The efficacy of telephone-delivered cognitive behavioral therapy in people with chronic illnesses and mental diseases: A meta-analysis

COVID-19 pandemic led to an increase of remote treatments, such as telephone-delivery cognitive behavioral therapy (T-CBT). To our knowledge, no meta-analyses studied the effect of T-CBT in chronic and/or mental illnesses on multiple psychological outcomes. Therefore, our study aims to evaluating the efficacy of T-CBT compared to other interventions (treatment as usual, TAU, or face-to-face CBT). Each effect size (ES) was calculated in Hedges' g and pooled together to produce a mean ES for each outcome (depression, anxiety, mental and physical QoL, worry, coping, and sleep disturbances). The meta-analysis included 33 studies with a randomized controlled trial design. A large ES was found when comparing the efficacy of T-CBT against TAU on depression (g = 0.84, p < 0.001), whereas a moderate ES was found on anxiety (g = 0.57; p < 0.001), and a small effect on mental quality of life (g = 0.33, p < 0.001), sleep disturbances (g = 0.37, p = 0.042), coping (g = 0.20, p = 0.016) and worry (g = 0.43, p = 0.001). The meta-analysis comparing the efficacy of T-CBT and CBT on depression revealed a not significant pooled ES (g = 0.06, p = 0.466). The results provided evidence that T-CBT could be to be more effective than TAU conditions in multiple psychological outcomes, and as efficient as face-to-face CBT in treating depression.

Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the front-line treatment for insomnia. Despite the demonstrated effectiveness of CBT-I, it is necessary to consider how CBT-I may be tailored to different individuals. The purpose of the present review is to provide a summary of literature on tailoring CBT-I to different individuals and provide directions for future research. This review focused on the following domains of adaptation: (i) tailoring CBT-I components to individuals with comorbid mental or physical health conditions such as comorbid depression and pain; (ii) adapting CBT-I delivery for different contexts in which individuals exist, such as inpatient, educational, and different social/cultural settings, (iii) adapting CBT-I to specific individuals via case-formulation in clinical settings. We highlight current gaps in the exploration of tailored CBT-I, including a lack of research methodology to evaluate tailored interventions, a need for the integration of ongoing individualised assessment to inform treatment, and the necessary involvement of consumers and stakeholders throughout the research and treatment development process. Together, this review showed abundant adaptations in CBT-I already exist in the literature. Future research is needed in understanding when and how to apply adaptations in CBT-I and evaluate the benefits of these adaptations.

Telehealth versus face-to-face delivery of cognitive behavioural therapy for insomnia: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

This systematic review and meta-analysis compared the effectiveness of the delivery of care to patients with insomnia via telehealth to its delivery face-to-face.

METHODS

We searched Medline, Embase, and Cochrane CENTRAL from inception to 11 January 2023, and conducted a citation analysis on 13 June 2023. No language restrictions were imposed. We included randomised controlled trials. Where feasible, mean differences were calculated; we used a random effects model.

RESULTS

Four trials (239 patients) were included. There were no significant differences between telehealth and face-to-face for insomnia severity scores shortly post-intervention (MD 1.13, 95% CI -0.29-2.55) or at 3 months (mean difference (MD) 1.79, 95% CI -0.01-3.59). There were no differences in Short Form-36 physical and mental scores, Work and Social Adjustment scores, and sleep quality components. Depression scores did not differ post-intervention or at 3 months (MD 0.42, 95% CI -2.42-3.26). Functioning likewise did not differ post-intervention or at 3 months (standardised mean difference (SMD) 0.15, 95% CI -0.37-0.67, P = 0.58). Treatment satisfaction did not differ (one trial) or favoured the face-to-face group (one trial).

CONCLUSIONS

Telehealth may be a viable alternative to the face-to-face provision of cognitive behavioural therapy for insomnia to patients with insomnia. However, the volume of the existing evidence is limited, therefore additional trials are needed, evaluating cognitive behavioural therapy for insomnia and other therapies for individuals for whom cognitive behavioural therapy for insomnia is not effective, and conducted with a wider range of populations, providers and settings.

Rapid Review on the Effectiveness of Telehealth Interventions for the Treatment of Behavioral Health Disorders

INTRODUCTION

The Psychological Health Center of Excellence conducted a rapid review of the literature to investigate the effectiveness of behavioral health treatments (i.e., evidence-based psychotherapy and psychiatry) delivered in person compared to telehealth (TH; i.e., video teleconference and telephone).

MATERIALS AND METHODS

The rapid review methods included a systematic search of a single database (PubMed), hand-searching of relevant systematic reviews, dual screening, single-person data abstraction verified by a second person, and dual risk of bias assessment. Due to heterogeneity across studies, no quantitative analyses were conducted.

RESULTS

Twenty-two randomized controlled trials (RCTs), eight of which were non-inferiority trials, evaluated the effectiveness of TH via telephone or video teleconferencing compared to in-person (IP) delivery for patient populations with posttraumatic stress disorder, depression, and mixed diagnoses. The majority of RCTs and all but one of the eight non-inferiority trials found that clinical outcomes did not differ between TH and IP treatment delivery. Two studies found that subgroups with higher symptom severity (hopelessness and anxiety disorders, respectively) in the TH group had worse treatment-related outcomes than IP participants with similar symptom profiles. The majority of studies found no significant differences in satisfaction with care, quality of the therapeutic alliance, or study discontinuation between TH and IP groups.

CONCLUSION

Based on evidence from 22 RCTs, the use of TH platforms, including video conference and telephone modalities, generally produces similar outcomes as face-to-face provision of psychotherapy and psychiatry services.

