Efficacy of a Theory-Based Cognitive Behavioral Technique App-Based Intervention for Patients With Insomnia: Randomized Controlled Trial

Effective Communication Supported by an App for Pregnant Women: Quantitative Longitudinal Study

BACKGROUND

In the medical field of obstetrics, communication plays a crucial role, and pregnant women, in particular, can benefit from interventions improving their self-reported communication behavior. Effective communication behavior can be understood as the correct transmission of information without misunderstanding, confusion, or losses. Although effective communication can be trained by patient education, there is limited research testing this systematically with an app-based digital intervention. Thus, little is known about the success of such a digital intervention in the form of a web-app, potential behavioral barriers for engagement, as well as the processes by which such a web-app might improve self-reported communication behavior.

OBJECTIVE

This study fills this research gap by applying a web-app aiming at improving pregnant women's communication behavior in clinical care. The goals of this study were to (1) uncover the potential risk factors for early dropout from the web-app and (2) investigate the social-cognitive factors that predict self-reported communication behavior after having used the web-app.

METHODS

In this study, 1187 pregnant women were recruited. They all started to use a theory-based web-app focusing on intention, planning, self-efficacy, and outcome expectancy to improve communication behavior. Mechanisms of behavior change as a result of exposure to the web-app were explored using stepwise regression and path analysis. Moreover, determinants of dropout were tested using logistic regression.

RESULTS

We found that dropout was associated with younger age (P=.014). Mechanisms of behavior change were consistent with the predictions of the health action process approach. The stepwise regression analysis revealed that action planning was the best predictor for successful behavioral change over the course of the app-based digital intervention (β=.331; P<.001). The path analyses proved that self-efficacy beliefs affected the intention to communicate effectively, which in turn, elicited action planning and thereby improved communication behavior (β=.017; comparative fit index=0.994; Tucker-Lewis index=0.971; root mean square error of approximation=0.055).

CONCLUSIONS

Our findings can guide the development and improvement of apps addressing communication behavior in the following ways in obstetric care. First, such tools would enable action planning to improve communication behavior, as action planning is the key predictor of behavior change. Second, younger women need more attention to keep them from dropping out. However, future research should build upon the gained insights by conducting similar internet interventions in related fields of clinical care. The focus should be on processes of behavior change and strategies to minimize dropout rates, as well as replicating the findings with patient safety measures.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03855735; https://classic.clinicaltrials.gov/ct2/show/NCT03855735.

Insomnia and anxiety among COVID-19 patients in China: the chain mediating effect of psychological capital and self-esteem

BACKGROUND

The outbreak of Corona Virus Disease (COVID-19) in 2019 has continued until now, posing a huge threat to the public's physical and mental health, resulting in different degrees of mental health problems. As a vulnerable segment of the public, anxiety is one of the most common mental health problems among COVID-19 patients. Excessive anxiety aggravates the physical and psychological symptoms of COVID-19 patients, which is detrimental to their treatment and recovery, increases financial expenditure, affects family relations, and adds to the medical burden.

OBJECTIVE

This study aimed to explore the role of psychological capital and self-esteem in the relationship between insomnia and anxiety, thereby shedding light on the mechanism of the effect of insomnia on anxiety in COVID-19 patients.

METHODS

A cross-sectional study was conducted from April to May 2022 in Fangcang hospital in Shanghai, China. The self-administered questionnaires were distributed to 718 COVID-19 patients via cell phone using the Internet platform "Questionnaire Star", which included Athens Insomnia Scale, Psychological Capital Questionnaire, Self-esteem Scale, Self-Rating Anxiety Scale, gender, age, marital status, education. Data analysis was performed using descriptive analysis, independent-samples t-test, one-way analysis of variance, Pearson correlation analysis, ordinary least-squares regression, and bootstrap method.

