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Chen Y, Markowitz JC, Blanco C, Hershman DL, Zhang JT, Hellerstein DJ. Geographical distance predicts psychiatric treatment retention for Hispanic women with comorbid major depression and breast cancer. Breast Cancer Res Treat 2024; 205:249-256. [PMID: 38376796 DOI: 10.1007/s10549-024-07250-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Depression is among the most common comorbid psychiatric disorders of patients with breast cancer. Depression decreases patient quality of life and, if untreated, can adversely affect cancer treatment. We sought to identify treatment barriers for women with breast cancer receiving psychotherapy for depression. Findings may help policy makers and researchers determine funding and design of future studies involving this population, especially in communities with high rates of health disparities. METHODS We used data from a randomized trial for women with breast cancer and current DSM-IV non-psychotic unipolar major depressive disorder (MDD). Patients were randomly assigned to 12 weeks of one of three psychotherapies and attrition was assessed by whether subjects completed 12 weekly treatment sessions. We used descriptive analyses and logistic regression to identify treatment barriers. R shiny was used to determine study patient residences. RESULTS Of 134 randomized patients, 84 (62.7%) were Hispanic. Fifty-nine patients (44%) either did not start or dropped out of treatment, 49 (83.1%) of them being Hispanic. Being a Hispanic woman, less educated, and geographically distant from treatment significantly predicted attrition. Single Hispanic mothers had significantly higher attrition risk than married and/or childless women. CONCLUSION Identifying barriers to treatment is important to improve treatment adherence for patients with concurrent diagnoses of breast cancer and MDD, especially for traditionally underserved minorities. Additional support such as affordable tele-medicine, multi-language assistance, financial aid for transportation and child-care, and allocation of more funds to address some identified barriers deserve consideration to improve treatment adherence and outcomes.
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Affiliation(s)
- Ying Chen
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA.
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA.
| | - John C Markowitz
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Carlos Blanco
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse (NIDA), Gaithersburg, MD, 20892, USA
| | - Dawn L Hershman
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Joy T Zhang
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- University of Virginia, Charlottesville, VA, 22904, USA
| | - David J Hellerstein
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
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Hertenstein E, Trinca E, Schneider CL, Fehér KD, Johann AF, Nissen C. Acceptance and Commitment Therapy, Combined with Bedtime Restriction, versus Cognitive Behavioral Therapy for Insomnia: A Randomized Controlled Pilot Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2024; 93:114-128. [PMID: 38417415 DOI: 10.1159/000535834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/08/2023] [Indexed: 03/01/2024]
Abstract
INTRODUCTION Cognitive behavioral therapy for insomnia (CBT-I) is the current first-line treatment for insomnia. However, rates of nonresponse and nonremission are high and effects on quality of life are only small to moderate, indicating a need for novel treatment developments. We propose that Acceptance and Commitment Therapy (ACT) addresses core pathophysiological pathways of insomnia. ACT therefore has the potential to improve treatment efficacy when combined with bedtime restriction, the most effective component of CBT-I. The aim of this study was to compare the efficacy of ACT for insomnia combined with bedtime restriction (ACT-I) and CBT-I in improving insomnia severity and sleep-related quality of life. METHODS Sixty-three patients with insomnia disorder (mean age 52 years, 65% female, 35% male) were randomly assigned to receive either ACT-I or CBT-I in a group format. The primary outcomes were insomnia severity (Insomnia Severity Index) and sleep-related quality of life (Glasgow Sleep Impact Index). Outcomes were assessed before randomization (T0), directly after treatment (T1), and at 6-month follow-up (T2). RESULTS The results indicated significant, large pre-to-post improvements in both groups, for both primary and secondary outcomes. Improvements were maintained at the 6-month follow-up. However, there was no significant group by time interactions in linear mixed models, indicating an absence of differential efficacy. On a subjective treatment satisfaction scale, patients in the ACT-I group indicated significantly greater satisfaction with their improvement of several aspects of health including their energy level and work productivity. CONCLUSIONS The results suggest that ACT-I is feasible and effective, but not more effective than CBT-I for the improvement of insomnia severity and sleep-related quality of life. Future studies are needed to assess whether ACT-I is noninferior to CBT-I and to shed light on mechanisms of change in both treatments.