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

IMPORTANCE

Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

OBJECTIVE

To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

DESIGN, SETTING, AND PARTICIPANTS

This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

INTERVENTIONS

Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

MAIN OUTCOMES AND MEASURES

The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

RESULTS

Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of -3.5 points (95% CI, -4.4 to -2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, -3.0 points; 95% CI, -4.1 to -2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, -2.0 points; 95% CI, -3.1 to -0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, -1.8 points; 95% CI, -3.1 to -0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT02946957.

Cultural adaptations of psychological interventions for prevalent sleep disorders and sleep disturbances: A systematic review of randomized controlled trials in the United States

Psychological interventions for sleep-wake disorders have medium-to-large effect sizes, however whether behavioral randomized controlled trials (RCTs) targeted underserved populations or addressed contextual and cultural factors is unknown. We conducted a systematic review to: (a) examine sociodemographic characteristics of behavioral RCTs for prevalent sleep-wake disorders and sleep disturbances that targeted undeserved adults, (b) identify types of cultural adaptations (surface-level, deep-level), and (c) describe intervention effectiveness on primary sleep outcomes. Overall, 6.97% of RCTs (56 studies) targeted underserved groups (veterans, women, racial/ethnic minorities, low socioeconomic status, disability status); 64.29% made surface-level and/or deep-level cultural adaptations. There was a lack of racial/ethnic, socioeconomic, sexual orientation, and linguistic diversity. Most cultural adaptations were made to behavioral therapies, and cognitive behavioral therapy for insomnia (CBT-I). Surface-level cultural adaptations to the delivery modality and setting were most common. Deep-level cultural adaptations of the content and core intervention components were also typical. Intervention effectiveness varied by type of adapted intervention and participant population. RCTs of adapted CBT-I interventions among participants with a definite sleep disorder or sleep disturbance showed consistent significant reductions in adverse sleep outcomes versus control. These findings have important implications for the use of cultural adaptations to address behavioral sleep medicine disparities.

Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review

BACKGROUND

A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce.

OBJECTIVE

This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury.

METHODS

Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis.

RESULTS

A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed.

CONCLUSIONS

Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

METHODS

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Comparing PTSD treatment retention among survivors of military sexual trauma utilizing clinical video technology and in-person approaches

INTRODUCTION

Interventions such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have demonstrated efficacy for the treatment of post-traumatic stress disorder (PTSD) following military sexual trauma (MST). However, MST survivors report a number of logistical and social barriers that impede treatment engagement. In an effort to address these barriers, the Veterans Health Administration offers remote delivery of services using clinical video technology (CVT). Evidence suggests PE and CPT can be delivered effectively via CVT. However, it is unclear whether rates of veteran retention in PTSD treatment for MST delivered remotely is comparable to in-person delivery in standard care.

METHODS

Data were drawn from veterans (N = 171, 18.1% CVT-enrolled) with PTSD following MST who were engaged in either PE or CPT delivered either via CVT or in person. Veterans chose their preferred treatment modality and delivery format in collaboration with providers. Data were analysed to evaluate full completion (FP) of the protocol and completion of a minimally adequate care (MAC) number of sessions.

RESULTS

FP treatment completion rates did not differ significantly by treatment delivery format. When evaluating receipt of MAC care, CVT utilizers were significantly less likely to complete. Kaplan-Meier analyses of both survival periods detected significant differences in attrition speed, with the CVT group having higher per-session attrition earlier in treatment.

DISCUSSION

Disengagement from CVT-delivered treatment generally coincided with early imaginal exposures and writing of trauma narratives. CVT providers may have to take special care to develop rapport and problem-solve anticipated barriers to completion to retain survivors in effective trauma-focused interventions.

Delivering Cognitive Behavioral Therapy for Insomnia in Military Personnel and Veterans

Insomnia is commonly reported by military populations, especially those with comorbid mental and physical health conditions. Co-occurring conditions result in an altered presentation of insomnia symptoms, and complicate provision of cognitive-behavioral therapy for insomnia (CBT-I), requiring supplementary assessment or modifications to traditional techniques. CBT-I has consistently demonstrated positive outcomes for active-duty service members and veterans, even in the context of significant comorbidities such as post-traumatic stress disorder, depression, sleep apnea, and chronic pain. Despite its promise, studies of CBT-I in some populations, including women and individuals with substance use disorders, remain relatively understudied in active-duty and veteran populations.

Obsessive-Compulsive Symptom Dimensions and Insomnia: Associations Among a Treatment-Seeking Veteran Sample

Sleep disturbances are a prevalent and pernicious correlate of most emotional disorders. A growing body of literature has recently found evidence for an association between sleep disturbances and obsessive-compulsive disorder (OCD). Though informative, this link has yet to be explored in a veteran population. Further, the degree to which this relationship is accounted for by relevant third variables is limited. The current study investigated the relationship between self-reported insomnia and OCD symptoms after controlling for probable depression and posttraumatic stress disorder (PTSD) using an unselected sample of veterans (N = 57). Most of the sample reported clinically significant OCD (61%) and insomnia symptoms (58%). Results revealed associations between insomnia and OCD unacceptable thoughts/neutralizing compulsions, but not contamination obsessions/washing compulsions, responsibility for harm obsessions/checking compulsions, or symmetry obsessions/ordering compulsions. Findings highlight the need for more research on OCD and sleep problems and clinical work focused on sleep for patients reporting increased OCD symptoms, particularly veterans.