A self-help book is better than sleep hygiene advice for insomnia: a randomized controlled comparative study

Disseminating cognitive behavioural therapy (CBT) for insomnia at scale: capitalising on the potential of digital CBT to deliver clinical guideline care

Cognitive behavioural therapy (CBT) is the recommended first-line treatment for insomnia. However, guideline care is very seldom available and most patients receive no treatment, or less effective second-line pharmacotherapy or sleep hygiene, neither of which are evidence-based for chronic insomnia. The primary challenge for CBT has been supply. There are not enough therapists to meet the enormous demand. We must accelerate clinician training, but this approach can never be sufficient, even with abbreviated, efficient therapies. Fortunately, however, the treatment landscape has also changed dramatically. Fully-automated digital CBT (dCBT) has emerged as a safe, effective, and scalable treatment delivery format. dCBT is software only, so it can be disseminated as readily and widely as sleep medication. Moreover, dCBT can be integrated into services. Just as medications can be delivered through health professionals and health systems, approved dCBT programmes can be the same. However, an ecosystem of psychologically-based care should not necessitate a medical prescription model. Our proposed stepped care framework, comprises both population health and clinical health service initiatives, enabling universal access to guideline care for insomnia. The diverse ways in which CBT may be delivered (in-person, face-to-face, using telehealth, group therapy, digitally) can operate congruently and efficiently to optimise treatment for people at all levels of complexity and need. With safe and clinically effective dCBT products now set to become established as treatments, clearly differentiated from wellness apps, there is potential to rapidly transform insomnia services and, for the first time, to deliver clinical guideline care at international scale.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

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).

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.

Is cognitive behavioral therapy for insomnia (CBTi) efficacious for treating insomnia symptoms in shift workers? A systematic review and meta-analysis

Shift workers commonly report insomnia symptoms. Cognitive behavioral therapy for insomnia (CBTi) is the first line treatment for insomnia, however efficacy in shift workers is not well understood. This systematic review and meta-analysis evaluates existing trials of CBTi in shift working populations. A systematic literature search was conducted across seven electronic databases (n = 2120). Fifty-two full-text articles were reviewed and of these, nine studies (across ten publications with a total of 363 participants) were deemed suitable for inclusion. Heterogeneity was considerable between studies, with variability in study design, style and delivery of intervention, and follow-up times. Small sample sizes were common and attrition was high. Some studies modified aspects of CBTi for use in shift workers, while others were limited to psycho-education as part of larger intervention studies. Mean differences (MD) pre and post CBTi were modest for both the insomnia severity index (ISI; MD: -3.08, 95% CI: -4.39, -1.76) and the Pittsburgh sleep quality index (PSQI; MD: -2.38, 95% CI: -3.55, -1.21). Neither difference was of a magnitude considered to reflect a clinically significant improvement. Tailored approaches to CBTi are needed for shift workers to improve efficacy, ideally including co-production with workers to ensure interventions meet this population's needs.

Reintroducing rest: evaluation of a patient-guided sleep workbook in a community mental health team setting

Purpose

Sleep disturbance is a common difficulty in the general population. It has become particularly prevalent in the context of disruption to routine brought about by the COVID-19 pandemic. The purpose of this study was to trial a patient-guided “sleep workbook” intervention, which was developed by multidisciplinary team members, combining principles of sleep hygiene education and cognitive behavioural therapy for insomnia behavioural strategies, and to evaluate its efficacy in a mixed-methods study.

Design/methodology/approach

Service users of the community mental health service were invited to participate. A total of 30 service users agreed to participate. A total of 15 participants completed both the intervention and the mixed-methods survey. Four participated in the focus group. Descriptive and inferential statistics were performed on the collected quantitative data. A thematic analysis was carried out of qualitative survey responses and focus group discourse.

