Telemedicine versus face-to-face delivery of cognitive behavioral therapy for insomnia: a randomized controlled noninferiority trial

Perpetuating and protective factors in insomnia across racial/ethnic groups of veterans

Few studies have examined racial/ethnic differences in rates and correlates of insomnia among veterans. This study compared rates of insomnia and interest in sleep treatment among veterans of diverse racial/ethnic backgrounds. Consistent with the 3P model, we tested racial discrimination as a predictor of insomnia, with post-traumatic stress disorder symptoms and romantic partners as perpetuating and protective moderators of this association, respectively. A total of 325 veterans (N = 236 veterans of colour; 12% Asian, 36% Black, 14% Hispanic/Latine) completed questionnaires online from remote locations. Descriptive statistics were used to compare patterns across racial/ethnic groups. Linear regression was used to test moderators of the association between racial discrimination and insomnia severity. Overall, 68% of participants screened positive for insomnia: 90% of Asian; 79% of Hispanic/Latine; 65% of Black; and 58% of White participants. Of those, 74% reported interest in sleep treatment, and 76% of those with partners reported interest in including their partner in treatment. Racial discrimination and post-traumatic stress disorder were correlated with more severe insomnia, while romantic partners were correlated with less severe insomnia. Only post-traumatic stress disorder moderated the association between racial discrimination and insomnia severity. Rates of insomnia were highest among Asian and Hispanic/Latine participants, yet these groups were among the least likely to express interest in sleep treatment. Racial discrimination may exacerbate insomnia symptoms among veterans, but only among those who do not already have disturbed sleep in the context of post-traumatic stress disorder. Romantic partners may serve as a protective factor in insomnia, but do not seem to mitigate the impact of racial discrimination.

Insomnia symptoms and related factors in a community-based population: The Yamagata Cohort study

Objective/background

Insomnia is prevalent and is a risk factor for the development of lifestyle-related diseases and early death. To improve insomnia, it is necessary to identify the factors that affect it. This study investigated the associations between insomnia symptoms and mental, physical, and environmental factors in the general Japanese population.

Patients/methods

The study participants were 7,873 individuals who responded to the Health and Lifestyle Survey questionnaire that included sleep-related items between December 2021 and March 2022. Insomnia symptoms were defined as a score of 6 or higher on the Athens Insomnia Scale (AIS). A multivariate logistic regression analysis was performed to identify factors independently associated with insomnia symptoms.

Results

Of all subjects, 23.4% had insomnia symptoms. Factors associated with insomnia symptoms were older age, female sex, very difficult living conditions on current income, pain/discomfort, anxiety, lack of happiness, frequent nocturia, long duration from bathing time to bedtime, bedroom lighting, and short walking duration. The subgroup analysis showed stronger associations between walking time in men, higher body mass index in women, time from bathing time to bedtime, and daily walking duration in older adults.

Conclusions

Insomnia symptoms were common in community-based populations and were independently associated with three different factor groups including physical, psychological, and environmental factors. Improvements in insomnia symptoms require appropriate practical support tailored to an individual's situation.

Digital consults to optimize guideline-directed therapy: design of a pragmatic multicenter randomized controlled trial

AIMS

Many heart failure (HF) patients do not receive optimal guideline-directed medical therapy (GDMT) despite clear benefit on morbidity and mortality outcomes. Digital consults (DCs) have the potential to improve efficiency on GDMT optimization to serve the growing HF population. The investigator-initiated ADMINISTER trial was designed as a pragmatic multicenter randomized controlled open-label trial to evaluate efficacy and safety of DC in patients on HF treatment.

METHODS AND RESULTS

Patients (n = 150) diagnosed with HF with a reduced ejection fraction will be randomized to DC or standard care (1:1). The intervention group receives multifaceted DCs including (i) digital data sharing (e.g. exchange of pharmacotherapy use and home-measured vital signs), (ii) patient education via an e-learning, and (iii) digital guideline recommendations to treating clinicians. The consults are performed remotely unless there is an indication to perform the consult physically. The primary outcome is the GDMT prescription rate score, and secondary outcomes include time till full GDMT optimization, patient and clinician satisfaction, time spent on healthcare, and Kansas City Cardiomyopathy Questionnaire. Results will be reported in accordance to the CONSORT statement.

CONCLUSIONS

The ADMINISTER trial will offer the first randomized controlled data on GDMT prescription rates, time till full GDMT optimization, time spent on healthcare, quality of life, and patient and clinician satisfaction of the multifaceted patient- and clinician-targeted DC for GDMT optimization.

The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis

Comorbid insomnia and sleep apnoea (COMISA) is a highly prevalent and debilitating sleep disorder. Cognitive behavioural therapy for insomnia (CBTi) may be an appropriate treatment for COMISA; however, no previous study has systematically reviewed and meta-analysed literature reporting on the effect of CBTi in people with COMISA. A systematic literature search was conducted across PsychINFO and PubMed (n = 295). In all, 27 full-text records were independently reviewed by at least two authors. Forward- and backward-chain referencing, and hand-searches were used to identify additional studies. Authors of potentially eligible studies were contacted to provide COMISA subgroup data. In total, 21 studies, including 14 independent samples of 1040 participants with COMISA were included. Downs and Black quality assessments were performed. A meta-analysis including nine primary studies measuring the Insomnia Severity Index indicated that CBTi is associated with a large improvement in insomnia severity (Hedges' g = -0.89, 95% confidence interval [CI] -1.35, -0.43). Subgroup meta-analyses indicated that CBTi is effective in samples with untreated obstructive sleep apnoea (OSA) (five studies, Hedges' g = -1.19, 95% CI -1.77, -0.61) and treated OSA (four studies, Hedges' g = -0.55, 95% CI -0.75, -0.35). Publication bias was evaluated by examining the Funnel plot (Egger's regression p = 0.78). Implementation programmes are required to embed COMISA management pathways in sleep clinics worldwide that currently specialise in the management of OSA alone. Future research should investigate and refine CBTi interventions in people with COMISA, including identifying the most effective CBTi components, adaptations, and developing personalised management approaches for this highly prevalent and debilitating condition.