RESULTS

Education background had significant impact on anxiety in COVID-19 patients (F = 7.70, P < 0.001). Insomnia, psychological capital, self-esteem and anxiety were significantly correlated, respectively (P < 0.001). And Regression analysis showed that insomnia had a direct negative predictive effect on psychological capital (β = -0.70, P < 0.001) and self-esteem (β = -0.13, P < 0.001). Psychological capital had a direct positive predictive effect on self-esteem (β = 0.12, P < 0.001). Insomnia had a direct positive predictive effect on anxiety (β = 0.61, P < 0.001). Both psychological capital and self-esteem had significant negative predictive effects on anxiety (β = -0.06, P < 0.05; β = -0.72, P < 0.001). The results showed that the mediating effect of psychological capital and self-esteem was significant, and the mediating effect value was 0.21. First, the indirect effect consisting of insomnia - psychological capital - anxiety was 0.04, showing that psychological capital had a significant mediating effect. Second, the indirect effect consisting of insomnia-self-esteem-anxiety had a value of 0.10, indicating that self-esteem had a significant mediating effect. Third, the indirect effect consisting of insomnia-psychological capital-self-esteem-anxiety had a value of 0.06, suggesting that psychological capital and self-esteem had a significant chain mediating effect between insomnia and anxiety.

CONCLUSIONS

Insomnia had a significant positive predictive effect on anxiety. Insomnia was first associated with a decrease in psychological capital, followed by a sequential decrease in self-esteem, which in turn was associated with increased anxiety symptoms in COVID-19 patients. Therefore, focusing on improving the psychological capital and self-esteem of patients can help alleviate the anxiety caused by insomnia in COVID-19 patients. It is recommended that patients and health care professionals increase the psychological capital and Self-esteem of COVID-19 patients through various methods to counter the effects of insomnia on anxiety.

Mobile cognitive behavioral therapy for insomnia: analysis of factors affecting treatment prognosis

This study aims to explore the factors that affect the prognosis of patients with insomnia who are treated with mobile cognitive behavioral therapy. Patients with insomnia who visited the sleep disorders clinic were selected and completed mobile Cognitive behavioral therapy. Patients completed at least three evaluations (including baseline, monthly evaluations thereafter, and a final evaluation at the end of one year) and responded well to treatment within one year of follow-up. Insomnia, anxiety, and depression symptoms were evaluated using the Pittsburgh Sleep Quality Index (PSQI), the Generalized Anxiety Disorder 7-item (GAD-7) scale, and the 9-item Patient Health Questionnaire (PHQ-9), respectively. Treatment prognosis including relapse, recurrence, and remission group. These 339 patients were divided into three groups: 160 patients who remission, 100 patients who relapsed, and 79 patients who experienced recurrence after remission. Demographic characteristics of the 339 patients showed no significant difference in gender between the three groups (P = 0.978). However, significant differences were found in age (P = 0.006) and onset time (P = 0.000) among the three groups. The remission group had a higher average age than the recurrence group and the relapse group, and the onset time was slower than the other two groups. Multivariate logistic regression analysis showed that age and delayed onset time were protective factors for good treatment prognosis, while low educational level and high GAD-7 scores were independent risk factors for poor prognosis. There are many factors that affect the treatment prognosis of insomnia. Age, low educational level, high GAD-7 scores, and delayed onset time can be used to predict the prognosis of insomnia treatment.

Cognitive Behavioral Therapy for Insomnia Self-Management Mobile Apps: A Review of Efficacy and Quality

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia, yet multiple barriers limit utilization. Digital CBT-I may present a solution, though related reviews have focused on Internet-based delivery rather than app use. The high utilization of health apps and prevalence of sleep apps indicate the need to equip clinicians with app-specific research. Toward this end, we reviewed efficacy and quality data on self-management CBT-I smartphone apps, revealing efficacy research on eleven apps, five of which were publicly available. While preliminary, these efficacy studies showed consistent positive findings. When examining quantitative quality indicators for the five publicly available apps, two had consistent data. Overall, two apps, CBTi Coach and Insomnia Coach, had positive, empirical findings across all efficacy and quality assessment approaches. We provide recommendations to guide clinician decision making regarding CBT-I self-management apps based on the literature and publicly available methods of app evaluations.

Well-being therapy and sleep hygiene in a non-clinical population of adults reporting poor sleep quality and distress: A remote pilot randomized controlled study

OBJECTIVES

This pilot randomized controlled study evaluates the feasibility and preliminary efficacy of a 7-week remote intervention combining well-being therapy and sleep hygiene to improve sleep and psychological outcomes among adults reporting poor sleep and distress.

METHODS

Thirty-one participants (81% women, 40.2 ± 13.0 y, 48% racial/ethnic minority) were recruited from the community during the COVID-19 pandemic through online and local advertisement, and randomized to well-being therapy+sleep hygiene or sleep hygiene-only. Study outcomes were evaluated by self-reported questionnaires administered at baseline and post-intervention and a daily sleep diary.

