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Benz F, Grolig L, Hannibal S, Buntrock C, Cuijpers P, Domschke K, Ebert DD, Ell J, Janneck M, Jenkner C, Johann AF, Josef A, Kaufmann M, Koß A, Mallwitz T, Mergan H, Morin CM, Riemann D, Riper H, Schmid SR, Smit F, Spille L, Steinmetz L, Van Someren EJW, Spiegelhalder K, Lehr D. Investigating non-inferiority of internet-delivered versus face-to-face cognitive behavioural therapy for insomnia (CBT-I): a randomised controlled trial (iSleep well). Trials 2024; 25:371. [PMID: 38858707 PMCID: PMC11163861 DOI: 10.1186/s13063-024-08214-6] [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: 02/26/2024] [Accepted: 05/30/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Insomnia is a highly prevalent disorder associated with numerous adverse health outcomes. Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment by clinical guidelines but is accessible to only a minority of patients suffering from insomnia. Internet-delivered CBT-I (iCBT-I) could contribute to the widespread dissemination of this first-line treatment. As there is insufficient evidence regarding non-inferiority, this study directly aims to compare therapist-guided internet-delivered versus face-to-face CBT-I in terms of insomnia severity post-treatment. Furthermore, a health-economic evaluation will be conducted, and potential benefits and disadvantages of therapist-guided iCBT-I will be examined. METHODS This study protocol describes a randomised controlled two-arm parallel-group non-inferiority trial comparing therapist-guided iCBT-I with face-to-face CBT-I in routine clinical care. A total of 422 patients with insomnia disorder will be randomised and treated at 16 study centres throughout Germany. Outcomes will be assessed at baseline, 10 weeks after randomisation (post), and 6 months after randomisation (follow-up). The primary outcome is insomnia severity measured using the Insomnia Severity Index. Secondary outcomes include depression-related symptoms, quality of life, fatigue, physical activity, daylight exposure, adverse events related to treatment, and a health-economic evaluation. Finally, potential moderator variables and several descriptive and exploratory outcomes will be assessed (e.g. benefits and disadvantages of internet-delivered treatment). DISCUSSION The widespread implementation of CBT-I is a significant healthcare challenge. The non-inferiority of therapist-guided iCBT-I versus face-to-face CBT-I will be investigated in an adequately powered sample in routine clinical care, with the same therapeutic content and same level of therapist qualifications provided with both interventions. If this trial demonstrates the non-inferiority of therapist-guided iCBT-I, healthcare providers may be more confident recommending this treatment to their patients, contributing to the wider dissemination of CBT-I. TRIAL REGISTRATION Trial registration number in the German Clinical Trials Register: DRKS00028153 ( https://drks.de/search/de/trial/DRKS00028153 ). Registered on 16th May 2023.
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Affiliation(s)
- F Benz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - L Grolig
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
| | - S Hannibal
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
| | - C Buntrock
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany
| | - P Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Babeș-Bolyai University, International Institute for Psychotherapy, Cluj-Napoca, Romania
| | - K Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - D D Ebert
- Psychology & Digital Mental Health Care, Department of Health Sciences, Technical University Munich, Munich, Germany
| | - J Ell
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Janneck
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - C Jenkner
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A F Johann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A Josef
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Kaufmann
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A Koß
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - T Mallwitz
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - H Mergan
- Institute for Interactive Systems, Department of Electrical Engineering and Computer Science, Technische Hochschule Lübeck, Lübeck, Germany
| | - C M Morin
- École de Psychologie, Centre d'étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada
| | - D Riemann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - H Riper
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - S R Schmid
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - F Smit
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
- Centre of Health-Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, the Netherlands
| | - L Spille
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - L Steinmetz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - E J W Van Someren
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, the Netherlands
| | - K Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - D Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute of Sustainability Psychology, Leuphana University of Lüneburg, Lüneburg, Germany
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Steinmetz L, Simon L, Baumeister H, Spiegelhalder K, Terhorst Y. Treatment effect heterogeneity of cognitive behavioral therapy for insomnia - A meta-analysis. Sleep Med Rev 2024; 77:101966. [PMID: 38850594 DOI: 10.1016/j.smrv.2024.101966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/18/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Investigation of the heterogeneity of the treatment effect (HTE) might guide the optimization of cognitive behavioral therapy for insomnia (CBT-I). This study examined HTE in CBT-I thereby analyzing if treatment setting, control group, different CBT-I components, and patient characteristics drive HTE. Randomized controlled trials investigating CBT-I were included. Bayesian random effect meta-regressions were specified to examine variances between the intervention and control groups regarding post-treatment symptom severity. Subgroup analyses analyzing treatment setting and control groups and covariate analysis analyzing treatment components and patient characteristics were specified. No significant HTE in CBT-I was found for the overall data set, settings and control groups. The covariate analyses yielded significant results for baseline severity and the treatment component relaxation therapy. Thus, this study identified potential causes for HTE in CBT-I for the first time, showing that it might be worthwhile to further examine possibilities for precision medicine in CBT-I.
