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Verreault MD, Granger É, Neveu X, Delage JP, Bastien CH, Vallières A. The effectiveness of stimulus control in cognitive behavioural therapy for insomnia in adults: A systematic review and network meta-analysis. J Sleep Res 2024; 33:e14008. [PMID: 37586843 DOI: 10.1111/jsr.14008] [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: 04/30/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023]
Abstract
Stimulus control is part of the widely used cognitive behavioural therapy for insomnia. However, there is a lack of knowledge about its mechanisms of action and effectiveness when used alone. This systematic review with network meta-analysis aimed to evaluate stimulus control efficacy when used alone compared with cognitive behavioural therapy for insomnia or its components. The review also documented stimulus control mechanisms of action proposed by the authors. A search was conducted in several bibliographic databases (MEDLINE, PsycINFO, Embase, CINAHL, Psychology Behavioural Sciences Collection, Web of Science, and Cochrane Library) and in two registers from 1972 to June 2022. Randomised studies with adult participants presenting a diagnosis of insomnia and including at least one stimulus control instruction in a treatment group were included. Risk of bias was assessed with the Quality Assessment of Controlled Intervention Studies. Twenty-three studies were included and three network meta-analyses were conducted. The quality of included studies was generally poor. Results indicate that stimulus control is an effective intervention to improve insomnia compared with control conditions. Not all stimulus control instructions seem essential, especially those known to recondition the bedroom for sleep. The review challenges the classical conditioning hypothesis. Results should be interpreted cautiously given the small number of studies included, bias risk, and inconsistencies in the network meta-analysis. Rigorous research is needed in evaluating stimulus control efficacy and mechanisms.
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Affiliation(s)
- Mikael Demers Verreault
- École de psychologie, Université Laval, Québec, QC, Canada
- Centre de recherche CERVO, Québec, QC, Canada
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Xavier Neveu
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Julia Pizzamiglio Delage
- École de psychologie, Université Laval, Québec, QC, Canada
- Centre de recherche CERVO, Québec, QC, Canada
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Célyne H Bastien
- École de psychologie, Université Laval, Québec, QC, Canada
- Centre de recherche CERVO, Québec, QC, Canada
| | - Annie Vallières
- École de psychologie, Université Laval, Québec, QC, Canada
- Centre de recherche CERVO, Québec, QC, Canada
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
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2
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Jansson-Fröjmark M, Nordenstam L, Alfonsson S, Bohman B, Rozental A, Norell-Clarke A. Stimulus control for insomnia: A systematic review and meta-analysis. J Sleep Res 2024; 33:e14002. [PMID: 37496454 DOI: 10.1111/jsr.14002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/28/2023]
Abstract
Stimulus control (SC) is commonly viewed as an evidence-based treatment for insomnia, but it has not been evaluated comprehensively with modern review and meta-analytic techniques. The aim of the current study was thus to perform a systematic review and meta-analysis of trials that examine the efficacy of stimulus control for insomnia. A systematic search for eligible articles and dissertations was conducted in six online bibliographic databases. The 11 included studies, with the majority published between 1978 and 1998, were randomised controlled and experimental studies in adults, comparing stimulus control for insomnia with passive and active comparators and assessing insomnia symptoms as outcomes. A random effects model was used to determine the standardised mean difference Hedge's g at post-treatment and follow-up for three sleep diary measures: the number of awakenings, sleep onset latency, and total sleep time. A test for heterogeneity was conducted, forest plots were produced, the risk of publication bias was estimated, and the study quality was assessed. In the trials identified, stimulus control resulted in small to large improvements on sleep onset latency and total sleep time, relative to passive comparators (g = 0.38-0.85). Compared with active comparators, the improvements following stimulus control were negligible (g = 0.06-0.30). Although methodological uncertainties were observed in the included trials, stimulus control appears to be an efficacious treatment for insomnia when compared with passive comparators and with similar effects to active comparators. More robust studies are, however, warranted before stronger conclusions are possible to infer.