RESULTS

Compared to sleep hygiene-only, well-being therapy+sleep hygiene led to greater improvements in wake after sleep onset (time-by-group interaction: 3.6 ± 1.5 min, p = .017), personal growth (β -3.0, 95%CI -5.2, -0.8, p = .01), and purpose in life (β -3.5, 95%CI -6.1, -0.9, p = .009). Anxiety, perceived stress, sleep quality, and insomnia symptoms improved similarly in both groups (between-group differences, p > .05). Improvements in sleep quality, insomnia, and sleep duration were associated with reductions in multiple measures of psychological distress (all p < .05).

CONCLUSIONS

These findings suggest that, in a non-clinical setting of individuals suffering from combined poor sleep and psychological distress, the addition of well-being therapy to sleep hygiene may provide additional benefits for sleep by promoting sleep continuity and well-being.

The efficacy of digital cognitive behavioral therapy for insomnia and depression: a systematic review and meta-analysis of randomized controlled trials

Background

Insomnia and depression often co-occur. Cognitive behavioral therapy for insomnia (CBT-I) seems to be effective and safe for mitigating insomnia and depression. However, the efficacy of digitally-delivered CBT-I (dCBT-I) remains unclear. Therefore, this meta-analysis of randomized controlled trials (RCTs) was to systematically review and evaluate the efficacy of dCBT-I in adults with insomnia and depression.

Methods

A systematic search in PubMed, Cochrane, Embase, and Web of Science databases (as of June 5, 2022) was conducted for RCTs on dCBT-I. Statistical analyses were performed using Revan Manager. The effects of dCBT-I on insomnia and depression were expressed as standardized mean difference (SMD) with 95% confidence intervals (CIs).

Results

Seven studies involving 3,597 participants were included. This meta-analysis showed that dCBT-I reduced the severity of insomnia (SMD = -0.85, 95% CI [-1.00 to -0.69], p < 0.001) and depression (SMD = -0.47, 95% CI [-0.55 to -0.38], p < 0.001) in short terms, and also mitigated the severity of insomnia (SMD = -0.71, 95% CI [-1.00 to -0.44], p < 0.001) and depression (SMD = -0.42, 95% CI [-0.68 to -0.15], p = 0.002) in long terms. The effect of dCBT-I was comparable to that of traditional face-to-face CBT-I, and was generally maintained at follow-ups of 6 weeks to 6 months.

Conclusion

dCBT-I seems to be effective in alleviating insomnia and depression and might be considered as a viable treatment option for depression.

Sleep Profiles of Caregivers for Persons Living with Dementia: A Qualitative Study

Sleep disturbance is prevalent among caregivers of people living with dementia. However, gaps exist about caregivers' sleep patterns before and during their caregiving trajectory. This exploratory secondary analysis using a qualitative descriptive approach aimed to (1) identify and describe current caregivers' patterns of change in sleep before and during caregiving, and (2) understand caregivers' perceptions of their current sleep compared to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers taking part in a larger randomized controlled trial. Participants were female (n = 11), white (n = 13) and on average 63 years of age. Interview questions focused on caregivers' sleep patterns. The interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Three distinct caregiver-sleep profiles emerged from the qualitative data: changed and dissatisfied, changed and satisfied, and unchanged and dissatisfied. Caregivers whose sleep was categorized as changed reported a difference when comparing their current sleep pattern to their pre-caregiving sleep pattern. This was usually a change from good to poor sleep. Caregivers whose sleep was unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being satisfied or dissatisfied with their current sleep pattern, defined in terms of distress and impairment. These three subtypes highlight the heterogeneity of caregivers' sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance, many who may be ready to engage in behaviors to improve their sleep. Knowing caregivers' sleep profiles will enable health care providers and researchers to determine caregivers' needs and readiness for interventions then work collaboratively with them to improve their sleep problems.

