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Sandlund C, Westman J, Norell-Clarke A. Characteristics of Patients with Subjective Sleep Problems after Cognitive Behavioral Therapy for Insomnia: Secondary Analyses of a Randomized Controlled Trial. Sleep Sci 2023; 16:e417-e424. [PMID: 38197018 PMCID: PMC10773518 DOI: 10.1055/s-0043-1776881] [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] [Received: 04/03/2022] [Accepted: 01/31/2023] [Indexed: 01/11/2024] Open
Abstract
Objective Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia, but half of the patients do not reach remission. This study aimed to explore subjective remission by investigating the characteristics of patients who reported lingering sleep problems after CBT-I. Methods Secondary analyses of a randomized controlled trial of group CBT-I in 72 primary care patients with insomnia disorder. Sociodemographic characteristics and outcomes (insomnia severity, sleep variables, hypnotics use, fatigue, depressive symptoms, and dysfunctional beliefs/attitudes), including baseline data and symptom change, were investigated in relation to patients' posttreatment response to the yes-or-no question "Would you say that you have sleep problems?" Results A total of 56.9% of patients reported sleep problems after CBT-I. At baseline, they had worse depressive symptoms (14.9 (SD 7.5) vs. 10.2 (SD 5.9), p = 0.006) and more awakenings (2.6 (SD 1.5) vs. 1.8 (SD 1.3), p = 0.034) than those in subjective remission from sleep problems. Patients in the non-remission and remission groups showed similar improvements in sleep, fatigue, and depressive symptoms, but patients in the non-remission group had improved less in insomnia severity, dysfunctional beliefs/attitudes about sleep, and hypnotic use. In patients with more pronounced depressive symptoms before CBT-I, change in depressive symptoms during treatment partially explained subjective remission from sleep problems. Discussion More severe depressive symptoms prior to CBT-I and less improvements in depressive symptoms during treatment predicted remaining subjective sleep problems after treatment. These findings highlight the importance of assessing depressive symptoms in primary care patients with insomnia, as patients with pronounced depressive symptoms may need tailored treatment.
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Affiliation(s)
- Christina Sandlund
- Karolinska Institutet, Neurobiology, Care Sciences and Society, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Jeanette Westman
- Karolinska Institutet, Neurobiology, Care Sciences and Society, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
- Marie Cederschiöld University, Health Sciences, Stockholm, Sweden
| | - Annika Norell-Clarke
- Örebro University, Law, Psychology and Social Work, Örebro, Sweden
- Kristianstad University, Health Sciences, Kristianstad, Sweden
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Cheung JMY, Bartlett DJ, Armour CL, Saini B. Treating Insomnia: A Review of Patient Perceptions Toward Treatment. Behav Sleep Med 2016; 14:235-66. [PMID: 26240937 DOI: 10.1080/15402002.2014.981818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patient views about their treatment for insomnia often dictate outcome. This review explores the literature relating to the patients' global perceptions toward treatment for insomnia. A strategic literature search was conducted using five databases (PubMed, CINAHL, Medline, PsycINFO, and Embase). The 57 research articles included for this review were mapped out chronologically across three key stages of treatment-seeking (pretreatment appraisal, actual treatment experiences, and posttreatment evaluation). Patient perceptions played an important role across these three key stages and influenced subsequent health behaviors such as the initiation of help-seeking, treatment uptake, treatment adherence, and treatment adjustment. Patients' perceptions toward treatment were heavily grounded by their psychosocial contexts. Clinical implications and future directions for including patient-centered metrics in mainstream practice and research are discussed.
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Affiliation(s)
- Janet M Y Cheung
- a Faculty of Pharmacy , The University of Sydney , Australia.,b Sleep and Circadian Research Group , The Woolcock Institute of Medical Research , Sydney , Australia
| | - Delwyn J Bartlett
- b Sleep and Circadian Research Group , The Woolcock Institute of Medical Research , Sydney , Australia
| | - Carol L Armour
- c Clinical Management Group , The Woolcock Institute of Medical Research , Sydney , Australia
| | - Bandana Saini
- a Faculty of Pharmacy , The University of Sydney , Australia.,b Sleep and Circadian Research Group , The Woolcock Institute of Medical Research , Sydney , Australia
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Zachariae R, Lyby MS, Ritterband LM, O'Toole MS. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - A systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev 2015; 30:1-10. [PMID: 26615572 DOI: 10.1016/j.smrv.2015.10.004] [Citation(s) in RCA: 398] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/04/2015] [Accepted: 10/14/2015] [Indexed: 01/13/2023]
Abstract
Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.