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Affiliation(s)
- Lisa Steinmetz
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany.
| | - Laura Simon
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany; Department of Psychology, Ludwig Maximilian University of Munich, Germany
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Germain A, Wolfson M, Klenczar B, Brock MS, Hearn H, O'Reilly B, Blue Star J, Mysliwiec V. Survey of Resources in Behavioral Sleep Medicine Across the Department of Defense, Defense Health Agency. Mil Med 2024; 189:e1089-e1097. [PMID: 37864822 DOI: 10.1093/milmed/usad409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/18/2023] [Indexed: 10/23/2023] Open
Abstract
INTRODUCTION Insomnia affects approximately 40% of active duty service members and adversely affects health, readiness, and safety. The VA/DoD Clinical Practice Guideline for the management of insomnia recommends cognitive-behavioral treatment of insomnia (CBTI) or its abbreviated version (brief behavioral treatment of insomnia [BBTI]) as the first-line insomnia treatment. The goal of this study was to assess CBTI/BBTI resources at MTFs, perceived facilitators and barriers for CBTI/BBTI, and gaps in these treatments across the Defense Health Agency. MATERIALS AND METHODS Between July and October 2022, we conducted an electronic survey of CBTI/BBTI resources across Contiguous United States and the District of Columbia (CONUS) and Outside Continental United States (OCONUS) MTFs. The survey was distributed to 154 military sleep health care providers from 32 MTFs, and a link to the survey was posted on two online military sleep medicine discussion forums. Fifteen providers from 12 MTFs volunteered to complete a 30-minute qualitative interview to explore their perception of barriers and facilitators of CBTI/BBTI at their facility. RESULTS Fifty-two of 154 providers (33.8%) at 20 MTFs completed the survey. A majority of providers indicated that hypnotics remain the most common treatment for insomnia at their facility. Sixty-eight percent reported that CBTI/BBTI was available at their facility and estimated that less than 50% of the patients diagnosed with insomnia receive CBTI/BBTI. The main facilitators were dedicated, trained CBTI/BBTI providers and leadership support. Referrals to the off-post civilian network and self-help apps were not perceived as significant facilitators for augmenting insomnia care capabilities. The primary barriers to offering CBTI/BBTI were under-resourced clinics to meet the high volume of patients presenting with insomnia and scheduling and workflow limitations that impede repeated treatment appointments over the period prescribed by CBTI/BBTI protocols. Four primary themes emerged from qualitative interviews: (1) CBTI/BBTI groups can scale access to insomnia care, but patient engagement and clinical outcomes are perceived as inferior to individual treatment; (2) embedding trained providers in primary or behavioral health care could accelerate access, before escalation and referral to a sleep clinic; (3) few providers have the time to adhere to traditional CBTI protocols, and appointment scheduling often does not support weekly or bi-weekly treatment visits; and (4) the absence of quality and/or continuity of care measures dampens providers' enthusiasm for using external referral resources or self-help apps. CONCLUSIONS Although there is a wide recognition that CBTI/BBTI is the first-line recommended insomnia treatment, the limited scalability of treatment protocols, clinical workflow limitations, and scarcity of trained CBTI/BBTI providers limit the implementation of the VA/DoD clinical guideline. Educating and engaging health care providers and leadership about CBTI, augmenting CBTI-dedicated resources, and adapting clinical workflows were identified as specific strategies needed to meet the current insomnia care needs of service members. Developing protocols for scaling the availability of CBTI expertise at diverse points of care, upstream from the sleep clinics, could accelerate access to care. Establishing standardized quality measures and processes across points of care, including for external providers and self-help apps, would enhance providers' confidence in the quality of insomnia care offered to service members.
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Affiliation(s)
| | | | - Brittany Klenczar
- University of Nevada, Las Vegas, Nevada, School of Public Health, Las Vegas, NV 89119, USA
| | - Matthew S Brock
- Department of Sleep Medicine, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, TX 78236, USA
| | - Hunter Hearn
- Carl R. Darnall Army Medical Center, Sleep Disorder Center, Fort Hood, TX 76544, USA
| | - Brian O'Reilly
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | | | - Vincent Mysliwiec
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Bushnell G, Ivanenko A, Horton DB, Lunsford-Avery JR, Posner J, Gerhard T, Suarez E, Olfson M. Psychiatric comorbidities and prescribing tendencies of sleep medications and related medications in young people with insomnia: a United States commercial claims-based analysis. Sleep 2024; 47:zsae057. [PMID: 38430553 PMCID: PMC11082474 DOI: 10.1093/sleep/zsae057] [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: 08/28/2023] [Revised: 02/05/2024] [Indexed: 03/04/2024] Open
Abstract
STUDY OBJECTIVES To characterize children and youth newly diagnosed with insomnia and to describe their use of sleep and other related prescription medications. METHODS Within a commercial claims database (January 1, 2016-December 31, 2021), we identified children and youth (2-24 years) with a newly recorded insomnia diagnosis (G47.0x; F51.0x) and examined psychiatric diagnoses in the prior 6 months. We evaluated sleep and related prescription medications dispensed in the week after new insomnia diagnoses (i.e. trazodone, other antidepressants, hydroxyzine, alpha-agonists, benzodiazepines, non-benzodiazepine hypnotics "z-drugs," antipsychotics, and others). Analyses were stratified by age and psychiatric comorbidities. RESULTS Among 68 698 children and 108 118 older youth (18-24 years) with a new insomnia diagnosis, three-quarters had a diagnosed comorbid psychiatric condition; anxiety disorders, depression, and ADHD were the most common. Among those without comorbid psychiatric diagnoses, 20.2% of children and 37.4% of older youth had a sleep or related medication dispensed in the following week. In children without a comorbid psychiatric diagnosis, alpha-agonists, hydroxyzine, and trazodone were the most common medications; in older youth, trazodone was the most common medication followed by hydroxyzine, z-drugs, and SSRIs. Sleep and related prescription medications were more commonly dispensed to those with psychiatric comorbidities. From 2017 to 2021, there was an increase in hydroxyzine prescriptions following a new insomnia diagnosis and decline in z-drug and benzodiazepine prescriptions. CONCLUSIONS Our findings from a nationwide sample of young people with insomnia highlight the high prevalence of psychiatric comorbidities and variety of sleep and related medications they receive. Characterizing prescribing tendencies informs guideline development and future research.