Digital cognitive behavioral therapy for insomnia on depression and anxiety: a systematic review and meta-analysis

Despite research into the development of digital cognitive behavioral therapy for insomnia (dCBT-I), research into the outcomes of dCBT-I on insomnia and the associated clinical conditions of depression and anxiety have been limited. The PubMed, PsycINFO (Ovid), Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) on adult patients with insomnia also having reported measures of depressive or anxiety symptoms. In total, 2504 articles were identified after duplicate removal, and 22 RCTs were included in the final meta-analysis. At the post-treatment assessment, the dCBT-I group had a small to moderate effect in alleviating depressive (standardized mean difference (SMD) = -0.42; 95% CI: -0.56, -0.28; p < 0.001; k = 21) and anxiety symptoms (SMD = -0.29; 95% CI: -0.40, -0.19; p < 0.001; k = 18), but had a large effect on sleep outcome measures (SMD = -0.76; 95% CI: -0.95, -0.57; p < 0.001; k = 22). When considering treatment adherence, the treatment effects of those in the high adherent groups identified a more robust outcome, showing greater effect sizes than those in the low adherent groups for depression, anxiety, and sleep outcomes. Furthermore, additional subgroup analysis on studies that have used the fully automated dCBT-I treatment without the support of human therapists reported significant treatment effects for depression, anxiety, and sleep outcomes. The results demonstrated that digital intervention for insomnia yielded significant effects on alleviating depressive and anxiety symptoms as well as insomnia symptoms. Specifically, the study demonstrated significant effects on the above symptoms when considering treatment adherence and implementing fully automated dCBT-I.

Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial

BACKGROUND

A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.

OBJECTIVE

This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.

METHODS

In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.

RESULTS

We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.

CONCLUSIONS

An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

Effectiveness of Digital Mental Health Tools to Reduce Depressive and Anxiety Symptoms in Low- and Middle-Income Countries: Systematic Review and Meta-analysis

BACKGROUND

Depression and anxiety contribute to an estimated 74.6 million years of life with disability, and 80% of this burden occurs in low- and middle-income countries (LMICs), where there is a large gap in care.

OBJECTIVE

We aimed to systematically synthesize available evidence and quantify the effectiveness of digital mental health interventions in reducing depression and anxiety in LMICs.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Embase, and Cochrane databases from the inception date to February 2022. We included randomized controlled trials conducted in LMICs that compared groups that received digital health interventions with controls (active control, treatment as usual, or no intervention) on depression or anxiety symptoms. Two reviewers independently extracted summary data reported in the papers and performed study quality assessments. The outcomes were postintervention measures of depression or anxiety symptoms (Hedges g). We calculated the pooled effect size weighted by inverse variance.

RESULTS

Among 11,196 retrieved records, we included 80 studies in the meta-analysis (12,070 participants n=6052, 50.14% in the intervention group and n=6018, 49.85% in the control group) and 96 studies in the systematic review. The pooled effect sizes were -0.61 (95% CI -0.78 to -0.44; n=67 comparisons) for depression and -0.73 (95% CI -0.93 to -0.53; n=65 comparisons) for anxiety, indicating that digital health intervention groups had lower postintervention depression and anxiety symptoms compared with controls. Although heterogeneity was considerable (I²=0.94 for depression and 0.95 for anxiety), we found notable sources of variability between the studies, including intervention content, depression or anxiety symptom severity, control type, and age. Grading of Recommendations, Assessments, Development, and Evaluation showed that the evidence quality was overall high.

CONCLUSIONS

Digital mental health tools are moderately to highly effective in reducing depression and anxiety symptoms in LMICs. Thus, they could be effective options to close the gap in depression and anxiety care in LMICs, where the usual mental health care is minimal.

TRIAL REGISTRATION

PROSPERO CRD42021289709; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=289709.

Effectiveness of one-week internet-delivered cognitive behavioral therapy for insomnia to prevent progression from acute to chronic insomnia: A two-arm, multi-center, randomized controlled trial

Acute insomnia is common and a substantial proportion of people with acute insomnia (i.e. 3 days to 3 months) transit into chronic insomnia (i.e. 3 months or longer). Therefore, early intervention for acute insomnia is vital to prevent chronicity. Previous trials with small sample sizes have shown that brief versions of both individual and group-based face-to-face cognitive behavioral therapy for insomnia (CBT-I) can improve insomnia symptoms among those with acute insomnia. However, it is unknown whether one-week internet-delivered cognitive behavioral therapy for insomnia (CBT-I) is effective in treating acute insomnia. This was a randomized controlled trial and 192 participants were randomly assigned to the CBT-I group (n = 95) or control group (n = 97). The primary outcome was the incidence of chronic insomnia, determined via a structured diagnostic questionnaire for insomnia disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Secondary outcomes were Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), Epworth Sleepiness Scale (ESS), Pre-sleep Arousal Scale (PSAS), Ford Insomnia Response to Stress Test (FIRST), Sleep Hygiene and Practices Scale (SHPS), Hospital Anxiety and Depression Scale (HADS), and Short-Form 12-Item Health Survey version 2 (SF-12v2). At week 12, the incidence of chronic insomnia was significantly lower in the CBT-I group compared with control group (33.3% [27/81] vs. 65.8% [52/79]). Participants in the CBT-I group achieved significantly more improvements in ISI, ESS, PSAS, FIRST, SHPS, HADS-Depression, and the mental component summary and physical component summary of SF-12v2 than control group, but not DBAS and HADS-Anxiety. This one-week internet-delivered CBT-I program is an effective tool to prevent the chronicity of acute insomnia.