Comparison of Telehealth and In-Person Behavioral Health Services and Payment in a Large Rural Multisite Usual Care Study

Background: Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods: We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results: We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions: Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others.

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association

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.

Effect of cognitive behavioral therapy for insomnia in workers: A systematic review and meta-analysis of randomized controlled trials

Although cognitive behavioral therapy for insomnia (CBT-I) is recommended as a first-line treatment, its efficacy for workers with insomnia remains unclear. This systematic review and meta-analysis aimed to determine the effectiveness of CBT-I in the management of insomnia symptoms in workers. We searched the literature in three electronic databases, namely PubMed, PsycINFO, and Embase, and included 21 studies in the meta-analysis. Compared with the control group, CBT-I overall resulted in significant improvements in terms of severity of insomnia (g = -0.91), sleep onset latency (g = -0.62), wakefulness after sleep onset (g = -0.60), early morning awakening (g = -0.58), and sleep efficiency (g = 0.71). However, there was no improvement in the total sleep time relative to that in the control group. Furthermore, CBT-I significantly alleviated depressive (g = -0.37) and anxiety (g = -0.35) symptoms and fatigue (g = -0.47) compared with the control group. Our study findings suggest that both web-based and face-to-face CBT-I are effective interventions for managing insomnia symptoms in daytime workers, although it is important to note that only face-to-face CBT-I achieved clinically meaningful changes. The effectiveness of CBT-I for shift workers could not be determined.

A non-pharmacological multi-modal therapy to improve sleep and cognition and reduce mild cognitive impairment risk: Design and methodology of a randomized clinical trial

Aging populations are at increased risk of sleep deficiencies (e.g., insomnia) that are associated with a variety of chronic health risks, including Alzheimer's disease and related dementias (ADRD). Insomnia medications carry additional risk, including increased drowsiness and falls, as well as polypharmacy risks. The recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBTi), but access is limited. Telehealth is one way to increase access, particularly for older adults, but to date telehealth has been typically limited to simple videoconferencing portals. While these portals have been shown to be non-inferior to in-person treatment, it is plausible that telehealth could be significantly improved. This work describes a protocol designed to evaluate whether a clinician-patient dashboard inclusive of several user-friendly features (e.g., patterns of sleep data from ambulatory devices, guided relaxation resources, and reminders to complete in-home CBTi practice) could improve CBTi outcomes for middle- to older-aged adults (N = 100). Participants were randomly assigned to one of three telehealth interventions delivered through 6-weekly sessions: (1) CBTi augmented with a clinician-patient dashboard, smartphone application, and integrated smart devices; (2) standard CBTi (i.e., active comparator); or (3) sleep hygiene education (i.e., active control). All participants were assessed at screening, pre-study evaluation, baseline, throughout treatment, and at 1-week post-treatment. The primary outcome is the Insomnia Severity Index. Secondary and exploratory outcomes span sleep diary, actiwatch and Apple watch assessed sleep parameters (e.g., efficiency, duration, timing, variability), psychosocial correlates (e.g., fatigue, depression, stress), cognitive performance, treatment adherence, and neurodegenerative and systemic inflammatory biomarkers.

Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study

BACKGROUND

Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP.

OBJECTIVE

This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes.

METHODS

We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes.

RESULTS

The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising.

CONCLUSIONS

Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.

Insomnia

OBJECTIVE

This article provides an overview of the current definitions, diagnostic tools, and overall management of insomnia.

LATEST DEVELOPMENTS

The treatment of insomnia has shifted over time, with a growing emphasis on nonpharmacologic therapies as a first-line intervention and the leveraging of technology to aid in the dissemination of these therapies. With this evolution, the definition of insomnia has changed to reflect a common treatment pathway. As pharmacologic treatment options have increased, so has concern about the dangerous short-term and long-term adverse effects of these treatment options.

ESSENTIAL POINTS

Insomnia is a common disorder, frequently overlapping with other neurologic and psychiatric disorders, which can cause significant distress and disruption to patients' lives. Nonpharmacologic therapies are highly effective and are now considered first-line treatments. Although efficacy is variable, numerous pharmacologic interventions are available, and many options come with considerable concern about adverse effects, particularly in populations over 65 years old.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy

OBJECTIVES

Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal.

METHODS

A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale.

RESULTS

Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components.

CONCLUSION

Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression.

CLINICALTRIALS

GOV ID

NCT04443959.

In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia disorder. The goal of this study was to evaluate clinical benefits of CBT-I to veterans with insomnia disorder during the early months of the COVID-19 pandemic using an uncontrolled observational design.

METHODS

A cohort of 63 Veterans Affairs (VA) mental health providers delivered CBT-I to 180 veterans as part of an evidence-based psychotherapy training program and captured de-identified treatment outcome data through a data portal. The main patient outcomes were change in the Insomnia Severity Index (ISI) total score from the initial clinical assessment session to the last treatment session, response rate (% with ISI change > 7 from assessment to last session), and remission rate (% with ISI < 8 at the last session). We tested the noninferiority of telehealth only compared with at least 1 in-person session.

RESULTS

Fifty-six percent of veterans seen for an evaluation completed CBT-I treatment during the structured training program phase and completed an initial and final ISI. Among these veterans, ISI scores decreased by an average of 9.9 points from before to after treatment (P < .001), 66% experienced a clinically meaningful treatment response, and 43% experienced insomnia symptom remission. Benefits were similar whether the veteran received some in-person care or received CBT-I entirely via telehealth.