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Affiliation(s)
- Elisabeth Hertenstein
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Ersilia Trinca
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Carlotta L Schneider
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Kristoffer D Fehér
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anna F Johann
- Clinic for Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Nissen
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals (HUG), Geneva, Switzerland
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3
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Manber R, Simpson N, Gumport NB. Perspectives on increasing the impact and reach of CBT-I. Sleep 2023; 46:zsad168. [PMID: 37903637 PMCID: PMC10710991 DOI: 10.1093/sleep/zsad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/06/2023] [Indexed: 11/01/2023] Open
Abstract
Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.
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Affiliation(s)
- Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Norah Simpson
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Nicole B Gumport
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
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Espie CA, Henry AL. Disseminating cognitive behavioural therapy (CBT) for insomnia at scale: capitalising on the potential of digital CBT to deliver clinical guideline care. J Sleep Res 2023; 32:e14025. [PMID: 37642008 DOI: 10.1111/jsr.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023]
Abstract
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.
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Affiliation(s)
- Colin A Espie
- Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Big Health Ltd., London, UK
- Big Health Inc., San Francisco, CA, USA
| | - Alasdair L Henry
- Big Health Ltd., London, UK
- Big Health Inc., San Francisco, CA, USA
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Ravyts SG, Erickson AJ, Washington DL, Yano EM, Carlson GC, Mitchell MN, Kelly M, Alessi CA, McGowan SK, Song Y, Martin JL, Dzierzewski JM. A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes. J Psychosom Res 2023; 175:111536. [PMID: 37913677 PMCID: PMC10872669 DOI: 10.1016/j.jpsychores.2023.111536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBTI) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined. METHODS Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up. RESULTS At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen's d = 0.41-0.67) and pain interference (p < .001, Cohen's d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen's d = 0.59). CONCLUSION CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.
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Affiliation(s)
- Scott G Ravyts
- Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation.
| | - Alexander J Erickson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System.
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, United States of America.
| | - Gwendolyn C Carlson
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, United States of America; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, United States of America; Department of Mental Health, VA Greater Los Angeles Healthcare System.
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System.
| | - Monica Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
| | - Sarah Kate McGowan
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, United States of America.
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America; School of Nursing, University of California Los Angeles.
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, (UCLA), United States of America.
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Riemann D, Espie CA, Altena E, Arnardottir ES, Baglioni C, Bassetti CLA, Bastien C, Berzina N, Bjorvatn B, Dikeos D, Dolenc Groselj L, Ellis JG, Garcia-Borreguero D, Geoffroy PA, Gjerstad M, Gonçalves M, Hertenstein E, Hoedlmoser K, Hion T, Holzinger B, Janku K, Jansson-Fröjmark M, Järnefelt H, Jernelöv S, Jennum PJ, Khachatryan S, Krone L, Kyle SD, Lancee J, Leger D, Lupusor A, Marques DR, Nissen C, Palagini L, Paunio T, Perogamvros L, Pevernagie D, Schabus M, Shochat T, Szentkiralyi A, Van Someren E, van Straten A, Wichniak A, Verbraecken J, Spiegelhalder K. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res 2023; 32:e14035. [PMID: 38016484 DOI: 10.1111/jsr.14035] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 11/30/2023]
Abstract
Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).
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Affiliation(s)
- Dieter Riemann
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Health (Department), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
| | | | - Erna Sif Arnardottir
- Reykjavik University Sleep Institute, School of Technology, Reykjavik University, Reykjavik, Iceland
- Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Chiara Baglioni
- Human Sciences Department, University of Rome Guglielmo Marconi Rome, Rome, Italy
| | | | - Celyne Bastien
- École de Psychologie, Université Laval, Québec, Québec, Canada
| | | | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Dimitris Dikeos
- First Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Leja Dolenc Groselj
- Institute of Clinical Neurophysiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Jason G Ellis
- Northumbria Sleep Research Laboratory, Northumbria University, Newcastle, UK
| | | | | | | | | | - Elisabeth Hertenstein
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Kerstin Hoedlmoser