Multicentre, England-wide randomised controlled trial of the 'Foundations' smartphone application in improving mental health and well-being in a healthcare worker population

BACKGROUND

Healthcare workers (HCWs) have faced considerable pressures during the COVID-19 pandemic. For some, this has resulted in mental health distress and disorder. Although interventions have sought to support HCWs, few have been evaluated.

AIMS

We aimed to determine the effectiveness of the 'Foundations' application (app) on general (non-psychotic) psychiatric morbidity.

METHOD

We conducted a multicentre randomised controlled trial of HCWs at 16 NHS trusts (trial registration number: EudraCT: 2021-001279-18). Participants were randomly assigned to the app or wait-list control group. Measures were assessed at baseline, after 4 and 8 weeks. The primary outcome was general psychiatric morbidity (using the General Health Questionnaire). Secondary outcomes included: well-being; presenteeism; anxiety; depression and insomnia. The primary analysis used mixed-effects multivariable regression, presented as adjusted mean differences (aMD).

RESULTS

Between 22 March and 3 June 2021, 1002 participants were randomised (500:502), and 894 (89.2%) followed-up. The sample was predominately women (754/894, 84.3%), with a mean age of 44⋅3 years (interquartile range (IQR) 34-53). Participants randomised to the app had a reduction in psychiatric morbidity symptoms (aMD = -1.39, 95% CI -2.05 to -0.74), improvement in well-being (aMD = 0⋅54, 95% CI 0⋅20 to 0⋅89) and reduction in insomnia (adjusted odds ratio (aOR) = 0⋅36, 95% CI 0⋅21 to 0⋅60). No other significant findings were found, or adverse events reported.

CONCLUSIONS

The app had an effect in reducing psychiatric morbidity symptoms in a sample of HCWs. Given it is scalable with no adverse effects, the app may be used as part of an organisation's tiered staff support package. Further evidence is needed on long-term effectiveness and cost-effectiveness.

Insomnia in primary care: Considerations for screening, assessment, and management

Insomnia, including insomnia disorder, is a common but often overlooked complaint in primary care settings. It is a risk factor for various medical and psychiatric diagnoses and is associated with substantial health care costs. While cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia disorder, access to CBT-I is limited. This article provides a pragmatic approach to screening, assessment, and treatment of insomnia in the primary care setting, promoting a population health approach. The authors review the role of CBT-I, treatment of comorbid conditions, and pharmacologic recommendations in working with primary care patients with insomnia. In addition, the authors highlight the potential utility of technology in improving access to insomnia care.

The Mediating Role of Selfitis in the Associations between Self-Esteem, Problematic Social Media Use, Problematic Smartphone Use, Body-Self Appearance, and Psychological Distress among Young Ghanaian Adults

Selfie-related activities have become pervasive to the point that they may affect the mental health of people who engage in them. To ascertain this mechanism, this study examined the mediating role of selfitis in the associations between self-esteem, problematic social media use, problematic smartphone use, body-self appearance, and psychological distress among young Ghanaian adults. A total of 651 participants completed a questionnaire with measures on self-esteem, body-self appearance, problematic social media use, problematic smartphone use, depression, anxiety, stress, coping skills, and selfitis. There were direct associations between all the variables except between self-esteem and selfitis. In addition, selfitis mediated the associations between problematic social media use, problematic smartphone use, body-self appearance, and psychological distress except between self-esteem and psychological distress. These findings suggest that selfitis can serve as a pathway by which people who overly engage in problematic social media use, problematic smartphone use, and have poor body-self appearance may experience psychological distress. Hence, there is a need for health communicators, school authorities, and opinion leaders to educate young adults on the consequences of the problematic use of technology, especially for selfitis behaviour. Future studies can examine the factors that predict selfitis behaviour among adults.