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Affiliation(s)
- Markus Jansson-Fröjmark
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
| | - Lisa Nordenstam
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
| | - Sven Alfonsson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
| | - Benjamin Bohman
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
| | - Alexander Rozental
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Annika Norell-Clarke
- Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
- School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
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Speed TJ, Hanks L, Turner G, Gurule E, Kearson A, Buenaver L, Smith MT, Antoine D. A comparison of cognitive behavioral therapy for insomnia to standard of care in an outpatient substance use disorder clinic embedded within a therapeutic community: a RE-AIM framework evaluation. Trials 2022; 23:965. [DOI: 10.1186/s13063-022-06885-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
Rates of substance use disorders (SUDs) continue to rise in the USA with parallel rises in admissions to outpatient SUD treatment programs. Insomnia symptoms reduce treatment adherence, trigger relapse, and generally undermine SUD recovery efforts. Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line treatment recommended for chronic insomnia. No study has examined the effectiveness of CBT-I for individuals who recently entered an outpatient SUD treatment program embedded within a therapeutic community (i.e., long-term drug-free residential setting).
Methods
A randomized controlled trial conducted at a SUD program embedded in a therapeutic community aimed to compare group-based CBT-I (gCBT-I) (N = 10) with the standard of care (SOC) (N = 11) among individuals who have SUDs and comorbid insomnia. We present a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework evaluation to provide empirical data on gCBT-I feasibility and facilitators and barriers of conducting an insomnia-focused clinical effectiveness study within a therapeutic community.
Results
Participants in both study arms reported moderately severe insomnia symptoms at admission and reductions in insomnia symptoms over time. Among participants who completed the Insomnia Severity Index (ISI) beyond admission, ISI decreased to ≤ 8 (the clinical cutoff for mild insomnia) in 80% of individuals in the gCBT-I group compared with 25% of individuals in the SOC group. A RE-AIM framework evaluation showed initial success with Reach and Adoption while Implementation, and Maintenance were limited. Effectiveness was inconclusive because of challenges with recruitment, intervention integrity, and missing data that precluded meeting the planned recruitment and study aims and led to study termination. Coordination and communication with staff and leadership facilitated gCBT-I implementation, yet well-known CBT-I barriers including time- and resource-intensive sleep medicine training for interventionalists and maintenance of treatment integrity during an 8-week intervention limited gCBT-I sustainability.
Conclusions
This analysis supports the feasibility of conducting behavioral sleep medicine research in outpatient SUD treatment programs embedded within therapeutic communities. Implementation of an insomnia-focused intervention was widely accepted by patients and providers and has potential to address insomnia symptoms in early SUD recovery. Addressing patient- and organizational-level implementation barriers may enhance the sustainability and scalability of sleep interventions and provide new hope to effectively treat insomnia among people living with SUDs.
Trial registration
Clinicaltrials.gov: NCT03208855. Registered July 6, 2017https://clinicaltrials.gov/ct2/show/NCT03208855?term=NCT03208855&draw=2&rank=1
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Hypnotic Discontinuation in Chronic Insomnia. Sleep Med Clin 2022; 17:523-530. [PMID: 36150811 DOI: 10.1016/j.jsmc.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Insomnia disorder is common in adults and children. The estimated prevalence ranges from 9% to 15% in the general population, with higher prevalence in certain subpopulations. Hypnotic medications are those that tend to produce sleep and are frequently used to treat insomnia. Commonly used hypnotics in adults include benzodiazepines (BZDs), BZD receptor agonists, antihistamines, antidepressants, melatonin receptor agonists, orexin receptor antagonists, and antipsychotics. However, hypnotic discontinuation is difficult and often unsuccessful. This article discusses strategies to discontinue hypnotics and evidence supporting their use.