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Affiliation(s)
- Greta Bushnell
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
| | - Anna Ivanenko
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine; Chicago, IL, USA
| | - Daniel B Horton
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School; New Brunswick, NJ, USA
| | - Jessica R Lunsford-Avery
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC, USA
| | - Jonathan Posner
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine; Durham, NC, USA
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
- Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University; New Brunswick, NJ, USA
| | - Elizabeth Suarez
- Center for Pharmacoepidemiology and Treatment Sciences, Institute for Health, Health Care Policy and Aging Research; Rutgers University; New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health; Piscataway, NJ, USA
| | - Mark Olfson
- Department of Psychiatry, Columbia University Irving Medical Center; New York, NY, USA
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Palagini L, Manni R, Liguori C, De Gennaro L, Gemignani A, Fanfulla F, Ferri R, Nobili L, Ferini-Strambi L. Evaluation and management of insomnia in the clinical practice in Italy: a 2023 update from the Insomnia Expert Consensus Group. J Neurol 2024; 271:1668-1679. [PMID: 38063870 DOI: 10.1007/s00415-023-12112-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Insomnia is the most reported sleep disorder in industrialized countries, affecting, in the chronic form, around 10% of the European population. In Italy, such a percentage seems to be even higher. Although insomnia can be an independent disorder, it is frequently described as comorbid condition and may precipitate, exacerbate, or prolong a broad range of physical and mental disorders. Evaluating and targeting insomnia in the Italian clinical practice should be a priority. METHODS The present expert opinions and recommendations represent an update from 2020 and insights from Insomnia Expert Consensus Group, based on systematic reviews according to PRISMA on available options in Italy from January 2020 to March 2023. RESULTS We evaluated 28 papers among international guidelines, expert opinions, systematic reviews, and meta-analysis produced during the last 26 months. CONCLUSIONS Our findings suggest that symptoms of insomnia must be assessed in the Italian clinical practice by evaluating nocturnal and daytime symptoms, comorbid conditions, and lifestyle. Cognitive behavioral therapy for insomnia should be the first option according to availability. The choice of the drug should be based on different factors including type of insomnia, age, comorbidities, and potential side effects. If the choice would be a Z-drug or a short-acting benzodiazepine (in subjects < 65 years old), the use should be in the short term (≤ 4 weeks). Indeed, eszopiclone, as a new option in Italy, may present a different profile and may be used for up to 6 months, also in the elderly. If the choice is melatonin, it should be used melatonin 2 mg prolonged release in adults ≥ 55 years for up to 13 weeks. A new dual orexin antagonist, daridorexant, is available in Italy; it has been shown to be effective in adults and elderly and it can be used for at least 3 months and up to 1 year.
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Affiliation(s)
- Laura Palagini
- Unit of Psychiatry, Department of Neuroscience, Azienda Ospedaliero Universitaria Pisana AUOP, Pisa, Italy.
| | - Raffaele Manni
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Neurology Unit, Sleep Medicine Centre, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Luigi De Gennaro
- Department of Psychology, Sapienza University of Rome, 00185, Rome, Italy
- Body and Action Lab, IRCSS Fondazione Santa Lucia, 00179, Rome, Italy
| | - Angelo Gemignani
- Psychology Unit, Department of Neuroscience, University of Pisa, Pisa, Italy
| | - Francesco Fanfulla
- Respiratory Function and Sleep Medicine Unit, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Raffaele Ferri
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Troina, Italy
| | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
- Child Neuropsychiatry Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - Luigi Ferini-Strambi
- Department of Clinical Neurosciences, Neurology Sleep Disorders Centre, RCCS San Raffaele Scientific Institute, Milan, Italy
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Thielecke J, Kuper P, Lehr D, Schuurmans L, Harrer M, Ebert DD, Cuijpers P, Behrendt D, Brückner H, Horvath H, Riper H, Buntrock C. Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis. Psychol Med 2024:1-14. [PMID: 38469832 DOI: 10.1017/s0033291724000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics. METHODS Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree. RESULTS IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators. CONCLUSIONS An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.