Association between trajectories of problematic mobile phone use and chronotype among Chinese college students

AIMS

This study aimed to describe the prevalence of problematic mobile phone use (PMPU) and chronotype among Chinese college students, estimate PMPU development trajectories, and further examine the effect of PMPU trajectories on chronotype.

DESIGN

In a stratified cluster sampling design, PMPU and chronotype were evaluated in 999 college students from two universities in a 2-year prospective investigation from April 2019 to April 2021, and an investigation was conducted every six months (time 1 ∼ time 5, T1 ∼ T5).

PARTICIPANTS

N = 999 college students (mean age at T1: 18.8 years (SD = 1.2), 37.7% male) took part in the study.

MEASUREMENTS

The Self-rating Questionnaire for Adolescent Problematic Mobile Phone Use (SQAPMPU) and the Pittsburgh Sleep Quality Index (PSQI) were used to assess the PMPU and sleep quality of college students at each time point. The Morning and Evening Questionnaire (MEQ) was adopted to investigate the chronotype of college students at T5.

FINDINGS

The prevalence of PMPU at T1 ∼ T5 was 24.3%, 27.3%, 35.1%, 31.2% and 31.9%, respectively. The prevalence rates of morning types (M-types), neutral types (N-types), and evening types (E-types) were 19.1%, 70.8%, and 10.1%, respectively. Using latent growth mixture modelling, we identified three trajectories of PMPU: low-level (49.5%), moderate-level (38.6%), and high-level score trajectories (11.9%). Multivariate logistic regression analysis results showed that a trajectory with a high score was positively associated with E-types (P < 0.05). After stratification by gender, a high-level score trajectory was positively associated with E-types only among female college students (P < 0.05). There were sex differences in the association between trajectories of PMPU and chronotype.

CONCLUSION

Long-term symptoms of PMPU may be a potential risk factor for circadian rhythm disturbance among college students, and this effect was significantly different between genders.

Network meta-analysis comparing the effectiveness of a prescription digital therapeutic for chronic insomnia to medications and face-to-face cognitive behavioral therapy in adults

OBJECTIVE

The purpose of this study was to compare the effectiveness of the only Food and Drug Administration-authorized prescription digital therapeutic (PDT) Somryst versus face-to-face cognitive behavioral therapy for insomnia (CBT-I), or FDA-approved prescription medications for insomnia.

METHODS

A systematic literature review was undertaken to identify relevant studies. A Bayesian network meta-analysis (NMA) was conducted to examine (1) mean change in insomnia severity index (ISI); (2) proportional change in ISI remitters; (3) mean change in wake after sleep onset (WASO); and (4) mean change in sleep onset latency (SOL).

RESULTS

Twenty studies provided data on the PDT, CBT-I, CBT-I in combination with self-help (SH), or two prescription medications (eszopiclone and zolpidem). The PDT was associated with significant mean change in ISI (-5.77, 95% Credible Interval [CrI] - 8.53, -3.07) and ISI remitters (OR 12.33; 95% CrI 2.28, 155.91) compared to placebo, and had the highest probability of being the most effective treatment overall for ISI mean change (56%), and ISI remitters (64%). All evaluated interventions significantly outperformed placebo for WASO but no significant differences were observed for SOL (five interventions). Sensitivity analyses excluding medications and meta-regression (assessing type, duration, delivery method for CBT-I) did not affect NMA results.

CONCLUSIONS

This network meta-analysis demonstrated that a PDT delivering CBT-I had the highest probability of being most effective compared to face-to-face CBT-I, prescription sleep medications, or placebo, as measured by reductions in mean ISI score from baseline and ISI-determined remittance.

The Mediating Roles of Anxiety, Depression, Sleepiness, Insomnia, and Sleep Quality in the Association between Problematic Social Media Use and Quality of Life among Patients with Cancer

The present study examined the mediating role of anxiety, depression, sleepiness, insomnia, and sleep quality in the association between problematic social media use and quality of life (QoL) among patients with cancer. This cross-sectional survey study recruited 288 patients with cancer to respond to measures on anxiety, depression, sleepiness, insomnia, sleep quality, problematic social media use, and QoL. Structural Equation Modeling was used for the mediation analysis. There were significant relationships between all of the variables used in the study. It was revealed that problematic social media use did not directly influence the QoL of patients with cancer except via anxiety, depression, sleepiness, and insomnia. Sleep quality did not mediate the association between problematic social media use and QoL. Healthcare workers managing cancer should pay attention to the mental health needs of their patients even as they treat their cancer so as to improve their quality of life. Future studies may examine other variables that affect the QoL of patients with cancer as well as other mediating and moderating variables.