Findings

There was a statistically and clinically significant improvement in quantity and quality of sleep following intervention. Mean hours of sleep prior to the intervention was 4.4 hours [standard deviation (SD) = 2.2], compared to 6.1 hours (SD = 2.2) afterwards (p = 0.003). Quality of sleep improved from a mean of 2.5 (SD = 2.1) to 6.1 (SD = 2.3) following the intervention (p = <0.001). Four themes were developed using the qualitative data: “under-recognition of sleep difficulties”, “ruminations”, “practical utility” and “therapeutic autonomy”.

Originality/value

There is a growing need for occupational therapists and clinicians to provide interventions for patients with sleep difficulties and to develop sleep management practice. This patient-guided sleep workbook may be an effective intervention for these patients.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.

METHODS

The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations.

RESULTS

The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

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

STUDY OBJECTIVES

In a randomized controlled noninferiority trial, we compared face-to-face and telemedicine delivery (via the AASM SleepTM platform) of cognitive-behavioral therapy (CBT) for insomnia for improving insomnia/sleep and daytime functioning at posttreatment and 3-month follow-up. A secondary objective compared the modalities on treatment credibility, satisfaction, and therapeutic alliance.

METHODS

A total of 65 adults with chronic insomnia (46 women, 47.2 ± 16.3 years of age) were randomized to 6 sessions of CBT for insomnia delivered individually via AASM SleepTM (n = 33, CBT-TM) or face-to-face (n = 32, CBT-F2F). Participants completed sleep diaries, the Insomnia Severity Index (ISI), and daytime functioning measures at pretreatment, posttreatment, and 3-month follow-up. Treatment credibility, satisfaction, and therapeutic alliance were compared between treatment modalities. The ISI was the primary noninferiority outcome.

RESULTS

Based on a noninferiority margin of four points on the ISI and, after adjusting for confounders, CBT-TM was noninferior to CBT-F2F at posttreatment (β = 0.54, SE = 1.10, 95% CI = 1.64 to 2.72) and follow-up (β = 0.34, SE = 1.10, 95% CI = 1.83 to 2.53). Daytime functioning measures, except the physical composite scale of the SF-12, were significantly improved at posttreatment and follow-up, with no difference between treatment formats. CBT-TM sessions were, on average, nearly 10 min shorter, yet participant ratings of therapeutic alliance were similar to CBT-F2F.

CONCLUSIONS

Telemedicine delivery of CBT for insomnia is not inferior to face-to-face for insomnia severity and yields similar improvements on other sleep and daytime functioning outcomes. Further, telemedicine allows for more efficient treatment delivery while not compromising therapeutic alliance.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03293745.

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.

METHODS

125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.

RESULTS

Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).

CONCLUSIONS

An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.

TRIAL REGISTRATION

ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

A Review of Digital Cognitive Behavioral Therapy for Insomnia (CBT-I Apps): Are They Designed for Engagement?

There are different ways to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), of which in-person (face to face) is the traditional delivery method. However, the scalability of in-person therapy is low. Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) is an alternative and there are tools on the market that are validated in clinical studies. In this paper, we provide a review of the existing evidence-based CBT-I apps and a summary of the published usability-oriented studies of these apps. The goal is to explore the range of interaction methods commonly applied in dCBT-I platforms, the potential impact for the users, and the design elements applied to achieve engagement. Six commercially available CBT-I apps tested by scientifically valid methods were accessed and reviewed. Commonalities were identified and categorized into interactive elements, CBT-I-related components, managerial features, and supportive motivational features. The dCBT-I apps were effectively assisting the users, and the type of interactions promoted engagement. The apps’ features were based on design principles from interactive product design, experience design, online social media, and serious gaming. This study contributes to the field by providing a critical summary of the existing dCBT-I apps that could guide future developers in the field to achieve a high engagement.