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Affiliation(s)
- Robert Zachariae
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital, and Department of Psychology and Behavioural Science, Aarhus University, Aarhus, Denmark.
| | - Marlene S Lyby
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital, and Department of Psychology and Behavioural Science, Aarhus University, Aarhus, Denmark
| | - Lee M Ritterband
- Behavioral Health and Technology Lab, Dept. of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Mia S O'Toole
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital, and Department of Psychology and Behavioural Science, Aarhus University, Aarhus, Denmark
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Abstract
Insomnia is a common sleep disorder associated with substantial direct and indirect costs, yet there is a strong propensity among patients to self-medicate which often delays professional help. Understanding the process which underpins the initiation, engagement and adherence to insomnia treatment(s) is a vital step for understanding this phenomenon. The current paper explores how the patient perspective has been conceptualized in the research literature and its implications for insomnia treatment and health care delivery. A literature search was conducted using Embase, Medline and PsycINFO databases. Articles have been thematically organized into patient correlates of health behaviors, patient experiences and treatment attitudes. Deferral of professional help among insomnia patients is partially related to barriers embedded in the health care system and patient health beliefs.
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Troxel WM, Conrad TS, Germain A, Buysse DJ. Predictors of treatment response to brief behavioral treatment of insomnia (BBTI) in older adults. J Clin Sleep Med 2013; 9:1281-9. [PMID: 24340290 PMCID: PMC3836339 DOI: 10.5664/jcsm.3270] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The extant literature on predictors of treatment response to behavioral treatments for insomnia is equivocal and limited in scope. The current study examined demographic, clinical, and sleep characteristics as predictors of clinically significant treatment response to brief behavioral treatment of insomnia (BBTI) in older adults with insomnia. METHODS Thirty-nine older adults with insomnia (67% females, mean age: 72.54 years) were randomized to BBTI treatment. Treatment outcomes were defined according to 2 criteria: (1) "response," defined as change in Pittsburgh Sleep Quality Index (PSQI) score ≥ 3 points or increase in sleep diary sleep efficiency ≥ 10%); or (2) remission, defined as absence of a clinical diagnosis of insomnia according to standard diagnostic criteria. Logistic regression examined whether baseline demographic, clinical, or sleep characteristics predicted treatment outcomes at 1 month follow-up. RESULTS Demographic variables did not predict treatment outcomes for either criterion. Higher anxiety, depression, poorer sleep quality, and longer polysomnography (PSG)-assessed sleep latency predicted greater likelihood of response at follow-up (p < 0.05). Longer sleep duration at baseline (measured by sleep diary and PSG) predicted greater likelihood of the remission at follow-up (p < 0.05). CONCLUSION Patients with insomnia who have greater distress at baseline or prolonged sleep latency are more likely to show positive response to BBTI. In contrast, short sleepers at baseline are less likely to have resolution of insomnia diagnosis following BBTI, perhaps due to the sleep restriction component of the treatment. Identifying the characteristics that predict positive BBTI treatment outcomes can facilitate personalized behavioral treatments to improve outcomes.
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Affiliation(s)
- Wendy M. Troxel
- Behavioral and Policy Sciences, RAND Corporation, Pittsburgh, PA
| | - Tyler S. Conrad
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anne Germain
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Daniel J. Buysse
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Vincent N, Walsh K. Stepped care for insomnia: an evaluation of implementation in routine practice. J Clin Sleep Med 2013; 9:227-34. [PMID: 23493468 DOI: 10.5664/jcsm.2484] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVES Stepped care models for chronic insomnia are in their infancy. This study evaluated predictors of movement in a stepped care pathway using a sample of 50 adult outpatients with chronic insomnia. METHODS At assessment periods, participants completed daily sleep diaries, the Insomnia Severity Index, the Multi-Dimensional Fatigue Inventory (MFI), and the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-10). Following this, data were collected regarding whether the individual went on to receive more intensive services (i.e., individual consultation, group or individual therapy). Data were analyzed using multi-nomial logistic regression. RESULTS Results showed that age, employment status, and sleep (quality, latency) predicted use of more intensive services. Results showed that psychiatric and sleep comorbidity, sleep attitudes, and insomnia severity did not. CONCLUSIONS Implications of these findings are that stepped care resulted in a 69% improvement in efficiency, and that low-intensity treatment delivered in step 1 may have been particularly sufficient for the young and employed, and for those with better sleep.
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Affiliation(s)
- Norah Vincent
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada.