- Centre for Cognitive Neurosciences, University of Salzburg, Salzburg, Austria
| | - Tuuliki Hion
- East-Viru Central Hospital, Kohtla-Järve, Estonia
| | | | - Karolina Janku
- Center for Sleep and Chronobiology Research, National Institute of Mental Health, Klecany, Czech Republic
| | - Markus Jansson-Fröjmark
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Stockholm Health Care Services, Stockholm, Sweden
| | - Heli Järnefelt
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Susanna Jernelöv
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Stockholm Health Care Services, Stockholm, Sweden
| | - Poul Jørgen Jennum
- Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Samson Khachatryan
- Department of Neurology and Neurosurgery, Armenian National Institute of Health, Yerevan, Armenia
| | - Lukas Krone
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
- Department of Neurology, Inselspital, University of Bern, Berne, Switzerland
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience at the University of Oxford, Oxford, UK
| | - Jaap Lancee
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Damien Leger
- Université Paris Cité, APHP, Hôtel Dieu de Paris, Centre du Sommeil et de la Vigilance, Paris, France
| | - Adrian Lupusor
- Functional Neurology, Institute of Neurology and Neurosurgery, Chisinau, Moldova
| | - Daniel Ruivo Marques
- Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
- CINEICC - Center for Research in Neuropsychology and Cognitive Behavioral Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Christoph Nissen
- Department of Psychiatry, University Hospital Geneve, Geneve, Switzerland
| | - Laura Palagini
- Psychiatry Unit, Department of Clinical and Experimental Medicine, School of Medicine, University of Pisa, Pisa, Italy
| | - Tiina Paunio
- Department of Psychiatry and SleepWell Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Dirk Pevernagie
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Manuel Schabus
- Centre for Cognitive Neurosciences, University of Salzburg, Salzburg, Austria
| | - Tamar Shochat
- The Cheryl Spencer Institute of Nursing Research, University of Haifa, Haifa, Israel
| | - Andras Szentkiralyi
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Eus Van Someren
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- Departments of Integrative Neurophysiology and Psychiatry, Center for Neurogenomics and Cognitive Research, Amsterdam UMC, Amsterdam Neuroscience, VU University, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro- and Developmental Psychology & Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Adam Wichniak
- Sleep Medicine Center and Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Kai Spiegelhalder
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Health (Department), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Drager LF, Assis M, Bacelar AFR, Poyares DLR, Conway SG, Pires GN, de Azevedo AP, Carissimi A, Eckeli AL, Pentagna Á, Almeida CMO, Franco CMR, Sobreira EST, Stelzer FG, Mendes GM, Minhoto GR, Linares IMP, Sousa KMM, Gitaí LLG, Sukys-Claudino L, Sobreira-Neto MA, Zanini MA, Margis R, Martinez SCG. 2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association. Sleep Sci 2023; 16:507-549. [PMID: 38370879 PMCID: PMC10869237 DOI: 10.1055/s-0043-1776281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.
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Affiliation(s)
- Luciano Ferreira Drager
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Unidades de HipertenSão, Instituto do Coração (InCor) e Disciplina de Nefrologia, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Márcia Assis
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Clínica do Sono de Curitiba, Hospital São Lucas, Curitiba, Brazil.
| | - Andrea Frota Rego Bacelar
- Associação Brasileira do Sono, São Paulo, SP, Brazil.
- Clínica Bacelar - Neuro e Sono, Rio de Janeiro, RJ, Brazil.
| | - Dalva Lucia Rollemberg Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- Instituto do Sono, São Paulo, SP, Brazil.
| | - Silvia Gonçalves Conway
- Instituto de Psiquiatria (IPq), Universidade de São Paulo, São Paulo, SP, Brazil.
- Departamento de Otoneurologia, Universidade de São Paulo, São Paulo, SP, Brazil.
- AkasA - Formação e Conhecimento, São Paulo, SP, Brazil.
| | - Gabriel Natan Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- Instituto do Sono, São Paulo, SP, Brazil.
| | | | - Alicia Carissimi
- Faculdade Dom Bosco, Porto Alegre, RS, Brazil.
- Cronosul Clínica de Psicologia do Sono, Psicoterapia e Neuropsicologia, Porto Alegre, RS, Brazil.
| | - Allan Luiz Eckeli
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Álvaro Pentagna
- Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | | | | | - Emmanuelle Silva Tavares Sobreira
- AkasA - Formação e Conhecimento, São Paulo, SP, Brazil.
- Universidade Federal do Ceará, Fortaleza, CE, Brazil.
- Clínica Sinapse Diagnóstico, Fortaleza, CE, Brazil.
| | - Fernando Gustavo Stelzer
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | | | | | - Ila Marques Porto Linares
- Instituto de Psiquiatria (IPq), Universidade de São Paulo, São Paulo, SP, Brazil.
- Instituto da Criança, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | - Ksdy Maiara Moura Sousa
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
- SleepUp Tecnologia e Saúde LTDA, São Paulo, SP, Brazil.
| | | | - Lucia Sukys-Claudino
- Disciplina de Neurologia, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil.
| | | | - Marcio Andrei Zanini
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMPSE), São Paulo, SP, Brazil.