Insomnia - A Heterogenic Disorder Often Comorbid With Psychological and Somatic Disorders and Diseases: A Narrative Review With Focus on Diagnostic and Treatment Challenges

Patients with insomnia complain of problems with sleep onset or sleep maintenance or early morning awakenings, or a combination of these, despite adequate opportunity and circumstances for sleep. In addition, to fulfill the diagnostic criteria for insomnia the complaints need to be associated with negative daytime consequences. For chronic insomnia, the symptoms are required to be present at least 3 days per week for a duration of at least 3 months. Lastly, for insomnia to be defined as a disorder, the sleep complaints and daytime symptoms should not be better explained by another sleep disorder. This criterion represents a diagnostic challenge, since patients suffering from other sleep disorders often complain of insomnia symptoms. For instance, insomnia symptoms are common in e.g., obstructive sleep apnea and circadian rhythm sleep-wake disorders. It may sometimes be difficult to disentangle whether the patient suffers from insomnia disorder or whether the insomnia symptoms are purely due to another sleep disorder. Furthermore, insomnia disorder may be comorbid with other sleep disorders in some patients, e.g., comorbid insomnia and sleep apnea (COMISA). In addition, insomnia disorder is often comorbid with psychological or somatic disorders and diseases. Thus, a thorough assessment is necessary for correct diagnostics. For chronic insomnia disorder, treatment-of-choice is cognitive behavioral therapy, and such treatment is also effective when the insomnia disorder appears comorbid with other diagnoses. Furthermore, studies suggest that insomnia is a heterogenic disorder with many different phenotypes or subtypes. Different insomnia subtypes may respond differently to treatment, but more research on this issue is warranted. Also, the role of comorbidity on treatment outcome is understudied. This review is part of a Research Topic on insomnia launched by Frontiers and focuses on diagnostic and treatment challenges of the disorder. The review aims to stimulate to more research into the bidirectional associations and interactions between insomnia disorder and other sleep, psychological, and somatic disorders/diseases.

The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review

Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.

Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis

BACKGROUND

Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.

METHODS

This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.

DISCUSSION

This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.

TRIAL REGISTRATION

NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).

Treating insomnia in Swiss primary care practices: A survey study based on case vignettes

Guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first-line treatment for chronic insomnia, but it is not clear how many primary care physicians (PCPs) in Switzerland prescribe this treatment. We created a survey that asked PCPs how they would treat chronic insomnia and how much they knew about CBT-I. The survey included two case vignettes that described patients with chronic insomnia, one with and one without comorbid depression. PCPs also answered general questions about treating chronic insomnia and about CBT-I and CBT-I providers. Of the 820 Swiss PCPs we invited, 395 (48%) completed the survey (mean age 54 years; 70% male); 87% of PCPs prescribed sleep hygiene and 65% phytopharmaceuticals for the patient who had only chronic insomnia; 95% prescribed antidepressants for the patient who had comorbid depression. In each case, 20% of PCPs prescribed benzodiazepines or benzodiazepine receptor agonists, 8% prescribed CBT-I, 68% said they knew little about CBT-I, and 78% did not know a CBT-I provider. In the clinical case vignettes, most PCPs treated chronic insomnia with phytopharmaceuticals and sleep hygiene despite their lack of efficacy, but PCPs rarely prescribed CBT-I, felt they knew little about it, and usually knew no CBT-I providers. PCPs need more information about the benefits of CBT-I and local CBT-I providers and dedicated initiatives to implement CBT-I in order to reduce the number of patients who are prescribed ineffective or potentially harmful medications.

Cognitive Behavioral Therapy for Insomnia: A Promising Treatment for Insomnia, Pain, and Depression in Patients With IBD

Over 75% of people with active inflammatory bowel diseases (IBDs) report sleep disturbances, which heighten risk for IBD relapse and flares. Despite mounting evidence for sleep disturbances in IBD, discussion of treatment is severely limited. The most common sleep disturbance, insomnia, occurs in over 50% of adults with chronic health conditions. Herein we describe the gold standard treatment for insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I). Although yet to be studied in IBD, CBT-I reduces a number of IBD-related comorbidities, including chronic pain, depression, and systemic inflammation. We describe treatment with CBT-I, the impact of CBT-I on these comorbidities, and recommendations for providers.