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Bianchi MT, Wang W, Klerman EB. Sleep misperception in healthy adults: implications for insomnia diagnosis. J Clin Sleep Med 2012; 8:547-54. [PMID: 23066367 PMCID: PMC3459201 DOI: 10.5664/jcsm.2154] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Time estimation is a complex cognitive task that is especially challenging when the time period includes sleep. To determine the accuracy of sleep duration perception, we investigated 44 healthy subjects participating in multi-day inpatient sleep protocols during which they had extended nighttime and short daytime sleep opportunities but no time cues or knowledge of time of day. METHODS The first sleep opportunity was at habitual sleep time and duration. The subsequent 3, 4, or 11 days had 12-h nighttime sleep opportunities and 4-h daytime nap opportunities, potentially creating an experimentally induced "insomnia" with substantial time awake during scheduled sleep. RESULTS Subjective sleep duration estimates were accurate for the first (habitual) sleep opportunity. The subjective reports following nighttime 12-h sleep opportunities significantly underestimated objective sleep duration, while those following daytime 4-h sleep opportunities significantly overestimated objective sleep duration. Misperception errors were not explained by poor sleep efficiency, which was lower during 4-h (~39%) than 12-h opportunities (~71%). Subjective sleep estimates after 4-h opportunities correlated with the percentage of REM and N3 sleep. Subjective sleep estimates following 12-h opportunities were, unexpectedly, negatively correlated with NREM stage 2 sleep. CONCLUSION The estimation of sleep duration in the absence of time cues may depend on length of sleep opportunity and/or time of day. The results have implications for understanding sleep state misperception, which is an important consideration in patients with insomnia.
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Affiliation(s)
- Matt T Bianchi
- Sleep Division, Neurology Department, Massachusetts General Hospital, Boston, MA 02114, USA.
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Althof SE, Brock GB, Rosen RC, Rowland DL, Aquilina JW, Rothman M, Tesfaye F, Bull S. Validity of the Patient-Reported Clinical Global Impression of Change as a Measure of Treatment Response in Men with Premature Ejaculation. J Sex Med 2010; 7:2243-2252. [DOI: 10.1111/j.1743-6109.2010.01793.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vincent N, Walsh K, Lewycky S. Sleep locus of control and computerized cognitive-behavioral therapy (cCBT). Behav Res Ther 2010; 48:779-83. [PMID: 20627268 DOI: 10.1016/j.brat.2010.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/12/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
This study investigated the relationship between sleep locus of control and sleep in a secondary data analysis. Participants were 100 adults with chronic insomnia previously involved in a randomized controlled trial of 5 weeks of computerized cognitive-behavioral therapy (cCBT). Additionally, a sample of 46 completers of an in-person group for insomnia were utilized as a comparison group. At pre-treatment, participants completed the Sleep Locus of Control Scale, the Insomnia Severity Index, the Pre-Sleep Arousal Scale, 7 days of sleep diaries, and participated in structured interviews to assess for psychiatric and medical conditions. Measures were re-administered at post-treatment and at a 4 week follow-up. Results showed that sleep locus of control mediated the impact of cCBT on insomnia severity at follow-up. cCBT more than waiting list control or a convenience sample of individuals treated with in-person CBT, enhanced an internal sleep locus of control. Implications are that sleep locus of control may be an important variable to assess in the internet context and that internet programs for insomnia may want to consider amplifying or giving priority to interventions which enhance an internal sleep locus.
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Affiliation(s)
- N Vincent
- Department of Clinical Health Psychology, University of Manitoba, PZ-350, Psychealth Center, 771 Bannatyne Avenue, Winnipeg, Manitoba, Canada R3E 3N4.
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Vincent N, Lewycky S. Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. Sleep 2009; 32:807-15. [PMID: 19544758 DOI: 10.1093/sleep/32.6.807] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Despite effective cognitive behavioral treatments for chronic insomnia, such treatments are underutilized. This study evaluated the impact of a 5-week, online treatment for insomnia. DESIGN This was a randomized controlled trial with online treatment and waiting list control conditions. PARTICIPANTS Participants were 118 adults with chronic insomnia. SETTING Participants received online treatment from their homes. INTERVENTION Online treatment consisted of psychoeducation, sleep hygiene, and stimulus control instruction, sleep restriction treatment, relaxation training, cognitive therapy, and help with medication tapering. MEASUREMENT AND RESULTS From pre- to post-treatment, there was a 33% attrition rate, and attrition was related to referral status (i.e., dropouts were more likely to have been referred for treatment rather than recruited from the community). Using a mixed model analysis of variance procedure (ANOVA), results showed that online treatment produced statistically significant improvements in the primary end points of sleep quality, insomnia severity, and daytime fatigue. Online treatment also produced significant changes in process variables of pre-sleep cognitive arousal and dysfunctional beliefs about sleep. CONCLUSIONS Implications of these findings are that identification of who most benefits from online treatment is a worthy area of future study.
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Affiliation(s)
- Norah Vincent
- Department of Clinical Health Psychology, University of Manitoba, Manitoba, Canada
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