CONCLUSIONS

Findings suggest, regardless of treatment modality, CBT-I remained highly effective during the early months of the pandemic, which was a challenging time for both clinical providers and veterans in need of insomnia treatment.

CITATION

Martin JL, DeViva J, McCarthy E, et al. In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. J Clin Sleep Med. 2023;19(7):1211-1217.

Improving Sleep Health Among Refugees: A Systematic Review

Purpose of Review

Sleep disorders among refugees are common yet understudied. Interventions are difficult in resource-limited settings where most of these populations live. A systematic review of sleep disorders in refugee populations is warranted to identify prevalence, comorbidities, and the limitations of the current state of sleep health among refugees.

Recent Findings

Sleep disturbances, particularly insomnia and nightmares, occur with a higher prevalence among refugees. Diseases associated with insomnia in this population included fibromyalgia, posttraumatic stress disorder, depression, and anxiety. Risk factors include trauma, migration, lower socioeconomic status, lower educational level, and settlement in areas with a high influx of new residents or proximity to conflict. Only a few partially successful therapies were identified.

Summary

This review identifies the high prevalence of the disturbed sleep in this population and its risk factors. It proposes ways of increasing awareness of it in this vulnerable population as a first step toward remediation.

eHealth-Based Psychosocial Interventions for Adults With Insomnia: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Worldwide, insomnia remains a highly prevalent public health problem. eHealth presents a novel opportunity to deliver effective, accessible, and affordable insomnia treatments on a population-wide scale. However, there is no quantitative integration of evidence regarding the effectiveness of eHealth-based psychosocial interventions on insomnia.

OBJECTIVE

We aimed to evaluate the effectiveness of eHealth-based psychosocial interventions for insomnia and investigate the influence of specific study characteristics and intervention features on these effects.

METHODS

We searched PubMed, Embase, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials from database inception to February 16, 2021, for publications investigating eHealth-based psychosocial interventions targeting insomnia and updated the search of PubMed to December 6, 2021. We also screened gray literature for unpublished data. Eligible studies were randomized controlled trials of eHealth-based psychosocial interventions targeting adults with insomnia. Random-effects meta-analysis models were used to assess primary and secondary outcomes. Primary outcomes were insomnia severity and sleep quality. Meta-analyses were performed by pooling the effects of eHealth-based psychosocial interventions on insomnia compared with inactive and in-person conditions. We performed subgroup analyses and metaregressions to explore specific factors that affected the effectiveness. Secondary outcomes included sleep diary parameters and mental health-related outcomes.

RESULTS

Of the 19,980 identified records, 37 randomized controlled trials (13,227 participants) were included. eHealth-based psychosocial interventions significantly reduced insomnia severity (Hedges g=-1.01, 95% CI -1.12 to -0.89; P<.001) and improved sleep quality (Hedges g=-0.58, 95% CI -0.75 to -0.41; P<.001) compared with inactive control conditions, with no evidence of publication bias. We found no significant difference compared with in-person treatment in alleviating insomnia severity (Hedges g=0.41, 95% CI -0.02 to 0.85; P=.06) and a significant advantage for in-person treatment in enhancing sleep quality (Hedges g=0.56, 95% CI 0.24-0.88; P<.001). eHealth-based psychosocial interventions had significantly larger effects (P=.01) on alleviating insomnia severity in clinical samples than in subclinical samples. eHealth-based psychosocial interventions that incorporated guidance from trained therapists had a significantly greater effect on insomnia severity (P=.05) and sleep quality (P=.02) than those with guidance from animated therapists or no guidance. Higher baseline insomnia severity and longer intervention duration were associated with a larger reduction in insomnia severity (P=.004). eHealth-based psychosocial interventions significantly improved each secondary outcome.

CONCLUSIONS

eHealth interventions for insomnia are effective in improving sleep and mental health and can be considered a promising treatment for insomnia. Our findings support the wider dissemination of eHealth interventions and their further promotion in a stepped-care model. Offering blended care could improve treatment effectiveness. Future research needs to elucidate which specific intervention components are most important to achieve intervention effectiveness. Blended eHealth interventions may be tailored to benefit people with low socioeconomic status, limited access to health care, or lack of eHealth literacy.

Group Cognitive Behavioural Therapy for Non-Rapid Eye Movement Parasomnias: Long-Term Outcomes and Impact of COVID-19 Lockdown

Prior to the COVID-19 pandemic, we demonstrated the efficacy of a novel Cognitive Behavioural Therapy programme for the treatment of Non-Rapid Eye Movement Parasomnias (CBT-NREMP) in reducing NREM parasomnia events, insomnia and associated mood severities. Given the increased prevalence and worsening of sleep and affective disorders during the pandemic, we examined the sustainability of CBT-NREMP following the U.K.'s longest COVID-19 lockdown (6 January 2021-19 July 2021) by repeating the investigations via a mail survey in the same 46 patient cohort, of which 12 responded. The survey included validated clinical questionnaires relating to NREM parasomnia (Paris Arousal Disorder Severity Scale), insomnia (Insomnia Severity Index) and anxiety and depression (Hospital Anxiety and Depression Scale). Patients also completed a targeted questionnaire (i.e., Impact of COVID-19 Lockdown Questionnaire, ICLQ) to assess the impact of COVID-19 lockdown on NREM parasomnia severity, mental health, general well-being and lifestyle. Clinical measures of NREM parasomnia, insomnia, anxiety and depression remained stable, with no significant changes demonstrated in questionnaire scores by comparison to the previous investigatory period prior to the COVID-19 pandemic: p (ISI) = 1.0; p (HADS) = 0.816; p (PADSS) = 0.194. These findings support the longitudinal effectiveness of CBT-NREMP for up to three years following the clinical intervention, and despite of the COVID-19 pandemic.