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Affiliation(s)
- Janika Thielecke
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Unit Healthy Living & Work, TNO (The Netherlands Organization for Applied Scientific Research), Leiden, Netherlands
| | - Paula Kuper
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Dirk Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Lea Schuurmans
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Mathias Harrer
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- GET.ON Institute for Online Health Trainings GmbH, Berlin, Germany
| | - David D Ebert
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, Netherlands
- Amsterdam Public Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Dörte Behrendt
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Hanna Brückner
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Hanne Horvath
- GET.ON Institute for Online Health Trainings GmbH, Berlin, Germany
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, Netherlands
- Amsterdam Public Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Department of Psychiatry, VU University Medical Center, Amsterdam, Netherlands
| | - Claudia Buntrock
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Edmonds M, Peynenburg V, Kaldo V, Jernelöv S, Titov N, Dear B, Hadjistavropoulos H. Treating comorbid insomnia in patients enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial. Internet Interv 2024; 35:100729. [PMID: 38425505 PMCID: PMC10901846 DOI: 10.1016/j.invent.2024.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/10/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance. Patients were randomly assigned to receive either the Standard transdiagnostic (n = 75) or a Sleep-Enhanced course (n = 142), which included information on sleep restriction and stimulus control. Intent-to-treat analyses using generalized estimating equation (GEE) showed significant, large reductions in all primary outcomes (insomnia: d = 0.96, 95 % CI [0.68, 1.24]; depression: d = 1.04, 95 % CI [0.76, 1.33]; and anxiety: d = 1.23, 95 % CI [0.94, 1.52]) from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course (Cohen's d = 0.31, 95 % CI [0.034, 0.60]) at post-treatment but no significant between-group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines (p = .03), but not stimulus control instructions (p = .84) was associated with greater reductions in insomnia symptoms during the course. Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression.
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Affiliation(s)
- M. Edmonds
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - V. Peynenburg
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - V. Kaldo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, SE 14186 Stockholm, Sweden
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, SE 35195 Växjo, Sweden
| | - S. Jernelöv
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, SE 35195 Växjo, Sweden
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, SE 17177 Stockholm, Sweden
| | - N. Titov
- MindSpot Clinic, School of Psychological Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - B.F. Dear
- eCentreClinic, School of Psychological Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - H.D. Hadjistavropoulos
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
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Tse KYK, Maurer LF, Espie CA, Kyle SD. The effect of single-component sleep restriction therapy on depressive symptoms: A systematic review and meta-analysis. J Sleep Res 2024:e14180. [PMID: 38419123 DOI: 10.1111/jsr.14180] [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: 10/20/2023] [Revised: 01/19/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
Sleep restriction therapy is a behavioural component within cognitive behavioural therapy for insomnia and is an effective standalone treatment for insomnia, but its effect on depressive symptoms remains unclear. This review aimed to synthesise and evaluate the impact of single-component sleep restriction therapy on depressive symptoms relative to a control intervention. We searched electronic databases and sleep-related journals for randomised controlled trials and uncontrolled clinical trials, published from 1 January 1986 until 19 August 2023, that delivered sleep restriction therapy to adults with insomnia. Random-effects meta-analysis of standardised mean differences and Cochrane risk of bias assessment were performed on randomised controlled trials, while uncontrolled clinical trials were discussed narratively. The meta-analysis was pre-registered on PROSPERO (ID: CRD42020191803). We identified seven randomised controlled trials (N = 1102) and two uncontrolled clinical trials (N = 22). Findings suggest that sleep restriction therapy is associated with a medium effect for improvement in depressive symptoms at post-treatment (Nc = 6, g = -0.45 [95% confidence interval = -0.70 to -0.21], p < 0.001) and a small effect at follow-up (Nc = 4, g = -0.31 [95% confidence interval = -0.45 to -0.16], p < 0.001). Five of the seven included randomised controlled trials were judged to have a high risk of bias. Standalone sleep restriction therapy appears to be efficacious for improving depressive symptoms at post-treatment and follow-up. However, conclusions are tentative due to the small number of trials and because none of the trials was performed in a population with clinically defined depression. Large-scale trials are needed to test the effect of sleep restriction therapy in patients experiencing depression and insomnia. Findings also highlight the need to improve the standardisation and reporting of sleep restriction therapy procedures, and to design studies with more rigorous control arms to reduce potential bias.
