maintaining their treatment gains at 1-year follow-up (FU).

METHODS

Participants (N = 179) completed 2 weeks of sleep diaries and measures of insomnia severity and safety behaviors at baseline and following four sessions of CBT-I. Of the 137 patients that achieved remission, 77 completed these measures at 1-year FU.

RESULTS

Improvements in insomnia severity and total wake time (TWT) at post-treatment were maintained at FU (ps ≥ .52). Similarly, reductions in safety behaviors were maintained at FU (p - 1.00), whereas lingering in bed reduced during treatment (p < .001) but increased at FU (p < .001). Changes in sleep habits after treatment did not predict insomnia severity at FU. However, increases in time in bed positively predicted TWT at FU (p = .001).

CONCLUSIONS

Those who remit after CBT-I may generally relax their adherence to behavioral recommendations without significantly impacting their perceived insomnia symptoms 1 year after treatment despite some increases in TWT. Results increase our confidence in CBT-I as a brief and durable intervention.

Association between insomnia patients' pre-treatment characteristics and their responses to distinctive treatment sequences

STUDY OBJECTIVES

It is common to provide insomnia patients a second treatment when the initial treatment fails, but little is known about optimal treatment sequences for different patient types. This study examined whether pre-treatment characteristics/traits predict optimal treatment sequences for insomnia patients.

METHODS

A community sample of 211 adults (132 women; Mage = 45.6 ± 14.9 years) with insomnia were recruited. Patients were first treated with behavioral therapy (BT) or zolpidem (Zol). Non-remitting BT recipients were randomized to a second treatment with either Zol or cognitive therapy; non-remitting Zol recipients underwent BT or Trazodone as a second treatment. Remission rates were assessed at the end of the first and second 6-week treatments. We then compared the remission rates of dichotomous groups formed on the basis of gender, age, pretreatment scores on SF36 and Multidimensional Fatigue Scale, the presence/absence of psychiatric/medical comorbidities or pain disorders, and mean subjective sleep duration and efficiency within and across treatment sequences.

RESULTS

Lower remission rates were noted for those: with a pain disorder, poor mental health perceptions, high MFI fatigue scores, and lower sleep times and efficiencies. Patients with a pain disorder responded best to the BT-to-Zol sequence, whereas patients with more mental impairment, severe fatigue, short sleep, and low sleep efficiency responded poorly to treatment starting with BT.

CONCLUSIONS

Pain, fatigue, poor mental health status, and subjective sleep duration and efficiency all affect response to different insomnia treatment sequences. Findings may guide clinicians in matching insomnia treatments to their patients.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01651442, Protocol version 4, April 20, 2011, registered June 26, 2012, https://clinicaltrials.gov/ct2/show/NCT01651442?rslt=With&type=Intr&cond=Insomnia&cntry=US&state=US%3ACO&city=Denver&age=12&draw=2&rank=1.

Scheme optimization of acupoints compatibility and influence factors of the effect

BACKGROUND

Acupuncture may be a clinically effective treatment for insomnia. We will perform a multicenter, large-scale, single-blinded, randomized controlled trial to compare the differences in the clinical efficacy between the use of singleacupoints and compatibilityacupoints in the treatment of primary insomnia.

METHODS/DESIGN

A total of 333 participants will be randomly assigned to 2 acupoint treatment groups or 1 nonacupoint control group in a 1:1:1 ratio by a central stochastic system. The acupuncture groups are: the single acupoint group: Shenmen (HT7); and he compatibility acupoint group: Shenmen (HT7), Baihui (DU20), and Sanyinjiao (SP6). The observation period of this trial will be 10 weeks. All patients will be followed for 1 week before randomization (baseline phase). After randomization, the patients will receive 30 minutes of electro-acupuncture once per day for 5 weeks. In the fourth week after the treatment, follow-up will be performed once. The primary outcome will be the Pittsburgh sleep quality index score at 1 week before randomization and 2 and 8 weeks after randomization. The secondary outcomes will include data from sleep diaries, Athens insomnia scale scores, ShortForm-36 Health Survey scores, electroencephalogram technology results and polysomnogram) results. Patients will be required to complete a sleep diary every day during the treatment period. Patients will also undergo electroencephalogram technology and polysomnogram 1 week before randomization and 5 weeks after randomization. The other secondary outcomes will be measured 1 week before randomization and 5 and 9 weeks after randomization.

DISCUSSION

This trial will be helpful in identifying whether acupuncture at compatibility acupoints is more effective than acupuncture at single acupoints.

TRIAL REGISTRATION

Clinical Trials.govNCT02448602, Registered 5May 2015, https://www.clinicaltrials.gov/ct2/show/NCT02448602?term=NCT02448602&rank=1.

Community promotion and application of Wuqinxi combined with brief behavioral therapy for insomnia: A study protocol

BACKGROUND

Brief behavioral therapy for insomnia (BBT-I) has been proven to be a simple and effective alternative to cognitive behavioral therapy. However, low adherence limits the application in Chinese primary medical institutions, resulting in delayed or irregular treatment for many patients. This study aimed to explore the efficacy of traditional Chinese medicine external treatments on the adherence to behavioral therapy for insomnia in Chinese primary healthcare institutions, with a particular focus on patients who live in regions with weak healthcare systems.