Stress and the hypothalamic-pituitary-adrenal axis: How can the COVID-19 pandemic inform our understanding and treatment of acute insomnia?

Stress and sleep are very closely linked, and stressful life events can trigger acute insomnia. The ongoing COVID-19 pandemic is highly likely to represent one such stressful life event. Indeed, a wide range of cross-sectional studies demonstrate that the pandemic is associated with poor sleep and sleep disturbances. Given the high economic and health burden of insomnia disorder, strategies that can prevent and treat acute insomnia, and also prevent the transition from acute insomnia to insomnia disorder, are necessary. This narrative review outlines why the COVID-19 pandemic is a stressful life event, and why activation of the hypothalamic-pituitary-adrenal axis, as a biological marker of psychological stress, is likely to result in acute insomnia. Further, this review outlines how sleep disturbances might arise as a result of the COVID-19 pandemic, and why simultaneous hypothalamic-pituitary-adrenal axis measurement can inform the pathogenesis of acute insomnia. In particular, we focus on the cortisol awakening response as a marker of hypothalamic-pituitary-adrenal axis function, as cortisol is the end-product of the hypothalamic-pituitary-adrenal axis. From a research perspective, future opportunities include identifying individuals, or particular occupational or societal groups (e.g. frontline health staff), who are at high risk of developing acute insomnia, and intervening. From an acute insomnia treatment perspective, priorities include testing large-scale online behavioural interventions; examining if reducing the impact of stress is effective and, finally, assessing whether "sleep vaccination" can maintain good sleep health by preventing the occurrence of acute insomnia, by preventing the transition from acute insomnia to insomnia disorder.

Comparative efficacy of onsite, digital, and other settings for cognitive behavioral therapy for insomnia: a systematic review and network meta-analysis

Given the limited availability and accessibility of onsite cognitive behavioral therapy for insomnia (CBT-I), other CBT-I settings, such as internet-delivered CBT-I (iCBT-I), have been proposed. The primary aim of the study was to compare the efficacy of available CBT-I settings on insomnia severity. A systematic review and frequentist network meta-analysis of available CBT-I settings was performed. PsycINFO, PsycARTICLES, MEDLINE, PubMed, and CINAHL were searched for randomized controlled trials (RCTs) investigating any CBT-I settings in adults with insomnia disorder. The systematic literature search (3851 references) resulted in 52 RCTs. For the primary outcome insomnia severity, all examined CBT-I settings except smartphone-delivered CBT-I yielded significant effects when compared to WL. Large standardized mean differences were found for individual onsite CBT-I (- 1.27;95%CI - 1.70, - 0.84), group-delivered CBT-I (- 1.00;95%CI - 1.42. - 0.59), telehealth (- 1.28;95%CI - 2.06, - 0.50), and guided bibliotherapy (- 0.99;95%CI - 1.67, - 0.32). Both guided iCBT-I (- 0.71;95%CI - 1.18, - 0.24) and unguided iCBT-I (- 0.78;95%CI - 1.18, - 0.38) yielded medium effect sizes. The results underline that health care systems should intensify their efforts to provide synchronously-delivered CBT-I (individual onsite, group-delivered, and telehealth), and particularly individual onsite CBT-I, given its solid evidence base. Medium to large effect sizes for iCBT-I and guided bibliotherapy indicate that self-help settings may be a viable alternative when synchronously-delivered CBT-I is not available.

Cereset Research Standard Operating Procedures for Insomnia: A Randomized, Controlled Clinical Trial

Background

Interventions for insomnia that also address autonomic dysfunction are needed.

Objective

We evaluate Cereset Research™ Standard Operating Procedures (CR-SOP) in a pilot randomized, controlled trial. CR-SOP is a less operator-dependent, more generalizable innovation of HIRREM^®, a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology demonstrated to improve insomnia and autonomic function.

Methods

Adults with Insomnia Severity Index (ISI) scores of ≥8 were randomized to receive ten sessions of CR-SOP, with tones linked to brainwaves (LB, intervention), or a sham condition of random tones not linked to brainwaves (NL, control). Measures were collected at enrollment and 0-14 days and 4-6 weeks post-allocated intervention. The primary outcome was differential change in ISI from baseline to 4-6 weeks post-intervention. Secondary self-report measures assessed sleep quality65 and behavioral outcomes. Ten-minute recordings of heart rate and blood pressure were collected to analyze autonomic function (heart rate variability [HRV] and baroreflex sensitivity).

Results

Of 22 randomized, 20 participants completed the allocated condition. Intention to treat analysis of change from baseline to the 4-6 week outcome demonstrated mean ISI score reduction of 4.69 points among controls (SE 1.40). In the intervention group, there was an additional 2.58 point reduction in ISI score (SE 2.13; total reduction of 7.27, P = .24). Sleep quality and some measures of autonomic function improved significantly among the intervention group compared to control.

Conclusions

This pilot study compared use of a standardized, allostatic, acoustic neurotechnology intervention with a sham, active control condition. The magnitude of change in insomnia severity was clinically relevant and similar to the findings in a prior, fully powered trial, but the differential improvement observed was not statistically significant. Significant improvements were demonstrated in sleep quality and some autonomic function measures.