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Affiliation(s)
- Katrina Yan Kei Tse
- Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Colin Alexander Espie
- Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Big Health Inc., San Francisco, California, USA
- Big Health Inc., London, UK
| | - Simon David Kyle
- Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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9
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Hinterberger A, Eigl ES, Schwemlein RN, Topalidis P, Schabus M. Investigating the subjective and objective efficacy of a cognitive behavioural therapy for insomnia (CBT-I)-based smartphone app on sleep: A randomised controlled trial. J Sleep Res 2023:e14136. [PMID: 38156655 DOI: 10.1111/jsr.14136] [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: 09/14/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
Due to insufficient treatment options for insomnia, effective solutions are urgently needed. We evaluated the effects of a CBT-I-based app combining sleep training with subjective and objective sleep monitoring on (i) sleep and (ii) subjective-objective sleep discrepancies (SOSD). Fifty-seven volunteers (20-76 years; MAge = 45.67 ± 16.38; 39 female) suffering from sleep problems were randomly assigned to an experimental group (EG, n = 28) or a waitlist control group (CG, n = 29). During the 6-week app phase, the EG used the CBT-I-based programme and a heart rate sensor for daily sleep monitoring and -feedback, while the CG used sleep monitoring only. Sleep was measured (i) subjectively via questionnaires (Insomnia Severity Index, ISI; Pittsburgh Sleep Quality Index, PSQI), (ii) objectively via ambulatory polysomnography (PSG), and (iii) continuously via heart-rate sensor and sleep diaries. Data revealed interactions for ISI (p = 0.003, ƞ2 part = 0.11) and PSQI (p = 0.050, ƞ2 part = 0.05), indicating training-specific improvements in EG, yet not in CG. While PSG-derived outcomes appear to be less training-specific, a tendential reduction in wake after sleep onset (WASO) was found in EG (p = 0.061, d = 0.55). Regarding changes in SOSD, the results indicate improvements during the app phase (EG) for sleep efficiency, sleep onset latency, and WASO (p ≤ 0.022, d ≥ 0.46); for total sleep time both groups showed a SOSD reduction. The findings indicate beneficial effects of a novel smartphone app on sleep and SOSD. More scientific evaluation of such digital programmes is needed to ultimately help in reducing the gap in non-pharmacological insomnia treatment.
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Affiliation(s)
- Alexandra Hinterberger
- Laboratory for Sleep, Cognition & Consciousness Research, University of Salzburg, Salzburg, Austria
| | - Esther-Sevil Eigl
- Laboratory for Sleep, Cognition & Consciousness Research, University of Salzburg, Salzburg, Austria
| | - Robyn Nina Schwemlein
- Laboratory for Sleep, Cognition & Consciousness Research, University of Salzburg, Salzburg, Austria
| | - Pavlos Topalidis
- Laboratory for Sleep, Cognition & Consciousness Research, University of Salzburg, Salzburg, Austria
| | - Manuel Schabus
- Laboratory for Sleep, Cognition & Consciousness Research, University of Salzburg, Salzburg, Austria
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, Salzburg, Austria
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10
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Freund W, Weber F. The Function of Sleep and the Treatment of Primary Insomnia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:863-870. [PMID: 37942822 PMCID: PMC10840130 DOI: 10.3238/arztebl.m2023.0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Approximately 21 900 women and 35 300 men developed lung cancer in Germany in 2018, and 16 999 women and 27 882 men died of it. The outcome mainly depends on the tumor stage. In early stages (stage I or II), treatment can be curative; unfortunately, because early-stage lung cancers are generally asymptom - atic, 74% of women and 77% of men already have advanced-stage disease (stage III or IV) at the time of diagnosis. Screening with low-dose computed tomography is an option enabling early diagnosis and curative treatment. METHODS This review is based on pertinent articles retrieved by a selective search of the literature on screening for lung cancer. RESULTS In the studies of lung cancer screening that have been published to date, sensitivity ranged from 68.5% to 93.8%, and specificity from 73.4% to 99.2%. A meta-analysis by the German Federal Office for Radiation Protection revealed a 15% reduction in lung cancer mortality when low-dose computed tomography was used in persons who were judged to be at high risk for lung cancer (risk ratio [RR] 0.85, 95% confidence interval [0.77; 0.95]). 1.9% of subjects died in the screening arm of the meta-analysis, and 2.2% in the control group. The observation periods ranged from 6.6 to 10 years; false-positive rates ranged from 84.9% to 96.4%. Malignant findings were confirmed in 45% to 70% of the biopsies or resective procedures that were performed. CONCLUSION Systematic lung cancer screening with low-dose CT lowers mortality from lung cancer in (current or former) heavy smokers. This benefit must be weighed against the high rate of false-positive findings and overdiagnoses.
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Affiliation(s)
- Wolfgang Freund
- Neurocenter Biberach
- Diagnostic and Interventional Radiology, Ulm University Hospital, Ulm
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11
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Manber R, Simpson N, Gumport NB. Perspectives on increasing the impact and reach of CBT-I. Sleep 2023; 46:zsad168. [PMID: 37903637 PMCID: PMC10710991 DOI: 10.1093/sleep/zsad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/06/2023] [Indexed: 11/01/2023] Open
Abstract
Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.