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Wang S, Lan Y, Liu Z, Xu S, Wu X. Effects of different interventions on insomnia in adults: Systematic review and network meta-analysis. J Psychiatr Res 2023; 165:140-149. [PMID: 37499485 DOI: 10.1016/j.jpsychires.2023.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 05/04/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Insomnia is a common sleep disorder. There are many clinical-intervention methods for treating this condition, but thus far, the most effective method has not been determined. METHODS We conducted a network meta-analysis by including random evidence of insomnia improvement in people over 18 years old, without other physical diseases. From January 1, 1990 to June 15, 2022, we searched multiple electronic databases for randomized controlled trials of different insomnia-related, clinical-intervention methods. R software was used to analyze 10 indices, in order to evaluate the effect of sleep improvement. Primary outcomes comprised Pittsburgh sleep quality-index (PSQI) scores and insomnia severity-index (ISI) scores. RESULTS Finally, 122 randomized controlled trials were included in our study. For the PSQI scores, we found the sequence of intervention measures by effect to be as follows: electroacupuncture, acupuncture, repetitive transcranial magnetic stimulation (rTMS), essential oils, herbal medicine, traditional Western medicine, Tai Chi and Baduanjin, music, supplements, cognitive behavioral therapy for insomnia (CBT-I), and exercise. The results for ISI were similar to those for PSQI, but with slight differences. CONCLUSION Our research results indicate that various measures have a certain effect on improving sleep, among which the effect of instruments is more prominent. The curative effect of placebo groups was better than that of blank control groups. There is essentially no statistical difference in detailed classification within the same intervention category.
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Affiliation(s)
- Shuwen Wang
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yueyan Lan
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zixiu Liu
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shuang Xu
- Library of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaomei Wu
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China.
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9
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Gabbay FH, Wynn GH, Georg MW, Gildea SM, Kennedy CJ, King AJ, Sampson NA, Ursano RJ, Stein MB, Wagner JR, Kessler RC, Capaldi VF. Toward personalized care for insomnia in the US Army: development of a machine-learning model to predict response to pharmacotherapy. J Clin Sleep Med 2023; 19:1399-1410. [PMID: 37078194 PMCID: PMC10394363 DOI: 10.5664/jcsm.10574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 04/21/2023]
Abstract
STUDY OBJECTIVES Although many military personnel with insomnia are treated with prescription medication, little reliable guidance exists to identify patients most likely to respond. As a first step toward personalized care for insomnia, we present results of a machine-learning model to predict response to insomnia medication. METHODS The sample comprised n = 4,738 nondeployed US Army soldiers treated with insomnia medication and followed 6-12 weeks after initiating treatment. All patients had moderate-severe baseline scores on the Insomnia Severity Index (ISI) and completed 1 or more follow-up ISIs 6-12 weeks after baseline. An ensemble machine-learning model was developed in a 70% training sample to predict clinically significant ISI improvement, defined as reduction of at least 2 standard deviations on the baseline ISI distribution. Predictors included a wide range of military administrative and baseline clinical variables. Model accuracy was evaluated in the remaining 30% test sample. RESULTS 21.3% of patients had clinically significant ISI improvement. Model test sample area under the receiver operating characteristic curve (standard error) was 0.63 (0.02). Among the 30% of patients with the highest predicted probabilities of improvement, 32.5.% had clinically significant symptom improvement vs 16.6% in the 70% sample predicted to be least likely to improve (χ21 = 37.1, P < .001). More than 75% of prediction accuracy was due to 10 variables, the most important of which was baseline insomnia severity. CONCLUSIONS Pending replication, the model could be used as part of a patient-centered decision-making process for insomnia treatment, but parallel models will be needed for alternative treatments before such a system is of optimal value. CITATION Gabbay FH, Wynn GH, Georg MW, et al. Toward personalized care for insomnia in the US Army: development of a machine-learning model to predict response to pharmacotherapy. J Clin Sleep Med. 2023;19(8):1399-1410.