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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: 0] [Impact Index Per Article: 0] [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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Wilson D, Driller M, Johnston B, Gill N. The effectiveness of a 17-week lifestyle intervention on health behaviors among airline pilots during COVID-19. JOURNAL OF SPORT AND HEALTH SCIENCE 2021; 10:333-340. [PMID: 33221534 PMCID: PMC7957121 DOI: 10.1016/j.jshs.2020.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 06/01/2023]
Abstract
PURPOSE The aim of this study was to evaluate the efficacy of a 17-week, 3-component lifestyle intervention for enhancing health behaviors during the coronavirus disease 2019 (COVID-19) pandemic. METHODS A parallel-group (intervention and control) study was conducted amongst 79 airline pilots over a 17-week period during the COVID-19 pandemic. The intervention group (n = 38) received a personalized sleep, dietary, and physical activity (PA) program. The control group (n = 41) received no intervention. Outcome measures for sleep, fruit and vegetable intake, PA, and subjective health were measured though an online survey before and after the 17-week period. The changes in outcome measures were used to determine the efficacy of the intervention. RESULTS Significant main effects for time × group were found for International Physical Activity Questionnaire-walk (p = 0.02) and for all other outcome measures (p < 0.01). The intervention group significantly improved in sleep duration (p < 0.01; d = 1.35), Pittsburgh Sleep Quality Index score (p < 0.01; d = 1.14), moderate-to-vigorous PA (p < 0.01; d = 1.44), fruit and vegetable intake (p < 0.01; d = 2.09), Short Form 12v2 physical score (p < 0.01; d = 1.52), and Short Form 12v2 mental score (p < 0.01; d = 2.09). The control group showed significant negative change for sleep duration, Pittsburgh Sleep Quality Index score, and Short Form 12v2 mental score (p < 0.01). CONCLUSION Results provide preliminary evidence that a 3-component healthy sleep, eating, and PA intervention elicit improvements in health behaviors and perceived subjective health in pilots and may improve quality of life during an unprecedented global pandemic.
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Affiliation(s)
- Daniel Wilson
- Te Huataki Waiora School of Health, The University of Waikato, Hamilton 3216, New Zealand; Faculty of Health, Education and Environment, Toi Ohomai Institute of Technology, Tauranga 3112, New Zealand.
| | - Matthew Driller
- Sport and Exercise Science, Human Services and Sport, La Trobe University, Melbourne 3086, Australia
| | - Ben Johnston
- Aviation and Occupational Medicine Unit, Wellington School of Medicine, Otago University, Wellington 6242, New Zealand
| | - Nicholas Gill
- Te Huataki Waiora School of Health, The University of Waikato, Hamilton 3216, New Zealand; New Zealand Rugby, Wellington 6011, New Zealand
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Sweetman A, Putland S, Lack L, McEvoy RD, Adams R, Grunstein R, Stocks N, Kaambwa B, Van Ryswyk E, Gordon C, Vakulin A, Lovato N. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Med Rev 2020; 56:101404. [PMID: 33370637 DOI: 10.1016/j.smrv.2020.101404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/26/2020] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
| | | | - Leon Lack
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Robert Adams
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; The Health Observatory, Discipline of Medicine, The Queen Elizabeth Hospital Campus, University of Adelaide, Woodville, South Australia, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Ron Grunstein
- Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics, College of Medicine and Public Health, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Emer Van Ryswyk
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Vakulin
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nicole Lovato
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
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Abstract
Patients with chronic insomnia are commonly prescribed hypnotic medications. The long-term effects of chronic hypnotics are not known and discontinuation is encouraged but often difficult to achieve. A gradual taper is preferred to abrupt cessation to avoid rebound insomnia and withdrawal symptoms. Written information provided to the patient about medication discontinuation may be helpful. Cognitive behavioral therapy or behavioral therapies alone can improve hypnotic discontinuation outcomes. There is limited evidence for adjunct medications to assist in hypnotic cessation for insomnia.