The effect of self-help cognitive behavioral therapy for insomnia on depressive symptoms: An updated meta-analysis of randomized controlled trials

BACKGROUND

Sleep disturbances commonly occur in patients with depression. Insomnia is considered not only a symptom of but also a risk factor for depression. Psychological treatments for insomnia have been demonstrated to be efficacious in alleviating depressive symptoms. This meta-analysis examined the effect of self-help cognitive behavioral therapy for insomnia (CBT-I) in treating depressive symptoms.

METHODS

A systematic review was performed up to April 2019 in 6 major electronic databases. The literature search retrieved 4190 potentially relevant citations; 30 randomized controlled trials (total N = 5945) that compared self-help CBT-I vs. waiting-list (WL), routine care, no treatment, individual cognitive behavioral therapy (CBT), group CBT and placebo were included in the current review.

RESULTS

Random effects models showed significant reduction in self-report depressive symptoms (Hedges' g = 0.35; 95% CI: -0.47, -0.23) and insomnia symptoms (Hedges' g = 0.79; 95% CI: -0.56, -1.03) in the self-help CBT-I group when compared to the WL/routine care/no treatment/psychoeducation control group.

LIMITATIONS

The findings should be interpreted with caution due to potential publication bias.

CONCLUSIONS

CBT-I appears to be efficacious in treating depressive symptoms. Given the current results and study limitations, large-scale, high-quality trials that specifically target individuals with a clinical diagnosis of depression are warranted in the future.

Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials

Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent and debilitating disorder, which results in additive impairments to patients' sleep, daytime functioning, and quality of life, and complex diagnostic and treatment decisions for clinicians. Although the presence of COMISA was first recognized by Christian Guilleminault and colleagues in 1973, it received very little research attention for almost three decades, until the publication of two articles in 1999 and 2001 which collectively reported a 30%-50% co-morbid prevalence rate, and re-ignited research interest in the field. Since 1999, there has been an exponential increase in research documenting the high prevalence, common characteristics, treatment complexities, and bi-directional relationships of COMISA. Recent trials indicate that co-morbid insomnia symptoms may be treated with cognitive and behavioral therapy for insomnia, to increase acceptance and use of continuous positive airway pressure therapy. Hence, the treatment of COMISA appears to require nuanced diagnostic considerations, and multi-faceted treatment approaches provided by multi-disciplinary teams of psychologists and physicians. In this narrative review, we present a brief overview of the history of COMISA research, describe the importance of measuring and managing insomnia symptoms in the presence of sleep apnea, discuss important methodological and diagnostic considerations for COMISA, and review several recent randomized controlled trials investigating the combination of CBTi and CPAP therapy. We aim to provide clinicians with pragmatic suggestions and tools to identify, and manage this prevalent COMISA disorder in clinical settings, and discuss future avenues of research to progress the field.

Insomnia Management in the Australian Primary Care Setting

BACKGROUND AND OBJECTIVE

Insomnia is one of the most prevalent and costly sleep disorders presenting in general practice, and when left untreated, has major health consequences. However, studies are limited on how general practitioners respond to this health issue, especially since the reconceptualization of insomnia in DSM 5. Therefore, the aim of this study was to explore how insomnia is diagnosed and treated in Australian general practices.

PARTICIPANTS

Twenty-four (54% male) general practitioners were recruited throughout the greater Sydney metropolitan area in New South Wales using the professional network of research team members and snowballing technique.

METHODS

Participants were interviewed using a semi-structured interview guide. The audio-taped interviews were transcribed verbatim and a framework approach was used for analysis of transcribed data.

RESULTS

Participant's responses highlighted that despite being a frequent presentation, insomnia is often trivialized with a low recognition rate in general practices. Lack of support and clear and effective management guidelines for general practitioners are the perceived barriers to early recognition of insomnia in general practices. Treating the underlying causes and initiating the treatment with general practitioners to manage insomnia. Medications including off-label antidepressants are often prescribed based on perceived patient expectation for a prescription.