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Affiliation(s)
- Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Norah Simpson
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Nicole B Gumport
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
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12
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Benjet C, Albor Y, Alvis-Barranco L, Contreras-Ibáñez CC, Cuartas G, Cudris-Torres L, González N, Cortés-Morelos J, Gutierrez-Garcia RA, Medina-Mora ME, Patiño P, Vargas-Contreras E, Cuijpers P, Gildea SM, Kazdin AE, Kennedy CJ, Luedtke A, Sampson NA, Petukhova MV, Zainal NH, Kessler RC. Internet-delivered cognitive behavior therapy versus treatment as usual for anxiety and depression among Latin American university students: A randomized clinical trial. J Consult Clin Psychol 2023; 91:694-707. [PMID: 38032621 PMCID: PMC11078571 DOI: 10.1037/ccp0000846] [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] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Untreated mental disorders are important among low- and middle-income country (LMIC) university students in Latin America, where barriers to treatment are high. Scalable interventions are needed. This study compared transdiagnostic self-guided and guided internet-delivered cognitive behavioral therapy (i-CBT) with treatment as usual (TAU) for clinically significant anxiety and depression among undergraduates in Colombia and Mexico. METHOD 1,319 anxious, as determined by the Generalized Anxiety Disorder-7 (GAD-7) = 10+ and/or depressed, as determined by the Patient Health Questionnaire-9 (PHQ-9) = 10+, undergraduates (mean [SD] age = 21.4 [3.2]); 78.7% female; 55.9% first-generation university student) from seven universities in Colombia and Mexico were randomized to culturally adapted versions of self-guided i-CBT (n = 439), guided i-CBT (n = 445), or treatment as usual (TAU; n = 435). All randomized participants were reassessed 3 months after randomization. The primary outcome was remission of both anxiety (GAD-7 = 0-4) and depression (PHQ-9 = 0-4). We hypothesized that remission would be higher with guided i-CBT than with the other interventions. RESULTS Intent-to-treat analysis found significantly higher adjusted (for university and loss to follow-up) remission rates (ARD) among participants randomized to guided i-CBT than either self-guided i-CBT (ARD = 13.1%, χ12 = 10.4, p = .001) or TAU (ARD = 11.2%, χ12 = 8.4, p = .004), but no significant difference between self-guided i-CBT and TAU (ARD = -1.9%, χ12 = 0.2, p = .63). Per-protocol sensitivity analyses and analyses of dimensional outcomes yielded similar results. CONCLUSIONS Significant reductions in anxiety and depression among LMIC university students could be achieved with guided i-CBT, although further research is needed to determine which students would most likely benefit from this intervention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Corina Benjet
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Yesica Albor
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | | | | | - Gina Cuartas
- Facultad de Psicología, Universidad Cooperativa de Colombia, Medellin, Colombia
| | - Lorena Cudris-Torres
- Programa de Psicología, Fundación Universitaria del Area Andina, Valledupar, Colombia
| | - Noé González
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Jacqueline Cortés-Morelos
- Departamento de Psiquiatría y Salud Mental, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Maria Elena Medina-Mora
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Pamela Patiño
- Center for Global Mental Health, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Eunice Vargas-Contreras
- Facultad de Ciencias Administrativas y Sociales, Universidad Autónoma de Baja California, Ensenada, Mexico
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
- Babeș-Bolyai University, International Institute for Psychotherapy, Cluj-Napoca, Romania
| | - Sarah M. Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Alan E. Kazdin
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Chris J. Kennedy
- Center for Precision Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Maria V. Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Nur Hani Zainal
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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13
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Riemann D, Espie CA, Altena E, Arnardottir ES, Baglioni C, Bassetti CLA, Bastien C, Berzina N, Bjorvatn B, Dikeos D, Dolenc Groselj L, Ellis JG, Garcia-Borreguero D, Geoffroy PA, Gjerstad M, Gonçalves M, Hertenstein E, Hoedlmoser K, Hion T, Holzinger B, Janku K, Jansson-Fröjmark M, Järnefelt H, Jernelöv S, Jennum PJ, Khachatryan S, Krone L, Kyle SD, Lancee J, Leger D, Lupusor A, Marques DR, Nissen C, Palagini L, Paunio T, Perogamvros L, Pevernagie D, Schabus M, Shochat T, Szentkiralyi A, Van Someren E, van Straten A, Wichniak A, Verbraecken J, Spiegelhalder K. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res 2023; 32:e14035. [PMID: 38016484 DOI: 10.1111/jsr.14035] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 11/30/2023]
Abstract
Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).