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Affiliation(s)
- Frances H. Gabbay
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Gary H. Wynn
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
| | - Matthew W. Georg
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Sarah M. Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Chris J. Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew J. King
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Robert J. Ursano
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, California
- Psychiatric Service, VA San Diego Healthcare System, San Diego, California
| | - James R. Wagner
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vincent F. Capaldi
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
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Bramoweth AD, Hough CE, McQuillan AD, Spitznogle BL, Thorpe CT, Lickel JJ, Boudreaux-Kelly M, Hamm ME, Germain A. Reduction of Sleep Medications via a Combined Digital Insomnia and Pharmacist-Led Deprescribing Intervention: Protocol for a Feasibility Trial. JMIR Res Protoc 2023; 12:e47636. [PMID: 37471122 PMCID: PMC10401195 DOI: 10.2196/47636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Chronic insomnia is one of the most common health problems among veterans and negatively impacts their health, function, and quality of life. Although cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommended treatment, sedative-hypnotic medications remain the most common. Sedative-hypnotics, however, have mixed effectiveness, are frequently prescribed longer than recommended, and are associated with numerous risks and adverse effects that negatively impact veteran function. Meeting the treatment needs of veterans impacted by insomnia requires delivering gold standard behavioral care, like CBT-I, and the reduction of sedative-hypnotics through innovative methods. OBJECTIVE The objective of this feasibility clinical trial is to test a digital CBT-I approach combined with deprescribing to improve the success of sedative-hypnotic reduction among veterans. The intervention combines Noctem Health Clinician Operated Assistive Sleep Technology (COAST), an effective and efficient, scalable, and adaptable digital platform to deliver CBT-I, with clinical pharmacy practitioner (CPP)-led deprescribing of sedative-hypnotic medications. METHODS In this nonrandomized single-group clinical trial, 50 veterans will be recruited and enrolled to receive CBT-I delivered via Noctem COAST and CPP-led deprescribing for up to 12 weeks. Assessments will occur at baseline, posttreatment, and 3-month follow-up. The aims are to (1) assess the feasibility of recruiting veterans with chronic sedative-hypnotic use to participate in the combined intervention, (2) evaluate veterans' acceptability and usability of the COAST platform, and (3) measure changes in veterans' sleep, sedative-hypnotic use, and function at baseline, posttreatment, and 3-month follow-up. RESULTS The institutional review board approved the study in October 2021 and the trial was initiated in May 2022. Recruitment and data collection began in September 2022 and is anticipated to be completed in April 2024. Aim 1 will be measured by tracking the response to a mail-centric recruitment approach using electronic medical records to identify potentially eligible veterans based on sedative-hypnotic use. Aim 2 will be measured using the Post-Study System Usability Questionnaire, assessing overall usability as well as system usefulness, information quality, and interface quality. Aim 3 will use the Insomnia Severity Index and sleep diaries to measure change in insomnia outcomes, the Patient-Reported Outcome Measurement Information System Profile to measure change in physical function, anxiety, depression, fatigue, sleep disturbance, participation in social roles, pain, cognitive function, and self-reported sedative-hypnotic use to measure change in dose and frequency of use. CONCLUSIONS Findings will inform the utility of a combined digital CBT-I and CPP-led deprescribing intervention and the development of an adequately powered clinical trial to test the effectiveness in a diverse sample of veterans. Further, findings will help inform potential new approaches to deliver care and improve access to care for veterans with insomnia, many of whom use sedative-hypnotics that may be ineffective and increase the risk for negative outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT05027438; https://classic.clinicaltrials.gov/ct2/show/NCT05027438. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/47636.
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Affiliation(s)
- Adam D Bramoweth
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Caroline E Hough
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Amanda D McQuillan
- Pharmacy Services, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | | | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States
| | - James J Lickel
- Behavioral Health, William S Middleton Memorial Veterans' Hospital, Madison, WI, United States
| | | | - Megan E Hamm
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Anne Germain
- Noctem Health Inc, Pittsburgh, PA, United States
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11
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Shin JW, Kim S, Shin YJ, Park B, Park S. Comparison of Acceptance and Commitment Therapy (ACT) and Cognitive Behavior Therapy (CBT) for Chronic Insomnia: A Pilot Randomized Controlled Trial. Nat Sci Sleep 2023; 15:523-531. [PMID: 37431325 PMCID: PMC10329838 DOI: 10.2147/nss.s409981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023] Open
Abstract
Purpose Acceptance and Commitment Therapy (ACT) is part of the third wave of cognitive behavior therapy, and has six core components: acceptance, cognitive defusion, self as context, being present, values, and committed behavior. This study aimed to examine the efficacy of ACT for insomnia compared with cognitive behavior therapy for insomnia (CBT-I) in patients with chronic primary insomnia. Methods The study recruited patients with chronic primary insomnia from a university hospital between August 2020 and July 2021. Thirty patients were enrolled and randomly assigned to receive either ACT (n = 15) or CBT-I (n = 15). Interventions were performed over four weeks, with four sessions of face-to-face therapy and four sessions of online therapy. The outcomes were measured using a sleep diary and a questionnaire. Results Post-intervention, the ACT and CBT-I groups had significantly improved sleep quality, insomnia severity, depression, beliefs about sleep, sleep onset latency (SOL), and sleep efficacy (SE) (p < 0.05). However, anxiety was significantly reduced in the ACT group (p = 0.015), but not in the CBT-I group. Conclusion ACT had a significant effect on primary insomnia and secondary symptoms, especially anxiety related to insomnia. These findings suggest that ACT could be a potential intervention for individuals who do not respond to CBT-I, who have high anxiety regarding sleep problems.