CONCLUSION

Findings of this exploratory study suggest the need for clearly contextualized guidelines that include information about a patient's insomnia experience and treatment expectations. Another significant implication of this study is the need to develop and evaluate a model of collaborative sleep health services in general practice.

No Effect of a Self-Help Book for Insomnia in Patients With Obstructive Sleep Apnea and Comorbid Chronic Insomnia - A Randomized Controlled Trial

Objective: To compare the effects of a self-help book for insomnia to that of sleep hygiene advice in a randomized controlled trial with follow-up after about 3 months among patients who were diagnosed with obstructive sleep apnea (OSA) and comorbid chronic insomnia, and who were concurrently initiating treatment with continuous positive airway pressure (CPAP). Methods: In all, 164 patients were included. OSA was diagnosed and categorized based on a standard respiratory polygraphic sleep study using a type 3 portable monitor. The self-help book focused on cognitive behavioral therapy for insomnia. The main outcome measure was insomnia severity assessed with the Bergen Insomnia Scale (BIS) and the Insomnia Severity Index (ISI). Results: The scores on the BIS improved significantly from pre-treatment to follow-up in the sleep hygiene advice group (26.8 vs. 21.8) and in the self-help book group (26.3 vs. 22.4). Similarly, the ISI scores were significantly improved in both conditions (sleep hygiene: 17.0 vs. 14.1; self-help book: 16.6 vs. 13.6). No time × condition interaction effects were detected, suggesting that the self-help book did not improve insomnia symptoms more than the sleep hygiene advice. Conclusion: In this randomized controlled trial among patients with OSA and comorbid insomnia who were initiating CPAP treatment, concurrently treating their insomnia with a self-help book did not improve sleep more than sleep hygiene advice. The statistically significant improved sleep at follow-up in both groups is most likely explained by the CPAP treatment.

Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis

BACKGROUND

Sleep hygiene education (SHE) is commonly used as a treatment of insomnia in general practice. Whether SHE or cognitive-behavioural therapy for insomnia (CBT-I), a treatment with stronger evidence base, should be provided first remains unclear.

OBJECTIVE

To review the efficacy of SHE for poor sleep or insomnia.

METHODS

We systematically searched six key electronic databases up until May 2017. Two researchers independently selected relevant publications, extracted data and evaluated methodological quality according to the Cochrane criteria.

RESULTS

Twelve of 15 studies compared SHE with CBT-I, three with mindfulness-based therapy, but none with sham or no treatment. General knowledge about sleep, substance use, regular exercise and bedroom arrangement were commonly covered; sleep-wake regularity and avoidance of daytime naps in seven programs, but stress management in only five programs. Major findings include (i) there were significant pre- to post-treatment improvements following SHE, with small to medium effect size; (ii) SHE was significantly less efficacious than CBT-I, with difference in effect size ranging from medium to large; (iii) pre- to post-treatment improvement and SHE-CBT-I difference averaged at 5% and 8% in sleep-diary-derived sleep efficiency, respectively, and two points in Pittsburgh Sleep Quality Index; (iv) only subjective measures were significant and (v) no data on acceptability, adherence, understanding and cost-effectiveness.

CONCLUSIONS

Although SHE is less effective than CBT-I, unanswered methodological and implementation issues prevent a firm conclusion to be made on whether SHE has a role in a stepped-care model for insomnia in primary care.

The effectiveness of behavioural and cognitive behavioural therapies for insomnia on depressive and fatigue symptoms: A systematic review and network meta-analysis

This review aimed to assess the impact of behavioural therapy for insomnia administered alone (BT-I) or in combination with cognitive techniques (cognitive-behavioural therapy for insomnia, CBT-I) on depressive and fatigue symptoms using network meta-analysis. PubMed, Scopus and Web of Science were searched from 1986 to May 2015. Studies were included if they incorporated sleep restriction, a core technique of BT-I treatment, and an adult insomnia sample, a control group and a standardised measure of depressive and/or fatigue symptoms. Face-to-face, group, self-help and internet therapies were all considered. Forty-seven studies were included in the meta-analysis. Eleven classes of treatment or control conditions were identified in the network. Cohen's d at 95% confidence interval (CI) was calculated to assess the effect sizes of each treatment class as compared with placebo. Results showed significant effects for individual face-to-face CBT-I on depressive (d = 0.34, 95% CI: 0.06-0.63) but not on fatigue symptoms, with high heterogeneity between studies. The source of heterogeneity was not identified even after including sex, age, comorbidity and risk of bias in sensitivity analyses. Findings highlight the need to reduce variability between study methodologies and suggest potential effects of individual face-to-face CBT-I on daytime symptoms.