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Affiliation(s)
- Jonathan P Hintze
- Division of Pediatric Sleep Medicine, University of South Carolina School of Medicine-Greenville, Greenville Health System, 200 Patewood Drive, Suite A330, Greenville, SC 29615, USA.
| | - Jack D Edinger
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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Jung HJ, Yu ES, Kim JH. Combined Program of Cognitive-Behavioral Therapy for Insomnia and Medication Tapering in Cancer Patients: A Clinic-Based Pilot Study. Behav Sleep Med 2020; 18:386-395. [PMID: 30966825 DOI: 10.1080/15402002.2019.1597718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: This preliminary study aimed to evaluate the efficacy of a combined program of group-based cognitive-behavioral therapy for insomnia (CBT-I) and medication tapering for reducing hypnotic use in cancer patients and to identify predictors of medication continuation. Participants: This study has a retrospective design and uses archival data from patient's medical records. Forty cancer patients with chronic insomnia received clinic- and group-based CBT-I alongside a medication tapering program. Methods: Clinical outcomes were collected from 32 patients who completed a six-week program, via their medical records. Medication dosages, Insomnia Severity Index scores, scores on the Korean version of the 16-item Dysfunctional Beliefs and Attitudes About Sleep scale, Symptom Checklist-90-Revised inventory scores, and sleep efficiency were measured pre- and posttreatment and at a follow-up after one month. Results: At posttreatment, 68.8% of patients were drug-free and 25.0% were taking hypnotic medication at a reduced dosage or frequency. Patients who were undergoing anticancer treatment were more likely to discontinue hypnotic use than patients who were off the anticancer treatment. Overall relapse rate for sleep medication at the one-month follow-up was 4.5%. Having more somatic symptoms at baseline was a significant predictor for continuing medication after CBT-I. Conclusions: The preliminary results imply that the combined program of group-based CBT-I and medication tapering may be helpful to reduce hypnotics in cancer patients with insomnia in a clinical setting. Along with combined treatment methods, future studies could explore the effects of added treatments for the reduction of physical pain on the prevention of chronic hypnotic use.
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Affiliation(s)
- Ho-Jun Jung
- Center for Tobacco Control, National Cancer Center, Gyeonggi-do, Republic of Korea
| | - Eun-Seung Yu
- Mental Health Clinic, National Cancer Center, Gyeonggi-do, Republic of Korea
| | - Jong-Heun Kim
- Mental Health Clinic, National Cancer Center, Gyeonggi-do, Republic of Korea
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Gee B, Orchard F, Clarke E, Joy A, Clarke T, Reynolds S. The effect of non-pharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials. Sleep Med Rev 2018; 43:118-128. [PMID: 30579141 DOI: 10.1016/j.smrv.2018.09.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/07/2018] [Accepted: 09/20/2018] [Indexed: 01/28/2023]
Abstract
Poor sleep is a significant risk factor for depression across the lifespan and sleep problems have been hypothesised to contribute to the onset and maintenance of depression symptoms. However, sleep problems are usually not a direct target of interventions for depression. A range of non-pharmacological treatments can reduce sleep problems but it is unclear whether these interventions also reduce other depression symptoms. The aim of this review was to examine whether non-pharmacological interventions for sleep problems are effective in reducing symptoms of depression. We carried out a systematic search for randomised controlled trials of non-pharmacological sleep interventions that measured depression symptoms as an outcome. Forty-nine trials (n = 5908) were included in a random effects meta-analysis. The pooled standardised mean difference for depression symptoms after treatment for sleep problems was -0.45 (95% CI: -0.55,-0.36). The size of the effect on depression symptoms was moderated by the size of the effect on subjective sleep quality. In studies of participants with mental health problems, sleep interventions had a large effect on depression symptoms (d = -0.81, 95% CI: -1.13,-0.49). The findings indicate that non-pharmacological sleep interventions are effective in reducing the severity of depression, particularly in clinical populations. This suggests that non-pharmacological sleep interventions could be offered as a treatment for depression, potentially improving access to treatment.