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Affiliation(s)
- Jung-Won Shin
- Department of Neurology, Memory Center, Bundang CHA Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Seonyeop Kim
- Graduate School of Clinical Counselling Psychology, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yoon Jung Shin
- Graduate School of Clinical Counselling Psychology, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Bomi Park
- Graduate School of Clinical Counselling Psychology, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sunyoung Park
- Graduate School of Clinical Counselling Psychology, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea
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El Rafihi-Ferreira R, do Brasil do Carmo MMI, Bassolli L, Hasan R, Aizawa IMN, Toscanini AC. Cognitive and psychological factors associated with severe insomnia in Brazilian women: a cross-sectional study. PSICOLOGIA-REFLEXAO E CRITICA 2022; 35:39. [PMID: 36550223 PMCID: PMC9780099 DOI: 10.1186/s41155-022-00243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Insomnia is the most prevalent sleep disorder in women. Sociodemographic, cognitive, and psychological factors may contribute to its severity. This study evaluated factors associated with severe insomnia in women with insomnia complaints. We evaluated 530 women aged 18-59 (mean = 40.5, SD = 10.2), who experienced insomnia complaints, using self-report instruments. Severe insomnia was defined as a score above 21 on the Insomnia Severity Index. Age, marital status, educational level, depression and anxiety, psychological inflexibility, and beliefs about sleep were assessed as potential factors associated with severe insomnia. Simple and multivariate analyses were conducted using binary logistic regression. Low education level (odds ratio; OR = 1.85 [1.27-2.69]), depression (OR = 2.17 [1.27-3.81]), psychological inflexibility (OR = 1.05 [1.02-1.08]), and dysfunctional beliefs about sleep (OR = 1.04 [1.02-1.06]) were factors associated with severe insomnia scores in the multiple logistic regression model. These findings are important from a public health perspective, because behavioral strategies designed to treat insomnia with a focus on cognitive and psychological factors are low-cost treatments and may help improve sleep quality in women, which also influences mental health.
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Affiliation(s)
- Renatha El Rafihi-Ferreira
- grid.11899.380000 0004 1937 0722Instituto de Psiquiatria, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
| | - Marwin Machay Indio do Brasil do Carmo
- grid.11899.380000 0004 1937 0722Instituto de Psiquiatria, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
| | - Lucas Bassolli
- grid.11899.380000 0004 1937 0722Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
| | - Rosa Hasan
- grid.11899.380000 0004 1937 0722Instituto de Psiquiatria, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
| | - Isabela Mayumi Nishino Aizawa
- grid.11899.380000 0004 1937 0722Instituto de Psiquiatria, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
| | - Andrea Cecilia Toscanini
- grid.11899.380000 0004 1937 0722Instituto de Psiquiatria, Universidade de São Paulo, 785 Doutor Ovídio Pires de Campos Street, São Paulo, SP 05403-903 Brazil
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13
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Han A, Kim TH. Efficacy of Internet-Based Acceptance and Commitment Therapy for Depressive Symptoms, Anxiety, Stress, Psychological Distress, and Quality of Life: Systematic Review and Meta-analysis. J Med Internet Res 2022; 24:e39727. [PMID: 36485030 PMCID: PMC9789494 DOI: 10.2196/39727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/24/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Acceptance and commitment therapy (ACT) is an empirically supported transdiagnostic approach that involves mindfulness processes and behavior change processes for valued living. OBJECTIVE This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of internet-based ACT (iACT) for depressive symptoms, anxiety, stress, psychological distress, and quality of life (QoL). METHODS PubMed, CINAHL, PsycINFO, and SCOPUS databases were searched to identify relevant RCTs published up to June 5, 2021. The included RCTs were assessed using the Cochrane Collaboration risk-of-bias tool. The use of either a random effects model or fixed effects model was determined using I2 statistic values for heterogeneity. Subgroup analyses were conducted according to the type of control group, the use of therapist guidance, delivery modes, and the use of targeted participants, when applicable. RESULTS A total of 39 RCTs met the inclusion criteria. Meta-analyses found small effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL at the immediate posttest and follow-up. There was no significant effect of iACT on stress at follow-up. Subgroup analyses showed small to medium effects of iACT on all the outcomes at the immediate posttest and follow-up compared with the passive control groups. In contrast, subgroup analyses that compared iACT with active control groups found no differences between groups on stress, psychological distress, and QoL at the immediate posttest or on depressive