Integrating technology to increase the reach of CBT-I: state of the science and challenges ahead

In this Round Table Discussion, an international panel of experts discuss issues related to the use of technology in the delivery of cognitive behavioral therapy for insomnia (CBT-I), in order to increase its reach. Panelists were, in alphabetical order, Carmela Alcántara, PhD, an Associate Professor at Columbia University School of Social Work in New York, USA, Bei Bei, PhD., an Associate Professor at Monash University in Melbourne, Australia, Charles M. Morin, PhD., a Professor of Psychology at Laval University in Quebec City, Canada, and Annemieke A. van Straten, PhD., a Professor of Clinical Psychology at the Vrije Universiteit in Amsterdam, the Netherlands. The session was chaired by Rachel Manber, PhD., a Professor of Psychiatry and Behavioral Sciences at Stanford University, in Palo Alto, California, USA. In their introductions each panelist discussed the use of technology in their respective country. All indicated that the most common way technology is used in the treatment of insomnia is through the use of video calls (telemedicine) to deliver individual CBT-I, and that this is mostly covered by publicly funded health insurance programs such as Medicare, especially since the COVID-19 pandemic. There are also some fully automated insomnia treatment programs, but they're often not covered by Medicare or other health insurance programs.

Adapting Group CBT-I for Telehealth-to-Home With Military Veterans in Primary Care

Utilization of telehealth modalities to provide cognitive and behavioral therapies is rapidly increasing. Limitations to access to care can prohibit individuals from getting the care they need, especially evidence-based treatments. In the U.S., Veterans are a population in great need of accessible and high-quality evidence-based psychotherapy for insomnia, as it often co-occurs with other common syndromes such as depression and PTSD. Cognitive Behavioral Therapy for Insomnia (CBT-I) offers effective treatment for insomnia and can be delivered via telehealth and in a group format to greatly increase availability and accessibility. To date, however, few programs exist offering telehealth-to-home CBT-I, fewer still are offered in a primary care setting, and none to our knowledge are offered in group format. We examine the feasibility and efficacy of a fully telehealth-to-home (TTH) group CBT-I pilot program in primary care and compare primary outcomes to those seen in a face-to-face (F2F) format as well as meta-analytic studies of group CBT-I. Primary endpoints, as typically defined such as sleep efficiency (SE) and scores on the insomnia severity index (ISI) appear comparable to those seen in F2F groups in our clinic, and to outcomes seen in the literature. We discuss challenges and strategies for successful implementation of such a program in integrated primary care to increase access and availability of this evidence-based treatment.

Credibility and expectancy of smartphone-based cognitive behavioral therapy among adults with body dysmorphic disorder

BACKGROUND

Few patients receive cognitive behavioral therapy, the gold-standard for body dysmorphic disorder (CBT-BDD). Smartphones can make evidence-based interventions, like CBT-BDD, more accessible and scalable. A key question is: how do patients view it? Low credibility and expectancy would likely translate to low uptake and engagement outside of research settings, diminishing the impact. Thus, it is important to understand patients' beliefs about digital CBT-BDD.

METHODS

We compared credibility and expectancy in a coach-guided app-based CBT-BDD trial (N=75) to a previous in-person CBT-BDD trial (N = 55). We further examined the relationship of perceptions of digital CBT-BDD to baseline clinical and demographic factors and dropout.

RESULTS

Credibility did not differ between the in-person (M=19.3) and digital (M=18.3) trials, p=.24. Expectancy for improvement was moderately higher for in-person (M=58.4) than digital (M=48.3) treatment, p=.005. In the digital trial, no demographic variables were associated with credibility or expectancy. Better BDD-related insight and past non-CBT BDD therapy were associated with greater expectancy. Credibility was associated with lower likelihood of dropout.

DISCUSSION

Digital CBT-BDD was regarded as similarly credible to in-person CBT-BDD but with lower expectancy. Tailored expectancy-enhancing strategies could strengthen this novel approach, particularly among those with poorer insight and without prior BDD treatment.

Sleep and mental health in pregnancy during COVID-19: A parallel process growth model

Objectives

Pregnancy is associated with elevated risk for poor sleep quality, which increases the risk for poor obstetrical outcomes and parent mental health problems. The COVID-19 pandemic has seen increased reports of disturbed sleep worldwide; however, the degree this extends to pregnancy or influences pregnancy mental health outcomes has not been examined. The goal of this study was to examine changes in pregnant individuals’ sleep, anxiety, and depression during the pandemic, and to understand how sleep was associated with symptoms of anxiety and depression over time.

Methods

The Pregnancy During the COVID-19 Pandemic (PdP) study is a prospective longitudinal cohort of pregnant individuals (at enrollment) with repeated follow-ups during pregnancy and the postpartum period. About 3747 pregnant individuals participated between April and July 2020. The present analysis was restricted to participants who completed at least 2 assessments, yielding a final sample of 1842 pregnant individuals.

Results

Depression symptoms were elevated at baseline, compared to prepandemic estimates of prevalence, but declined gradually over time. Shorter sleep duration, higher sleep disturbance, and more sleep-related impairments at baseline predicted a slower decline in depression symptoms over time. More sleep disturbances at baseline also predicted slower decline in anxiety symptoms over time. In contrast, rates of depression and anxiety symptoms at baseline were not predictive of changes in any of the 3 sleep variables over time.

Conclusions

These findings highlight the importance of early intervention for sleep problems in pregnancy, in order to optimize mental health throughout pregnancy and mitigate long-term negative outcomes.

Mindfulness-based Cognitive Therapy to Improve Sleep Quality in Older Adults with Insomnia

There is a high prevalence of insomnia in older adults, which has negative consequences for their well-being and quality of life. The recommendation for first-line treatments is to administer non-pharmacological interventions. The objective of this research was to verify the effectiveness of Mindfulness-Based Cognitive Therapy in older adults with subclinical and moderate insomnia, studying its impact on sleep quality. One hundred and six older adults participated and were assigned to the subclinical insomnia (n = 50) or moderate insomnia (n = 56) groups; subsequently, they were randomly assigned to the control and intervention groups. Subjects were evaluated at two times with the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. Significant results were obtained on both scales, with a reduction in insomnia symptoms in the subclinical and moderate intervention groups. The administration of a treatment that combines mindfulness and cognitive therapy is effective for treating insomnia in older adults.