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Affiliation(s)
- Brioney Gee
- Norfolk and Suffolk NHS Foundation Trust, UK; Norwich Medical School, University of East Anglia, UK.
| | - Faith Orchard
- School of Psychology and Clinical Language Sciences, University of Reading, UK
| | | | - Ansu Joy
- Norfolk and Suffolk NHS Foundation Trust, UK
| | - Tim Clarke
- Norfolk and Suffolk NHS Foundation Trust, UK; Norwich Medical School, University of East Anglia, UK
| | - Shirley Reynolds
- School of Psychology and Clinical Language Sciences, University of Reading, UK
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12
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van Straten A, van der Zweerde T, Kleiboer A, Cuijpers P, Morin CM, Lancee J. Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Med Rev 2018; 38:3-16. [DOI: 10.1016/j.smrv.2017.02.001] [Citation(s) in RCA: 296] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/11/2017] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
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Abstract
Despite the proliferation of safe, effective, and cost-effective behavioral treatments of insomnia, hypnotic medication remains the most common treatment of insomnia by primary care providers. Such treatment in many cases leads to a pattern of tolerance and dependence on sleep medication, as well as difficulty discontinuing treatment and subsequent rebound insomnia. Recent research suggests promise for behavioral interventions in the treatment of hypnotic dependent insomnia. In this article, the authors report on the treatment of a particularly challenging case: an older adult with a history of addictive behavior now dependent on hypnotics. The authors demonstrate the best possible outcome: elimination of sleep medication combined with sleep improvement.
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14
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Yang CM, Tseng CH, Lai YS, Hsu SC. Self-efficacy enhancement can facilitate hypnotic tapering in patients with primary insomnia. Sleep Biol Rhythms 2015. [DOI: 10.1111/sbr.12111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Chien-Ming Yang
- Department of Psychology/Research Center for Mind, Brain, & Learning; National Cheng-Chi University; Taipei Taiwan
| | | | - Yin-Shi Lai
- Changhua Christian Medical Foundation; Lu-Tung Christian Hospital; Changhua Taiwan
| | - Shih-Chieh Hsu
- Department of Psychiatry; Chang-Gung University; Taipei Taiwan
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15
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Phillips KD, Gunther ME. Sleep and HIV Disease. Sleep Med 2015. [DOI: 10.1007/978-1-4939-2089-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Lichstein KL, Nau SD, Wilson NM, Aguillard RN, Lester KW, Bush AJ, McCrae CS. Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample. Behav Res Ther 2013; 51:787-96. [PMID: 24121096 PMCID: PMC3838504 DOI: 10.1016/j.brat.2013.09.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/17/2013] [Accepted: 09/18/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study tested cognitive behavior therapy (CBT) in hypnotic-dependent, late middle-age and older adults with insomnia. METHOD Seventy volunteers age 50 and older were randomized to CBT plus drug withdrawal, placebo biofeedback (PL) plus drug withdrawal, or drug withdrawal (MED) only. The CBT and PL groups received eight, 45 min weekly treatment sessions. The drug withdrawal protocol comprised slow tapering monitored with about six biweekly, 30 min sessions. Assessment including polysomnography (PSG), sleep diaries, hypnotic consumption, daytime functioning questionnaires, and drug screens collected at baseline, posttreatment, and 1-year follow-up. RESULTS Only the CBT group showed significant sleep diary improvement, sleep onset latency significantly decreased at posttreatment. For all sleep diary measures for all groups, including MED, sleep trended to improvement from baseline to follow-up. Most PSG sleep variables did not significantly change. There were no significant between group differences in medication reduction. Compared to baseline, the three groups decreased hypnotic use at posttreatment, down 84%, and follow-up, down 66%. There was no evidence of withdrawal side-effects. Daytime functioning, including anxiety and depression, improved by posttreatment. Rigorous methodological features, including documentation of strong treatment implementation and the presence of a credible placebo, elevated the confidence due these findings. CONCLUSIONS Gradual drug withdrawal was associated with substantial hypnotic reduction at posttreatment and follow-up, and withdrawal side-effects were absent. When supplemented with CBT, participants accrued incremental self-reported, but not PSG, sleep benefits.