symptoms, anxiety, and stress at follow-up. In addition, subgroup analyses conducted according to the use of therapist guidance, delivery modes, and the use of targeted participants found no statistically significant subgroup differences among studies in all the outcomes, except for the subgroup difference among studies according to the use of targeted participants for depressive symptoms at the immediate posttest (ie, a statistically significant, larger effect of iACT when studies targeted people with depressive symptoms). The overall risk of bias across the studies was unclear. CONCLUSIONS The findings of this study contribute to the body of evidence regarding the effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL and may be applicable in any population, as ACT is a transdiagnostic approach. Few studies have compared iACT with active control conditions, especially for stress and psychological distress at the immediate posttest and follow-up. In addition, the active control conditions varied among the included studies. Further high-quality studies are needed to better understand whether iACT is comparable or superior to other evidence-based interventions, such as cognitive behavioral therapy, in decreasing depressive symptoms, anxiety, stress, and psychological distress and improving QoL.
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Affiliation(s)
- Areum Han
- Department of Occupational Therapy, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tae Hui Kim
- Department of Psychiatry, Yonsei Wonju Medical College, Wonju, Republic of Korea
- Department of Psychiatry, Wonju Severance Christian Hospital, Wonju, Republic of Korea
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14
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Comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combination for the treatment of adult insomnia: A systematic review and network meta-analysis. Sleep Med Rev 2022; 65:101687. [PMID: 36027795 DOI: 10.1016/j.smrv.2022.101687] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022]
Abstract
This study aims to explore the comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combinations for insomnia. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and ClinicalTrials.gov were searched for randomized clinical trials (RCTs) examining the comparative efficacy in which a psychotherapy and a pharmacotherapy for insomnia were directly compared with each other, or in which a combination of psychotherapy and pharmacotherapy was compared with either alone. The analysis included data from 23 RCTs. In 18 of 23 studies, cognitive behavior therapy for insomnia (CBT-I) was the psychotherapy. At post-treatment, CBT-I showed higher subjective sleep efficiency (SE), and lower subjective wake time after sleep onset (WASO) and insomnia severity index (ISI) score. Compared with CBT-I plus pharmacotherapy, pharmacotherapy showed lower subjective SE, and higher subjective sleep latency (SL), PSG measured SL, subjective WASO, and ISI score. Overall, the findings derived from post-treatment data suggested that CBT-I is more beneficial in treating insomnia compared with pharmacotherapy. CBT-I combined with pharmacotherapy is beneficial in improving some sleep parameters (i.e., subjective SE, SL, WASO, and PSG measured SL) compared with pharmacotherapy alone. Daily clinical decisions should consider these findings on the relative efficacy of the principal approaches to insomnia treatment.
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15
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Han A, Kim TH. Effects of internet-based acceptance and commitment therapy on process measures: A systematic review and meta-analysis (Preprint). J Med Internet Res 2022; 24:e39182. [PMID: 36040783 PMCID: PMC9472046 DOI: 10.2196/39182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background Acceptance and commitment therapy (ACT) is based on a psychological flexibility model that encompasses 6 processes: acceptance, cognitive defusion, self-as-context, being present, values, and committed action. Objective This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to examine the effects of internet-based ACT (iACT) on process measures. Methods A comprehensive search was conducted using 4 databases. The quality of the included RCTs was assessed using the Cochrane Collaboration Risk of Bias Tool. A random-effects or fixed-effects model was used. Subgroup analyses for each outcome were conducted according to the type of control group, use of therapist guidance, delivery modes, and use of targeted participants, when applicable. Results A total of 34 RCTs met the inclusion criteria. This meta-analysis found that iACT had a medium effect on psychological flexibility and small effects on mindfulness, valued living, and cognitive defusion at the immediate posttest. In addition, iACT had a small effect on psychological flexibility at follow-up. The overall risk of bias across studies was unclear. Conclusions Relatively few studies have compared the effects of iACT with active control groups and measured the effects on mindfulness, valued living, and cognitive defusion. These findings support the processes of change in iACT, which mental health practitioners can use to support the use of iACT.