Effectiveness of Digital Cognitive Behavior Therapy for the Treatment of Insomnia: Spillover Effects of dCBT

The effects of digital Cognitive Behavior Therapy for insomnia (dCBT-i) on sleep quality have been previously demonstrated but the spillover effects on fatigue, flow (a state of immersion in activities of interest), and cognitive flexibility remain unclear. The current study examined the effectiveness of dCBT-i. A total of 97 college students (20.96 ± 1.87 years, 73.1% female students) were randomly selected from a shortlist and divided into sleep intervention (n = 39), conventional education (n = 37), and healthy control (n = 21) groups. Task switching paradigm, Fatigue Severity Scale (FSS), Flow Experience Scale (FES), and the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) were measured pre- and post-intervention. Results show that the sleep quality of the intervention group improved, and fatigue was relieved. Participants in the sleep intervention group had increased flow experience scores post-intervention and improved cognitive flexibility. The control group’s sleep quality deteriorated and fatigue level increased. dCBT-i can not only achieve a significant improvement in sleep quality and reduce fatigue, but also improve learning abilities, quality of life, flow, and cognitive flexibility. Future research should pay attention to indicators such as work efficiency, sedative use, and the durability and stability of such effects.

The effect of a social network-based cognitive behavioral therapy intervention on the severity of premenstrual syndrome symptoms: a protocol of a randomized clinical trial study

Background

Premenstrual syndrome (PMS) is one of the most widespread menstrual disorders in women of reproductive age. This recurrent syndrome is a combination of physically, mentally, or behaviorally disturbing changes occurring during the secretory phase of the menstrual cycle. The aim of this study is to determine the effect of a cognitive-behavioral therapy-based educational intervention using social networks on PMS in female health center employees in Rudbar, Iran.

Methods/design

A randomized superiority controlled trial will be conducted involving 140 female employees of health centers affiliated with the Guilan University of Medical Sciences, Rudbar. The study involves a block size of 4 and 6 in a randomly varied order, 140 women who meet all the inclusion criteria will be randomly and equally divided into 2 groups: the intervention and the control groups. Those in the former group will receive a cognitive-behavioral therapy-based treatment for eight consecutive weeks on the social network platform WhatsApp; however, those in the control group will not be offered any treatment except usual care practices (unprotocolized usual care). The study’s primary outcome is the severity of PMS symptoms, and the secondary outcomes include general self-efficacy, work-related quality of life, the impact of PMS on daily life, coping with the symptoms, and experiencing anxiety and depression at the beginning of the study to identify people with PMS. A daily record of the symptoms will be completed for two consecutive months by all female employees aged 20–45 years who wish to participate in the study. According to the initial screening, those with moderate to severe PMS will be included. We will use the MLwin software for the analyses. All questionnaires will be completed by both groups immediately and 8 weeks after the termination of the treatment. The data will be analyzed using linear mixed-effects modeling with random intercepts and slopes.

Discussion

It is anticipated that the findings of the present study may demonstrate the effectiveness of the cognitive behavioral therapy intervention on the severity of PMS symptoms that could guide healthcare providers in opting for suitable treatment alternatives for the syndrome.

Ethics and dissemination

The research proposal is approved by the Human Ethics Committee of Qazvin University of Medical Sciences (IR.QUMS.REC.1399.252). The results of this intervention trial will be submitted for publication in a peer-reviewed research journal.

Trial registration

Iranian Registry of Clinical Trials IRCT20180218038789N4. Registered prospectively on October 28, 2020

A longitudinal study of the effects of problematic smartphone use on social functioning among people with schizophrenia: Mediating roles for sleep quality and self-stigma

Background and aims

Individuals with schizophrenia may often experience poor sleep, self-stigma, impaired social functions, and problematic smartphone use. However, the temporal relationships between these factors have not been investigated. The present study used a longitudinal design to examine potential mediating roles of poor sleep and self-stigma in associations between problematic smartphone use and impaired social functions among individuals with schizophrenia.

Methods

From April 2019 to August 2021, 193 individuals with schizophrenia (mean [SD] age = 41.34 [9.01] years; 88 [45.6%] males) were recruited and asked to complete three psychometric scales: the Smartphone Application-Based Addiction Scale to assess problematic smartphone use; the Pittsburgh Sleep Quality Index to assess sleep quality; and the Self-Stigma Scale-Short Scale to assess self-stigma. Social functioning was evaluated by a psychiatrist using the Personal and Social Performance Scale. All measures were assessed five times (one baseline and four follow-ups) at three-month intervals between assessments.