High prevalence of insomnia and hypnotic use in patients visiting their general practitioner

BACKGROUND

Sleep problems are common in the general population, but there are few prevalence studies among patients visiting their GP. Since sleep problems frequently co-occur with existing psychological and somatic conditions, the prevalence is likely to be higher in patients visiting their GPs compared to the prevalence in the general population.

OBJECTIVES

To estimate the prevalence of insomnia [based on the Diagnostic and Statistical Manual for Mental disorders (DSM)-version IV] and hypnotic use among patients in general practice and to evaluate whether the prevalence depended on sex and age.

METHODS

Questionnaire data were collected by 66 medical students while deployed in different general practices during their last year of school. A total of 1346 (response rate 74%) consecutive and unselected patients visiting their GPs answered the validated Bergen Insomnia Scale (BIS) and single questions on self-reported sleep problems and hypnotic use.

RESULTS

The prevalence of insomnia according to BIS was 53.6%. Sleep problems (based on the single question) were self-reported by 55.8%, with 18.0% reporting to experience sleep problems a lot/very much. Hypnotic use was reported by 16.2% (daily use by 5.5%). Insomnia and hypnotic use were all more prevalent in females compared with males. Hypnotic use increased with age, whereas the prevalence of insomnia was highest in the younger age groups.

CONCLUSIONS

Insomnia and hypnotic use were very prevalent among patients visiting their GPs. As insomnia can be effectively treated, we maintain that the diagnosis has a high pay-off and should earn greater awareness in GP's diagnostic evaluation and management.

[Awareness on sleep hygiene rules in Russian population]

AIM

To estimate public awareness on sleep hygiene in general Russian population.

MATERIAL AND METHODS

A sample consisted of 398 people (173 men, 225 women), aged from 18 to 82 years (mean age - 36.3±13.2 years), who were interviewed with the Sleep Beliefs Scale (SBS). Sociodemographic variables (gender, age, residence, education), sleep habits and disorders were recorded as well.

RESULTS AND CONCLUSION

The low public awareness on sleep hygiene rules was demonstrated. Mean number of correct answers out of 20 in SBS was 8.1±3.6. Most informed were women and more educated persons, worst results were demonstrated in smoking and habitual alcohol consuming respondents. The connection between disordered sleep and awareness on sleep hygiene rules was revealed.

An exploration of the role of the occupational therapist in relation to sleep problems in mental health settings

Introduction

An adequate quantity and quality of sleep is a necessary pre-requisite for optimal occupational performance and participation in everyday life. Occupational therapists in various settings encounter people who are affected by sleep problems, but the contribution occupational therapists can make to help those experiencing sleep problems has not yet been fully defined.

Method

This paper reports upon a focus group study designed to elicit the views of occupational therapists working in mental health settings (where sleep disturbances are particularly prevalent) regarding their role in relation to sleep problems. Thematic analysis using a constant comparative approach was used to capture key themes.

Findings

Occupational therapists identified sleep as a significant and persistent occupational problem for many of their clients, and acknowledged that sleep was often overlooked. Although they could identify a series of possible strategies to address sleep needs they were uncertain regarding optimal practice.