Viability of an Early Sleep Intervention to Mitigate Poor Sleep and Improve Well-being in the COVID-19 Pandemic: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic has led to drastic increases in the prevalence and severity of insomnia symptoms. These increases in insomnia complaints have been paralleled by significant decreases in well-being, including increased symptoms of depression, anxiety, and suicidality and decreased quality of life. However, the efficacy and impact of early treatment of insomnia symptoms on future sleep and well-being remain unknown.

OBJECTIVE

Here, we present the framework and protocol for a novel feasibility, pilot study that aims to investigate whether a brief telehealth insomnia intervention targeting new insomnia that developed during the pandemic prevents deterioration of well-being, including symptoms of insomnia, depression, anxiety, suicidality, and quality of life.

METHODS

The protocol details a 2-arm randomized controlled feasibility trial to investigate the efficacy of a brief, telehealth-delivered, early treatment of insomnia and evaluate its potential to prevent deterioration of well-being. Participants with clinically significant insomnia symptoms that began during the pandemic were randomized to either a treatment group or a 28-week waitlist control group. Treatment consists of 4 telehealth sessions of cognitive behavioral therapy for insomnia (CBT-I) delivered over 5 weeks. All participants will complete assessments of insomnia symptom severity, well-being, and daily habits checklist at baseline (week 0) and at weeks 1-6, 12, 28, and 56.

RESULTS

The trial began enrollment on June 3, 2020 and closed enrollment on June 17, 2021. As of October 2021, 49 participants had been randomized to either immediate treatment or a 28-week waitlist; 23 participants were still active in the protocol.

CONCLUSIONS

To our knowledge, this protocol would represent the first study to test an early sleep intervention for improving insomnia that emerged during the COVID-19 pandemic. The findings of this feasibility study could provide information about the utility of CBT-I for symptoms that emerge in the context of other stressors before they develop a chronic course and deepen understanding of the relationship between sleep and well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04409743; https://clinicaltrials.gov/ct2/show/NCT04409743.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34409.

Telehealth-Delivered Cognitive Behavioral Therapy for Insomnia in Individuals with Multiple Sclerosis: A Pilot Study

Background

Over 50% of individuals with multiple sclerosis (MS) have moderate or severe sleep disturbances, insomnia being the most common. In-person cognitive behavioral therapy for insomnia (F2F-CBTi) is currently the first-line treatment for insomnia. However, given potential limitations to access including mobility difficulty, fatigue, or living in a rural area, telehealth-delivered CBT-I (tele-CBTi) has been considered as an alternative treatment. The purpose of this study was to assess the feasibility and treatment effect of tele-CBTi in people with MS and compare it to outcomes from a F2F-CBTi study in individuals with MS.

Methods

11 individuals with MS and symptoms of insomnia participated in 6 weekly CBT-I sessions with a trained CBT-I provider via live video. Insomnia severity (ISI), sleep quality (PSQI), and fatigue severity (FSS and MFIS) were assessed pre- and posttreatment as primary outcomes. Sleep onset latency (SOL), sleep efficiency (SE) and total sleep time (TST) from the PSQI, depression (PHQ-9), anxiety (GAD-7), sleep self-efficacy (SSES), and quality of life (MSIS-29) were also assessed pre- and posttreatment as secondary outcomes.

Results

Participants resided in 9 different states. Retention and adherence rates were 100%. There were significant improvements in ISI, PSQI, MFIS, FSS, SOL, SSES, PHQ-9, and MSIS-29, but not SE, TST, or GAD-7. There were no significant differences between the F2F-CBTi group and tele-CBTi group for magnitude of change in the primary outcomes (ISI, PSQI, MFIS, and FSS) or the secondary outcomes (SOL, SE, TST, SSES, PHQ-9, GAD-7, and MSIS-29).

Conclusions

Tele-CBTi is feasible and has outcome measures that are similar to that of in-person CBT-I treatment. Tele-CBTi may increase access to insomnia treatment in individuals with MS.

Telemedicine-delivered cognitive-behavioral therapy for insomnia in alcohol use disorder (AUD): study protocol for a randomized controlled trial

BACKGROUND

Alcohol use disorder (AUD) is a leading preventable cause of morbidity and mortality, but relapse rates are high even with available treatments. Insomnia is a robust predictor of relapse and pilot studies have shown that CBT for insomnia improves insomnia and daytime functioning in adults with AUD and insomnia. The impact of CBT for insomnia on relapse, however, is unclear. This trial will compare telemedicine-delivered CBT for insomnia (CBT-TM) with sleep hygiene education (SHE-TM) on improving insomnia/sleep, daytime symptom, and drinking outcomes in treatment-seeking AUD adults with insomnia. The study will also determine the effects of treatment on sleep mechanisms and their association with clinical outcomes.

METHODS

This is a single-site randomized controlled trial with planned enrollment of 150 adults meeting criteria for both AUD and chronic insomnia. Eligible participants will be randomized 1:1 to 6 sessions of telemedicine-delivered Cognitive Behavioral Therapy for Insomnia (CBT-TM) or Sleep Hygiene Education (SHE-TM) with clinical assessments conducted at pre-treatment, post- treatment, and at 3, 6, and 12 months post-treatment. Overnight polysomnography will be conducted before and after treatment. Primary clinical outcomes will include post-treatment scores on the Insomnia Severity Index and the General Fatigue subscale of the Multidisciplinary Fatigue Inventory, and the percent of days abstinent (PDA) on the interview-administered Time Line Follow Back. EEG delta activity, derived from overnight polysomnography, will be the primary endpoint to assess the sleep homeostasis mechanism.