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Affiliation(s)
- Dieter Riemann
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Health (Department), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
| | | | - Erna Sif Arnardottir
- Reykjavik University Sleep Institute, School of Technology, Reykjavik University, Reykjavik, Iceland
- Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Chiara Baglioni
- Human Sciences Department, University of Rome Guglielmo Marconi Rome, Rome, Italy
| | | | - Celyne Bastien
- École de Psychologie, Université Laval, Québec, Québec, Canada
| | | | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Dimitris Dikeos
- First Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Leja Dolenc Groselj
- Institute of Clinical Neurophysiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Jason G Ellis
- Northumbria Sleep Research Laboratory, Northumbria University, Newcastle, UK
| | | | | | | | | | - Elisabeth Hertenstein
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Kerstin Hoedlmoser
- Centre for Cognitive Neurosciences, University of Salzburg, Salzburg, Austria
| | - Tuuliki Hion
- East-Viru Central Hospital, Kohtla-Järve, Estonia
| | | | - Karolina Janku
- Center for Sleep and Chronobiology Research, National Institute of Mental Health, Klecany, Czech Republic
| | - Markus Jansson-Fröjmark
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Stockholm Health Care Services, Stockholm, Sweden
| | - Heli Järnefelt
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Susanna Jernelöv
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Stockholm Health Care Services, Stockholm, Sweden
| | - Poul Jørgen Jennum
- Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Samson Khachatryan
- Department of Neurology and Neurosurgery, Armenian National Institute of Health, Yerevan, Armenia
| | - Lukas Krone
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
- Department of Neurology, Inselspital, University of Bern, Berne, Switzerland
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
| | - Jaap Lancee
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Damien Leger
- Université Paris Cité, APHP, Hôtel Dieu de Paris, Centre du Sommeil et de la Vigilance, Paris, France
| | - Adrian Lupusor
- Functional Neurology, Institute of Neurology and Neurosurgery, Chisinau, Moldova
| | - Daniel Ruivo Marques
- Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
- CINEICC - Center for Research in Neuropsychology and Cognitive Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Christoph Nissen
- Department of Psychiatry, University Hospital Geneve, Geneve, Switzerland
| | - Laura Palagini
- Psychiatry Unit, Department of Clinical and Experimental Medicine, School of Medicine, University of Pisa, Pisa, Italy
| | - Tiina Paunio
- Department of Psychiatry and SleepWell Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Dirk Pevernagie
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Manuel Schabus
- Centre for Cognitive Neurosciences, University of Salzburg, Salzburg, Austria
| | - Tamar Shochat
- The Cheryl Spencer Institute of Nursing Research, University of Haifa, Haifa, Israel
| | - Andras Szentkiralyi
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Eus Van Someren
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- Departments of Integrative Neurophysiology and Psychiatry, Center for Neurogenomics and Cognitive Research, Amsterdam UMC, Amsterdam Neuroscience, VU University, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro- and Developmental Psychology & Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Adam Wichniak
- Sleep Medicine Center and Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Kai Spiegelhalder
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Health (Department), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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14
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Baglioni C, Espie CA, Altena E, Gavriloff D, Jernelöv S, Holzinger B, Schlarb A, Riemann D. Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model. J Sleep Res 2023; 32:e14016. [PMID: 37584390 DOI: 10.1111/jsr.14016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 08/17/2023]
Abstract
Despite cognitive behaviour therapy for insomnia (CBT-I) being the first-line intervention for the disorder, it is often not readily available to patients in need. The stepped care model (SCM) represents an approach to facilitating efficient and wide-ranging provision of evidence-based care to those with insomnia. The SCM reflects a pyramid of therapeutics based on CBT-I gradually increasing in clinical intensity and addressing clinical complexity. By applying CBT-I through the SCM it is hoped that the treatment gap can be bridged such that not only more patients can be reached, but that clinical resource can be more effectively distributed, with patients receiving more tailored care as needed. Nevertheless, this should not be done at the risk of a lower quality of care being offered, and high-standard training for clinicians and scrutiny of non-clinician led interventions remains important. As national health laws within European countries have substantial differences, the application of the SCM as it relates to the treatment of insomnia may be challenged by contrasting interpretations. In order that the SCM is appropriately implemented: (a) only evidence-based CBT-I treatments should be promoted within the model; (b) clinicians involved in SCM should be suitably qualified to offer CBT in general, and have appropriate further training in CBT-I; (c) professionals involved in interventions not included in the SCM, but related to it, such as preventive and educational programmes, diagnostic procedures, and pharmacological treatments, should also have good knowledge of the SCM in order to promote correct allocation to the appropriate interventional step.
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Affiliation(s)
- Chiara Baglioni
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Department of Human Sciences, Guglielmo Marconi University, Rome, Italy
| | - Colin A Espie
- Sir Jules Thorne Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
| | | | - Dimitri Gavriloff
- Sir Jules Thorne Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
| | - Susanna Jernelöv
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Angelika Schlarb
- Department of Psychology and Sports Science, University of Bielefeld, Bielefeld, Germany
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
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15
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Jernelöv S, Blom K. Training of professionals in cognitive behavioural therapy for insomnia - A systematic review of peer-reviewed studies. J Sleep Res 2023; 32:e14024. [PMID: 37610075 DOI: 10.1111/jsr.14024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023]
Abstract
Insomnia is common, and causes substantial individual suffering and costs for society. The recommended first-line treatment is cognitive behavioural therapy for insomnia (CBT-I), which is under-used partly due to a lack of trained providers. To train providers is thus important, but what is the current situation regarding CBT-I training? A systematic search of databases was conducted to identify scientific peer-reviewed papers describing CBT-I training with regards to: existing amounts of training, proposed curricula, trainees, delivery context, content of training, modes of delivery, evaluation of the training from a trainee perspective, and effects on patients. This systematic review shows that research on training in CBT-I is an emerging field, with the literature presenting a limited number of papers, with varying objectives. One group of papers investigate the amount of training that exists in a region or educational context and/or propose training curricula; and another group evaluate training initiatives and describe CBT-I training trainees, context, content, modes of delivery, and outcomes on trainees and on treated patients. The studies show that little training is currently provided and proposed curricula vary, and evaluations present promising results: training is feasible in different contexts and modes, digital training may be used to disseminate training efforts at a large scale, trainees' skills increase and positive effects on patients can be seen. To move the field forward, more high-quality studies on CBT-I training are needed, and we propose that training in CBT-I should be targeted towards varying levels of expertise, matching a stepped-care model.