METHODS

This randomized controlled clinical trial will be conducted in primary medical institutions and will recruit 98 adult participants with insomnia. BBT-I will be used as the base treatment. The participants will be divided into experimental (combined with Wuqinxi and other traditional Chinese medicine [TCM] external treatment n = 49) and control (combined with trazodone treatment, n = 49) groups, and each group will be treated for 4 consecutive weeks. The severity index of insomnia will be used as the main indicator of disease evaluation, with an 8-point reduction in the score considered as effective and a score <8 considered as cured. The secondary indicators of the disease evaluation will include the Pittsburgh sleep quality index, Zung's self-rating anxiety scale, Zung's self-rating depression scale, treatment adherence, and adverse event reports. All participants will be followed up at the time of enrollment, 4 weeks after treatment, and 3 months after the end of treatment.

DISCUSSION

This clinical trial will provide evidence for the efficacy of traditional Chinese medicine external treatment on the adherence to behavioral therapy for insomnia in primary medical institutions. This cheap and accessible model may benefit insomnia patients in medically underserved areas.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100042845. Registered on 30 January 2021, dataset: http://www.chictr.org.cn/showproj.aspx?proj=65691. Official scientific title of the research topic: Wuqinxi and other external treatment of Chinese Medicine combined with brief behavior therapy for insomnia.

Who to Refer to a Behavioral Insomnia Clinic? - Recommendations Based on Treatment Rationale and Response Prediction

Purpose of Review

Response to cognitive-behavioral therapy for insomnia (CBT-I) is variable across individuals, and specialty insomnia clinics that provide CBT-I are few. To personalize insomnia treatments and maximize the cost-effectiveness of CBT-I, this paper reviews the conceptual model and content of CBT-I and the predictors of adherence/response to CBT-I as the basis for understanding who is most likely to benefit from CBT-I.

Recent Findings

Specific patient-related attributes that predict benefit from CBT-I include (1) presence of maladaptive behaviors that serve as perpetuating factors of insomnia; (2) greater motivation to pursue therapy and higher treatment expectancies regarding CBT-I; (3) reduced use of hypnotics; (4) longer sleep duration; and (5) adequately treated psychiatric comorbidities.

Summary

People presenting with chronic insomnia and these attributes may warrant prioritization in referral to behavioral insomnia clinics. Conversely, those who do not have such favorable characteristics may require interventions that address modifiable factors associated with poor adherence/response to CBT-I.

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.

Internet-Delivered Cognitive Behavioral Therapy for Insomnia: Tailoring Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Insomnia

Chronic insomnia is preferably treated with cognitive behavioral therapy for insomnia (CBTI), but many insomnia sufferers receive medication instead, likely because of high costs, lack of knowledge about optimal insomnia treatment among physicians, and lack of CBTI-trained professionals in mental health care. A possible solution is to offer CBTI through the Internet: I-CBTI. I-CBTI is generally acceptable to patients and greatly improves insomnia symptoms. We review the state of knowledge around I-CBTI and its effects. CBTI's effectiveness is influenced by treatment characteristics and patient-specific factors. We review potential factors that help identify which patients may benefit from I-CBTI.

A Propensity Score Analysis of Homework Adherence-Outcome Relations in Cognitive Behavioral Therapy for Depression

Little is known about whether or not a consistently high level of homework adherence over the course of therapy benefits patients. This question was examined in two samples of patients who were receiving individual Cognitive Behavioral Therapy (CBT) for depression (Ns = 128 [Sequenced Treatment Alternatives to Relieve Depression: STAR-D] and 183 [Continuation Phase Cognitive Therapy Relapse Prevention: C-CT-RP]). Logistic and linear regression and propensity score models were used to identify whether or not clinician assessments of homework adherence differentiated symptom reduction and remission, as assessed by the Hamilton Depression Rating Scale-17 (HDRS-17), the Quick Inventory of Depressive Symptomatology-Self-Reported Scale (QIDS-SR), and the QIDS-Clinician Scale (QIDS-C). CBT-related response and remission were equally likely between both high and low homework adherers in both studies and in all models. But in propensity adjusted models that adjusted for session attendance, for both the STAR-D and C-CT-RP samples, greater homework adherence was significantly associated with greater response and remission from depression in the first and last 8 sessions of CBT. Our results suggest that homework adherence can account for response and remission early and late in treatment, with adequate session attendence.

Clinical effects of mindfulness meditation and cognitive behavioral therapy standardized for insomnia: A protocol for a systematic review and meta-analysis

INTRODUCTION

This systematic review protocol describes the methods that will be used to evaluate the efficacy and safety of mindfulness meditation and cognitive behavioral therapy programs as a psychological intervention for insomnia disorders.

METHODS AND ANALYSIS

We will search the following 11 electronic databases without language or publication status restrictions: MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and PsycARTICLES. Furthermore, we will also search 5 Korean-language databases (Oriental Medicine Advanced Searching Integrated System, Korean studies Information Service System, Research Information Service System, Korean Medical Database, and Korea Citation Index). The study selection and data extraction will be performed independently by 2 authors. The study quality assessment and evaluation of the quality of evidence for the main findings will be performed independently by 2 authors using the Cochrane tool for assessing risk of bias and predefined criteria (the Grading of Recommendations Assessment, Development, and Evaluation approach). Data synthesis and analysis will be performed using RevMan Version 5.3. Data will be synthesized by either a fixed effects or random effects model according to a heterogeneity test or the number of studies included in the meta-analysis. If any plan for documenting important protocol amendments changes, the researchers will have a revision agreement and then register the modification in the International Prospective Register of Systematic Reviews (PROSPERO).

ETHICS AND DISSEMINATION

Ethical approval will not be required because individual patient data are not included and because this protocol is for a systematic review. The findings of this systematic review will be disseminated through conference presentations.PROSPERO registration number: CRD42018111217.