DISCUSSION

This adequately powered randomized controlled trial will provide clinically relevant information about whether targeting insomnia is effective for improving treatment outcomes among treatment-seeking adults with AUD. Additionally, the study will offer new scientific insights on the impact of an evidence-based non-medication treatment for insomnia on a candidate mechanism of sleep dysfunction in this population - sleep homeostasis.

TRIAL REGISTRATION

CClinicalTrials.gov NCT # 04457674 . Registered on 07 July 2020.

Teletherapy Versus In-Person Psychotherapy for Depression: A Meta-Analysis of Randomized Controlled Trials

Introduction: The recent surge in telehealth service delivery represents a promising development in the field's ability to address access gaps in health care across underserved populations. Telehealth also carries the potential to help reduce the societal burden of mental illnesses such as major depression, which often go untreated. There is now a sufficiently large corpus of randomized controlled trials to examine the comparative effectiveness of teletherapy and in-person services meta-analytically. Methods: We searched the PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for articles from January 1, 2000 to February 1, 2021 to identify randomized head-to-head trials of video-based versus in-person delivery of psychotherapy to reduce depressive symptoms. We conducted a random-effects meta-analysis to evaluate potential differences in efficacy rates. We calculated and meta-analyzed odds ratios to examine differential attrition rates between video and in-person conditions. Finally, we conducted subgroup analyses based on the primary treatment focus (depression or another condition) of each trial. Results: Primary study analyses yielded evidence that video-based psychotherapy is roughly comparable in efficacy with in-person psychotherapy for reducing depressive symptoms (g = 0.04, 95% confidence interval [CI = -0.12 to 0.20], p = 0.60, I² = 5%). Likewise, attrition rates between the two conditions were not significantly different (odds ratio = 1.07, 95% CI = [0.78 to 1.49], p = 0.63, I² = 25%). Finally, we did not observe significant subgroup differences in either efficacy (p = 0.38) or attrition (p = 0.94). Conclusions: The present findings suggest that video-based teletherapy may be a feasible and effective alternative to in-person services for reducing depressive symptoms. Continued research on the effectiveness of telehealth in clinically depressed samples, and further elucidation of the access barriers entailed by each delivery modality, can help the field better determine which patients will derive the greatest benefit from each mode of intervention.

Delivery of Distance Counselling to Survivors of Sexual Violence: A Scoping Review of Promising and Best Practices

Distance counselling holds immense potential for improving access to trauma supports for survivors of sexual violence (SV), and particularly for under-served groups who disproportionately experience violence and myriad barriers to accessing in-person supports. And yet, the evidence-base for the practice and delivery of distance counselling remains under-developed. In the context of COVID-19, where telehealth applications have undergone a rapid uptake, we undertook a scoping review of existing evidence of therapeutic and organizational practices related to the real-time (synchronous) delivery of distance counselling to survivors of SV. We based our scoping review methods on Arksey and O’Malley framework and in accordance with the guidance on scoping reviews from the Joanna Briggs Institute (JBI) and PRISMA reporting guidelines for scoping reviews. A comprehensive search of MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Sociological Abstracts was undertaken in October 2020, and again in March 2022. Searching, reviewing, appraisal, and data extraction was undertaken by two reviewers. In total, 1094 records were identified that resulted in 20 studies included. Descriptions, findings, and recommendations were gleaned and synthesized into potential practices using inductive thematic analysis. While many studies have an appreciative orientation to distance counselling, these benefits tend to be framed as non-universal, and conditional on survivor safety, flexibility, anonymity, survivor choice, strong and inclusive technology, and a supported workforce.

Despite the limited evidence-base, we present several clusters of findings that, taken together, can be used to support current COVID-19 distance counselling initiatives with survivors, as well as guide the future development of best practices.

The Survivorship Sleep Program (SSP): A synchronous, virtual cognitive behavioral therapy for insomnia pilot program among cancer survivors

BACKGROUND

For cancer survivors, insomnia is prevalent, distressing, and persists for years if unmanaged. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment yet can be difficult to access and may require modification to address survivorship-specific barriers to sleep. In this 2-phase study, the authors adapted and assessed the feasibility, acceptability, and preliminary effects of synchronous, virtual CBT-I adapted for cancer survivors (the Survivorship Sleep Program [SSP]).

METHODS

From April to August 2020, cancer survivors with insomnia (N = 10) were interviewed to refine SSP content and delivery. From October 2020 to March 2021, 40 survivors were recruited for a randomized controlled trial comparing 4 weekly SSP sessions with enhanced usual care (EUC) (CBT-I referral plus a sleep hygiene handout). Feasibility and acceptability were assessed by enrollment, retention, attendance, fidelity, survey ratings, and exit interviews. Insomnia severity (secondary outcome), sleep quality, sleep diaries, and fatigue were assessed at baseline, postintervention, and at 1-month follow-up using linear mixed models.

RESULTS

The SSP included targeted content and clinician-led, virtual delivery to enhance patient centeredness and access. Benchmarks were met for enrollment (56% enrolled/eligible), retention (SSP, 90%; EUC, 95%), attendance (100%), and fidelity (95%). Compared with EUC, the SSP resulted in large, clinically significant improvements in insomnia severity (Cohen d = 1.19) that were sustained at 1-month follow-up (Cohen d = 1.27). Improvements were observed for all other sleep metrics except sleep diary total sleep time and fatigue.

CONCLUSIONS

Synchronous, virtually delivered CBT-I targeted to cancer survivors is feasible, acceptable, and seems to be efficacious for reducing insomnia severity. Further testing in larger and more diverse samples is warranted.