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Affiliation(s)
- Susanna Jernelöv
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | - Kerstin Blom
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
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16
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Nazem S, Barnes SM, Forster JE, Hostetter TA, Monteith LL, Kramer EB, Gaeddert LA, Brenner LA. Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial. JMIR Ment Health 2023; 10:e50516. [PMID: 37999953 DOI: 10.2196/50516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans. OBJECTIVE The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans. METHODS We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters. RESULTS Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported. CONCLUSIONS Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach. TRIAL REGISTRATION ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.
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Affiliation(s)
- Sarra Nazem
- Dissemination & Training Division, National Center for Posttraumatic Stress Disorder, Menlo Park, CA, United States
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Sean M Barnes
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jeri E Forster
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Trisha A Hostetter
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lindsey L Monteith
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Emily B Kramer
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Laurel A Gaeddert
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lisa A Brenner
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Eigl ES, Hauser T, Topalidis PI, Schabus M. On the Efficacy of a CBT-I-Based Online Program for Sleep Problems: A Randomized Controlled Trial. Clocks Sleep 2023; 5:590-603. [PMID: 37873840 PMCID: PMC10594462 DOI: 10.3390/clockssleep5040039] [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: 08/31/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/25/2023] Open
Abstract
There is an urgent need for easily accessible treatment options for sleep problems to reduce the current treatment gap in receiving cognitive behavioral therapy for insomnia (CBT-I). Using a randomized controlled trial, we evaluated the efficacy of a CBT-I-based online program on sleep. Fifty-three volunteers (21-71 years; MAge = 44.6 ± 12.5; 27 female) suffering from impaired sleep were randomly allocated either to the experimental group (EG, n = 27) or to an active control group (CG, n = 26). The EG participated in a 6-week CBT-I-based online program, while the CG received psychoeducation and sleep hygiene instructions. Sleep was assessed both objectively via ambulatory polysomnography (PSG) as well as subjectively via questionnaires at three time points (baseline, pre- and post-intervention). A one-month follow-up assessment was performed using questionnaires. The EG showed small but reliable improvements from pre- to post-intervention in PSG-derived wake after sleep onset (from 58.6 min to 42.5 min; p < 0.05) and sleep efficiency (from 86.0% to 89.2%; p < 0.05). Furthermore, subjective sleep quality (assessed via Pittsburgh Sleep Quality Index) improved significantly during intervention (p = 0.011) and follow-up (p = 0.015) in the EG alone. The Insomnia Severity Index decreased from pre- to post-intervention in both groups (EG: p = 0.003, CG: p = 0.008), while it further improved during follow-up (p = 0.035) in the EG alone. We show that a CBT-I-based online program can improve sleep not only subjectively but also objectively and can be a viable alternative when face-to-face interventions are not available.
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Affiliation(s)
- Esther-Sevil Eigl
- Laboratory for Sleep, Cognition & Consciousness Research, Department of Psychology, Paris-Lodron University of Salzburg, 5020 Salzburg, Austria; (E.-S.E.)
| | - Theresa Hauser
- Laboratory for Sleep, Cognition & Consciousness Research, Department of Psychology, Paris-Lodron University of Salzburg, 5020 Salzburg, Austria; (E.-S.E.)
| | - Pavlos I. Topalidis
- Laboratory for Sleep, Cognition & Consciousness Research, Department of Psychology, Paris-Lodron University of Salzburg, 5020 Salzburg, Austria; (E.-S.E.)
| | - Manuel Schabus
- Laboratory for Sleep, Cognition & Consciousness Research, Department of Psychology, Paris-Lodron University of Salzburg, 5020 Salzburg, Austria; (E.-S.E.)
- Centre for Cognitive Neuroscience Salzburg (CCNS), Paris-Lodron University of Salzburg, 5020 Salzburg, Austria
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18
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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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19
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van Straten A, van Trigt S, Lancee J. How to boost implementation for insomnia treatment in primary care? Lancet 2023; 402:940-941. [PMID: 37573860 DOI: 10.1016/s0140-6736(23)01040-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/11/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Annemieke van Straten
- Department of Clinical, Neuro, and Developmental psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
| | - Shanna van Trigt
- Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, Netherlands
| | - Jaap Lancee
- Department of Psychiatry and Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
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