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Affiliation(s)
- Areum Han
- Department of Occupational Therapy, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tae Hui Kim
- Department of Psychiatry, Yonsei University Wonju College of Medicine, Wonju, Gangwon province, Republic of Korea
- Department of Psychiatry, Yonsei University Wonju Christian Hospital, Wonju, Gangwon province, Republic of Korea
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16
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Sharafkhaneh A, Salari N, Khazaie S, Ghasemi H, Darvishi N, Hosseinian-Far A, Mohammadi M, Khazaie H. Telemedicine and insomnia: a comprehensive systematic review and meta-analysis. Sleep Med 2022; 90:117-130. [DOI: 10.1016/j.sleep.2022.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
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Paulos-Guarnieri L, Linares IMP, El Rafihi-Ferreira R. Evidence and characteristics of Acceptance and Commitment Therapy (ACT)-based interventions for insomnia: A systematic review of randomized and non-randomized trials. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2022. [DOI: 10.1016/j.jcbs.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Uzdavines A, Gonzalez RD, Price A, Broadway D, Smith TL, Rodrigues M, Woods K, Zimmerman MB, Jorge R, Dindo L. Acceptance and Commitment Training for Veterans with polytrauma: A randomized controlled trial protocol. Contemp Clin Trials 2021; 111:106601. [PMID: 34687944 DOI: 10.1016/j.cct.2021.106601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/20/2021] [Accepted: 10/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination - referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response. METHODS This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic. RESULTS The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months. CONCLUSION Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.
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Affiliation(s)
- Alex Uzdavines
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America
| | - Raquel D Gonzalez
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - Alexandra Price
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Dakota Broadway
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - Tracey L Smith
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America
| | - Merlyn Rodrigues
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Ken Woods
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - M Bridget Zimmerman
- College of Public Health, University of Iowa, Iowa City, IA, United States of America
| | - Ricardo Jorge
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Lilian Dindo
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America.
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Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910222. [PMID: 34639523 PMCID: PMC8508349 DOI: 10.3390/ijerph181910222] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 01/23/2023]
Abstract
Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.
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Jiang A, Rosario M, Stahl S, Gill JM, Rusch HL. The Effect of Virtual Mindfulness-Based Interventions on Sleep Quality: A Systematic Review of Randomized Controlled Trials. Curr Psychiatry Rep 2021; 23:62. [PMID: 34297230 PMCID: PMC8300082 DOI: 10.1007/s11920-021-01272-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW We summarized peer-reviewed literature investigating the effect of virtual mindfulness-based interventions (MBIs) on sleep quality. We aimed to examine the following three questions: (1) do virtual MBIs improve sleep quality when compared with control groups; (2) does the effect persist long-term; and (3) is the virtual delivery method equally feasible compared to the in-person delivery method? RECENT FINDINGS Findings suggest that virtual MBIs are equivalent to evidence-based treatments, and to a limited extent, more effective than non-specific active controls at reducing some aspects of sleep disturbance. Overall, virtual MBIs are more effective at improving sleep quality than usual care controls and waitlist controls. Studies provide preliminary evidence that virtual MBIs have a long-term effect on sleep quality. Moreover, while virtual MBI attrition rates are comparable to in-person MBI attrition rates, intervention adherence may be compromised in the virtual delivery method. This review highlights virtual MBIs as a potentially effective alternative to managing sleep disturbance during pandemic-related quarantine and stay-at-home periods. This is especially relevant due to barriers of accessing in-person interventions during the pandemic. Future studies are needed to explore factors that influence adherence and access to virtual MBIs, with a particular focus on diverse populations.
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Affiliation(s)
- Amanda Jiang
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael Rosario
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sara Stahl
- TEACCH Autism Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessica M Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Heather L Rusch
- National Institutes of Health, 3 Center Drive, Building 3, Room 5E/26, Bethesda, MD, 20892, USA.
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Sommers-Spijkerman M, Austin J, Bohlmeijer E, Pots W. New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials. JMIR Ment Health 2021; 8:e28168. [PMID: 34279240 PMCID: PMC8329762 DOI: 10.2196/28168] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/05/2021] [Accepted: 05/16/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing. OBJECTIVE This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects. METHODS We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model. RESULTS The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs. CONCLUSIONS Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.
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Affiliation(s)
- Marion Sommers-Spijkerman
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht, Netherlands
| | - Judith Austin
- Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | - Ernst Bohlmeijer
- Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | - Wendy Pots
- Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
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