Understanding the Impact of the COVID-19 Pandemic, Lockdowns and Social Isolation on Sleep Quality

The uncertain, ever-changing and an ongoing nature of the COVID-19 pandemic means that it may take some time before we can fully appreciate the negative effect of the pandemic and lockdown on our sleep and mental health. It is increasingly recognised that in the aftermath of pandemic, several persistent sleep, neuropsychiatric and physical sequelae may continue long after the pandemic is over. A body of evidence to date also highlights a significant disparity in sleep and mental health difficulties in specific vulnerable groups in the community, with different temporal profiles and sleep issues that are reported. In this perspective, we argue for a possible mechanistic impact of the COVID-19 pandemic, with its imposed restrictions and social isolation on sleep quality. We similarly discuss some of the potential international differences, as well as similarities, behind reported idiosyncratic biological vulnerabilities that may have contributed to the genesis of sleep issues. Lastly, we propose some possible implementations and innovations that may be needed in restructuring of sleep disorders services in order to benefit recovering COVID-19 patients.

Comparative efficacy of digital cognitive behavioral therapy for insomnia: A systematic review and network meta-analysis

The comparative efficacy of various approaches of digital cognitive behavioral therapy for insomnia (CBTi) is still unclear. This network meta-analysis explored the comparative efficacy of digital CBTi approaches in adults with insomnia. Four electronic databases were searched from inception to June 27, 2020. Primary outcomes were self-reported total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), and insomnia symptoms; these were measured using sleep diaries or valid questionnaires. A random-effects network meta-analysis in a frequentist framework was used. Fifty-four randomized controlled trials comprising 11,815 participants were included. Compared with usual care, web-based CBTi with a therapist demonstrated significantly longer TST (mean difference [MD]: 23.19 min, 95% confidence interval [CI]: 18.98-27.39 min), shorter SOL (MD: -18.76 min, 95% CI -24.20 to -13.31 min), lower WASO (MD: -31.40 min, 95% CI: -36.26 to -26.55 min), and greater SE (MD: 10.37%, 95% CI: 8.08%-12.65%). The surface under the cumulative ranking curve indicates that web-based CBTi with therapists is most likely to be ranked the highest among all treatments, and thus, this network meta-analysis suggests that such a treatment is the optimal intervention for improving sleep duration and SE as well as the reductions in SOL and WASO. PROSPERO REGISTRATION NUMBER: CRD42020171134.

Videoconferencing Psychotherapy During the Pandemic: Exceptional Times With Enduring Effects?

With the advent of COVID-19, a sudden, unexpected, and forced shift has been produced in the field of psychotherapy. Worldwide, many therapists closed their offices and started to deliver psychotherapy online through a screen. Although different media started to be incorporated, videoconferencing is undoubtedly the most common way in which therapists are doing therapy these days. This is catalyzing a rapid change in the practice of psychotherapy with probable lasting effects and deserves to be carefully reflected upon. Therefore, in this paper our aim is to outline the main challenges for a medium that may have arrived to stay. In that sense, we review the literature to describe the state-of-the-art regarding the main aspects of videoconferencing psychotherapy as well as to suggest possible avenues for future research and practice.

The effects of COVID-19 stay-at-home order on sleep, health, and working patterns: a survey study of US health care workers

STUDY OBJECTIVES

By March 2020, COVID-19 forced much of the world to stay at home to reduce the spread of the disease. Whereas some health care workers transitioned to working from home, many continued to report to work in person as essential employees. We sought to explore changes in sleep, health, work, and mood in health care workers during the stay-at-home orders.

METHODS

We developed a cross-sectional online survey administered to health care workers. The survey assessed changes in sleep, work, screen time, media exposure, diet, exercise, substance use, and mood. The survey data were collected between March 28, 2020, and April 29, 2020.

RESULTS

A total of 834 of 936 individuals completed the entire survey. Respondents were from 41 US states. Mood after the stay-at-home orders worsened, and screen time and substance use increased. Total sleep time shortened in those continuing to work in person (P < .001), whereas it was unchanged in those working from home (P = .73). Those working from home went to bed later, woke up later, and worked fewer hours. Reduced total sleep time and increased screen time before bed were associated with worse mood and screen time. Longer sleep time was associated with better mood.

CONCLUSIONS

Health care workers' mood worsened regardless of whether work was in person or remote, although total sleep time was shorter for those working in person. Those working from home may have shifted their sleep time to be more in line with their endogenous circadian phase. Peer or other support services may be indicated to address sleep, mood, and health behaviors among health care workers during these unprecedented times.

Rationale and protocol for a randomized waitlist controlled trial of videoconference delivered cognitive behaviour therapy for insomnia (CBT-I) to improve perceived cognitive impairment (PCI) among cancer survivors

Perceived cognitive impairment (PCI) and sleep disturbances (such as insomnia) are commonly reported barriers preventing cancer survivors from resuming normal functioning. Cognitive-behaviour therapy for insomnia (CBT-I) is the treatment of choice for insomnia among cancer survivors. Literature suggests that treatment with CBT-I may lead to an improvement in PCI, but this needs to be tested in a sample of patients with PCI at study entry with cognitive impairments as the primary study outcome. Here we describe the design of a clinical trial to evaluate the efficacy of videoconference-delivered CBT-I for the improvement of PCI among cancer survivors. This project is a randomized waitlist-controlled trial with a recruitment target of 124 adult cancer survivors (solid tumors and hematological malignancies) who have completed primary treatment at least 6 months prior, report PCI and meet criteria for insomnia disorder. Participants will complete assessments at baseline, 4 weeks (mid-treatment), 8 weeks (post treatment), and 3 and 6 months post-treatment. The primary outcome is the Functional Assessment of Cancer Therapy - Cognitive Function (FACT-Cog). Treatment of PCI in cancer patients is a priority for clinicians, researchers, and patients. This research will increase our understanding of the mechanisms of cognitive impairment associated with cancer, and potentially expand currently available treatment options.

Non-pharmacological Approaches for Management of Insomnia

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