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Abstract
Insomnia is a general clinical term that refers to a difficulty in initiating or maintaining sleep. Insomnia is widely prevalent in the general population, especially in the elderly and in those with medical and psychiatric disorders. Hypnotic drug treatments of insomnia are effective but are associated with potential disadvantages. This article presents an overview of behavioral interventions for insomnia. Behavioral interventions for insomnia include relaxation training, stimulus control therapy, sleep restriction therapy, sleep hygiene, paradoxical intention therapy, cognitive restructuring, and other approaches. These are briefly explained. Research indicates that behavioral interventions are efficacious, effective, and likely cost-effective treatments for insomnia that yield reliable, robust, and long-term benefits in adults of all ages. Detailed guidance is provided for the practical management of patients with insomnia.
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Affiliation(s)
- Mahendra P Sharma
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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McGowan SK, Behar E. A Preliminary Investigation of Stimulus Control Training for Worry. Behav Modif 2012; 37:90-112. [DOI: 10.1177/0145445512455661] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
For individuals with generalized anxiety disorder, worry becomes associated with numerous aspects of life (e.g., time of day, specific stimuli, environmental cues) and is thus under poor discriminative stimulus control (SC). In addition, excessive worry is associated with anxiety, depressed mood, and sleep difficulties. This investigation sought to provide preliminary evidence for the efficacy of SC procedures in reducing anxiety-, mood-, and sleep-related symptoms. A total of 53 participants with high trait worry were randomly assigned to receive 2 weeks of either SC training (consisting of a 30-min time- and place-restricted worry period each day) or a control condition called focused worry (FW; consisting of instructions to not avoid naturally occurring worry so that worry and anxiety would not paradoxically increase). At post-training, SC was superior to FW in producing reductions on measures of worry, anxiety, negative affect, and insomnia, but not on measures of depression or positive affect. Moreover, SC was superior to FW in producing clinically significant change on measures of worry and anxiety. Results provide preliminary support for the use of SC training techniques in larger treatment packages for individuals who experience high levels of worry.
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Ong J, Suh S. Utilizing Cognitive-Behavioral Therapy for Insomnia to Facilitate Discontinuation of Sleep Medication in Chronic Insomnia Patients. SLEEP MEDICINE RESEARCH 2012. [DOI: 10.17241/smr.2012.3.1.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Abstract
Sleep disturbance is intricately entwined with our sense of well-being, health, emotion regulation, performance and productivity, memory and cognitive functioning, and social interaction. A longitudinal perspective underscores the conclusion that persistent sleep disturbance, insomnia, at any time during the life span from infancy to old age has a lasting impact. We examine how insomnia develops, the evidence for competing explanations for understanding insomnia, and the evidence about psychological and behavioral treatments that are used to reduce insomnia and change daytime consequences. There are new directions to expand access to treatment for those who have insomnia, and thus a critical analysis of pathways for dissemination is becoming increasingly important.
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Affiliation(s)
- Richard R Bootzin
- Department of Psychology, University of Arizona, Tucson, Arizona 85721, USA.
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Van Houdenhove L, Buyse B, Gabriëls L, Van den Bergh O. Treating Primary Insomnia: Clinical Effectiveness and Predictors of Outcomes on Sleep, Daytime Function and Health-Related Quality of Life. J Clin Psychol Med Settings 2011; 18:312-21. [DOI: 10.1007/s10880-011-9250-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Abstract
The management of hypnotic discontinuation following regular and prolonged use may be a challenging task for patients and clinicians alike. Current evidence suggests that a stepped-care approach may be a cost-effective approach to assist patients in tapering hypnotics. This approach may involve simple information about the need to discontinue medication, implementation of a supervised and systematic tapering schedule, with or without professional guidance, and cognitive-behavioral therapy. Research evidence shows that this approach appears promising; further research is however necessary to identify treatment and individual characteristics associated with better outcome.