Conclusion

Sleep is a valid and relevant area of concern for the profession. Given the findings of this study and the paucity of literature there is an urgent need to identify, design and evaluate occupational therapy assessments and interventions to address sleep problems in mental health and in other settings.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Insomnia

Insomnia, as the term is used by patients and in primary care, is a symptom: dissatisfaction with the quality or quantity of sleep obtained, despite attempts. For acute insomnia, reversal of the trigger (if possible) and treatment with safe, effective sleep medication are advised. For chronic insomnia, as with other types of symptoms, trying to distinguish between several potential underlying causes is key, because no single treatment approach is appropriate for all situations. Specific conditions such as restless legs syndrome, circadian rhythm disorders, and sleep apnea have specific treatment approaches.

A 10-year trend of insomnia prevalence in the adult Norwegian population

OBJECTIVE

We aimed to investigate the 10-year trend in the prevalence of insomnia symptoms, insomnia cases, and use of hypnotic agents in the adult Norwegian population.

METHODS

Data from two representative surveys assessing identical insomnia symptoms in the adult population of Norway, one conducted in 1999-2000 (N=2001) and one conducted in 2009-2010 (N=2000), were compared.

RESULTS

Controlling for basic demographic variables, significant increases were found over the 10-year study period in the prevalence of sleep-onset insomnia from 13.1% to 15.2%, dissatisfaction with sleep from 8.2% to 13.6%, daytime impairment from 14.8% to 18.8%, Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) insomnia cases from 11.9% to 15.5%, and hypnotic agent use from 6.9% to 11.1%. No secular trend was found for maintenance insomnia or for early morning awakening insomnia. Across the two surveys, women reported a higher prevalence of insomnia than men. Age was positively associated with the prevalence of nocturnal sleep problems and use of hypnotic agents but was inversely associated with daytime impairment. Individuals with low socioeconomic status (SES) reported a higher prevalence of several insomnia symptoms.

CONCLUSIONS

Insomnia seems to be on the rise in the general adult population, which gives reason for concern. Prevention of insomnia and cost-effective interventions should receive higher priority in the future.

Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia

STUDY OBJECTIVES

To compare the efficacy of telephone-delivered cognitive-behavioral therapy for insomnia to an information pamphlet control on sleep and daytime functioning at pretreatment, posttreatment, and 12-wk follow-up.

DESIGN

Randomized controlled parallel trial.

SETTING

N/A.

PARTICIPANTS

Thirty individuals with chronic insomnia (27 women, age 39.1 ± 14.4 years, insomnia duration 8.7 ± 10.7 years).

INTERVENTIONS

Cognitive behavioral therapy for insomnia (CBTI) delivered in up to eight weekly telephone sessions (CBTI-Phone, n = 15) versus an information pamphlet control (IPC, n = 15).

MEASUREMENTS AND RESULTS

Sleep/wake diary, sleep-related questionnaires (Insomnia Severity Index, Pittsburgh Sleep Quality Index, 16-item Dysfunctional Beliefs and Attitudes about Sleep), and daytime symptom assessments (fatigue, depression, anxiety, and quality of life) were completed at pretreatment, posttreatment, and 12-wk follow-up. Linear mixed models indicated that sleep/wake diary sleep efficiency and total sleep time improved significantly at posttreatment in both groups and remained stable at 12-wk follow-up. More CBTI-Phone than IPC patients showed posttreatment improvements in unhelpful sleep-related cognitions (P < 0.001) and were classified as "in remission" from insomnia at follow-up (P < 0.05). Posttreatment effect sizes on most daytime symptoms were large (Cohen d = 0.8-2.5) for CBTI-Phone patients and small to moderate (Cohen d = -0.1-0.6) for IPC patients. All CBTI-Phone patients completed posttreatment and 12-wk follow-up assessments, but three IPC patients discontinued the study.

CONCLUSIONS

The findings provide preliminary support for telephone-delivered CBTI in the treatment of chronic insomnia. Future larger-scale studies with more diverse samples are warranted. Some individuals with insomnia may also benefit from pamphlet-delivered CBTI with brief telephone support.

CITATION

Arnedt JT; Cuddihy L; Swanson LM; Pickett S; Aikens J; Chervin RD. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. SLEEP 2013;36(3):353-362.