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Affiliation(s)
- Lynda Bélanger
- Université Laval, Québec, Canada
- Centre de Recherche Université Laval/Robert-Giffard, Québec
| | - Geneviève Belleville
- Université du Québec à Montréal, Canada
- Centre de Recherche Fernand-Seguin, Hôpital Louis-H.-Lafontaine, Montréal, Canada
| | - Charles Morin
- Université Laval, Québec, Canada
- Centre de Recherche Université Laval/Robert-Giffard, Québec
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Stoia-Caraballo R, Rye MS, Pan W, Brown Kirschman KJ, Lutz-Zois C, Lyons AM. Negative affect and anger rumination as mediators between forgiveness and sleep quality. J Behav Med 2008; 31:478-88. [PMID: 18787939 DOI: 10.1007/s10865-008-9172-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 08/25/2008] [Indexed: 11/30/2022]
Abstract
Research indicates that forgiveness of interpersonal transgressions relates to better sleep quality, whereas maintaining feelings of anger and hostility relates to poorer sleep quality. However, the mechanisms explaining these relationships have yet to be determined. We examined whether negative affect and anger rumination mediate the relationship between forgiveness of others and sleep quality using a sample of 277 undergraduates from a medium-sized Midwestern Catholic university. Participants completed self-report questionnaires assessing forgiveness of others (situational and dispositional), sleep quality (nocturnal sleep and daytime fatigue), negative affect (depression and anxiety), and anger rumination. Using structural equation modeling, we found that negative affect and anger rumination mediated the relationship between forgiveness and sleep quality through two indirect pathways. In one pathway, negative affect mediated between forgiveness and sleep quality. In the second pathway, both negative affect and anger rumination functioned as mediators. Implications for clinicians and researchers are discussed.
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25
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Bélanger L, Vallières A, Ivers H, Moreau V, Lavigne G, Morin CM. Meta-analysis of sleep changes in control groups of insomnia treatment trials. J Sleep Res 2007; 16:77-84. [PMID: 17309766 DOI: 10.1111/j.1365-2869.2007.00566.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A meta-analysis assessing the magnitude of sleep changes from baseline in placebo-treated (psychological and pharmacological placebo) and untreated groups issued from independent trials was conducted. Comparisons were then performed to assess if the magnitude of sleep changes in the placebo control groups were significantly different than those of the untreated group. Medline, PsychInfo and Current Contents databases (1990-2004) were searched for primary insomnia treatment studies using a randomized controlled parallel-group design. Effect sizes were computed for each end-point variable based on subjective (patient-reported) and polysomnographic measures. Thirty-four studies (n = 1392 subjects) met inclusion criteria; twenty-three used a pharmacological placebo (n = 1163), four used a psychological placebo (n = 81), and seven used a waitlist condition (n = 148). Between-group comparisons were performed using a random effects model analysis. Significant pre-post changes were observed in the pharmacological placebo condition on several sleep parameters, both on objectively and subjectively measured outcomes [objective and subjective sleep onset latency (SOL) and total sleep time (TST) and subjective wake after sleep onset]. Although a tendency was observed for objective SOL, only the changes on subjective SOL and TST in the pharmacological placebo condition were significantly different from the corresponding changes in the untreated group. No differences were significant for the psychological placebo groups. Although the present findings suggest that sleep may significantly change in response to a pharmacological placebo, conclusions remain tentative because of possible confounds that may arise when comparing groups issued from different trials. Further research directly comparing placebo groups and untreated groups from the same randomized trials remains necessary.
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Affiliation(s)
- Lynda Bélanger
- Ecole de Psychologie, Université Laval, Québec, QC, Canada.
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27
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Abstract
Insomnia outcome studies from the last 15 years show consistent success for behavioral treatment with older adults. The present review of evaluation and treatment covers the effects of aging on ability to sleep, the insomnia classification system, the treatment efficacy database, and critical outcome research methodology. Clinical trial methodology with older adults includes familiar challenges; for example, the need for placebo controls, and frequent failures to document the adequacy of treatment implementation. Recommendations for improving methodology are offered. A new review of treatment for primary insomnia in older adults shows strong improvement and consistent results for popular behavioral treatments. Older adult clinical trials show proven efficacy of behavioral treatment for primary insomnia, efficacy for secondary insomnia, and efficacy for insomnia associated with hypnotic dependency.
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Affiliation(s)
- Sidney D Nau
- Department of Psychology, University of Memphis, Memphis, TN 38152-3230, USA.
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28
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Abstract
AIM This paper reports a systematic review of seven studies evaluating the efficacy of cognitive behavioural therapy (CBT) for persistent primary insomnia. BACKGROUND Insomnia is one of the most common health complaints reported in the primary care setting. Although non-pharmacological treatments such as the CBT have been suggested to be useful in combating the persistent insomnia, the efficacy and clinical utility of CBT for primary insomnia have yet to be determined. METHOD A systematic search of Ovid, MEDLINE, psychINFO, PsycARTICLES, CINAHL, and EMBASE databases of papers published between 1993 and 2004 was conducted, using the following medical subject headings or key words: insomnia, primary insomnia, psychophysiological insomnia, sleep maintenance disorders, sleep initiation disorders, non-pharmacological treatment, and cognitive behavioural therapy. A total of seven papers was included in the review. FINDINGS Stimulus control, sleep restriction, sleep hygiene education and cognitive restructuring were the main treatment components. Interventions were provided by psychiatrists except for one study, in which the CBT was delivered by nurses. Among beneficial outcomes, improvement of sleep efficacy, sleep onset latency and wake after sleep onset were the most frequently reported. In addition, participants significantly reduced sleep medication use. Some studies gave follow-up data which indicated that the CBT produced durable clinical changes in total sleep time and night-time wakefulness. CONCLUSIONS These randomized controlled trial studies demonstrated that CBT was superior to any single-component treatment such as stimulus control, relaxation training, educational programmes, or other control conditions. However, heterogeneity in patient assessment, CBT protocols, and outcome indicators made determination of the relative efficacy and clinical utility of the therapy difficult. Therefore, the standard components of CBT need to be clearly defined. In addition, a comprehensive assessment of patients is essential for future studies.
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Affiliation(s)
- Mei-Yeh Wang
- Cardinal Tien College of Nursing, National Taiwan University, Taipei, Taiwan
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Abstract
Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (> or =3 nights a week) and duration (> or =6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity-specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) > or =31 min; (b) occurring > or =3 nights a week; (c) for > or =6 months are the most defensible quantitative criteria for insomnia.
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Affiliation(s)
- K L Lichstein
- Department of Psychology, University of Memphis, TN 38152-3230, USA.
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30
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Morin CM. Primary insomnia. Sleep 2003. [DOI: 10.1007/978-1-4615-0217-3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Patients with persistent insomnia are long-suffering and in dire need of treatment. These individuals can be a challenge to treat. Duration and severity of the problem, current and prior use of sleeping medications, medical and psychiatric conditions, and experience with rebound insomnia are just some of the factors that affect treatment. Most of the insomnia problems that nurses encounter are secondary to a medical or psychiatric condition. Knowledge of assessment methods and implementation of nonpharmacological interventions can make a substantial contribution to the quality of life of persons with insomnia.
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Affiliation(s)
- Dana R Epstein
- Department of Veterans Affairs, Carl T. Hayden VA Medical Center, 650 E. Indian School Road, Phoenix, AZ 85015, USA.
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32
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Martin JL, Ancoli-Israel S. Assessment and diagnosis of insomnia in non-pharmacological intervention studies. Sleep Med Rev 2002. [DOI: 10.1053/smrv.2001.0208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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