Results

General estimating equations found that problematic smartphone use (coefficient = -0.096, SE = 0.021; P < 0.001), sleep quality (coefficient = -0.134, SE = 0.038; P < 0.001), and self-stigma (coefficient = -0.612, SE = 0.192; P = 0.001) were significant statistical predictors for social functioning. Moreover, sleep quality and self-stigma mediated associations between problematic smartphone use and social functioning.

Conclusion

Problematic smartphone use appears to impact social functioning longitudinally among individuals with schizophrenia via poor sleep and self-stigma concerns. Interventions aimed at reducing problematic smartphone use, improving sleep, and addressing self-stigma may help improve social functioning among individuals with schizophrenia.

Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis

Background

Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally.

Objective

The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally.

Methods

The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time.

Results

Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI –0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=–.23, 95% CI −0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI −0.11 to 0.23) or 6-month (β=.09, 95% CI −0.10 to 0.28) follow-up.

Conclusions

Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis.

Suicidal Ideation during the COVID-19 Pandemic among A Large-Scale Iranian Sample: The Roles of Generalized Trust, Insomnia, and Fear of COVID-19

The novel 2019 coronavirus disease (COVID-19) is still not under control globally. The pandemic has caused mental health issues among many different cohorts and suicidal ideation in relation to COVID-19 has been reported in a number of recent studies. Therefore, the present study proposed a model to explain the associations between generalized trust, fear of COVID-19, insomnia, and suicidal ideation during the COVID-19 pandemic among a large-scale Iranian sample. Utilizing cluster sampling with multistage stratification, residents from Qazvin province in Iran were invited to participate in the present study. Adults aged over 18 years (n = 10,843; 6751 [62.3%] females) completed ‘paper–and-pencil’ questionnaires with the assistance of a trained research assistant. Structural equation modeling (SEM) was applied to understand the associations between generalized trust, fear of COVID-19, insomnia, and suicidal ideation. Slightly over one-fifth of the participants (n = 2252; 20.8%) reported suicidal ideation. Moreover, the SEM results indicated that generalized trust was indirectly associated with suicidal ideation via fear of COVID-19 and insomnia. Furthermore, generalized trust was not directly associated with suicidal ideation. The proposed model was invariant across gender groups, age groups, and participants residing in different areas (i.e., urban vs. rural). Generalized trust might reduce individuals’ suicidal ideation during the COVID-19 pandemic period via reduced levels of fear of COVID-19 and insomnia. Healthcare providers and policymakers may want to assist individuals in developing their generalized trust, reducing fear of COVID-19, and improving insomnia problems to avoid possible suicidal behaviors.

Factors influencing the efficiency of cellphone-based CBT for treating sleep disorders

OBJECTIVE

This survey aimed to better comprehend the factors influencing patient response to insomnia treatment.

METHODS

We conducted an online survey. A total of 1,395 patients completed the questionnaire at baseline. Insomnia, anxiety and depressive symptoms were evaluated using the Pittsburgh Sleep Quality Index (PSQI), 7-item Generalized Anxiety Disorder assessment (GAD-7) and 9-item Patient Health Questionnaire (PHQ-9), respectively. A total of 488 patients completed at least two surveys (baseline and monthly surveys thereafter) and reported that the online CBT was effective at the 1-year follow-up. The 488 patients were divided into three groups: the rapid (treatment effective at 4 weeks), intermediate (4-16 weeks), and delayed-response group (over 16 weeks).

RESULTS

Analysis of the demographic characteristics of the 488 patients did not reveal significant sex differences among the three groups (P = 0.111). However, the groups significantly differed in age (P = 0.001) and education (P = 0.006). Compared to the rapid response group, the delayed-response group had a higher mean age (P < 0.01) and a slightly lower level of education. The duration of the disorder was longer in the delayed-response group. Multivariate logistic regression showed that male sex, junior high school education, and higher PSQI were independent risk factors for the delayed response to treatment.

CONCLUSION

Many factors affected the efficiency of insomnia treatment. Male sex, junior school education, and a high PSQI score predicted delayed response to insomnia treatment.

Effects of mindful breathing combined with sleep-inducing exercises in patients with insomnia

BACKGROUND

Insomnia is the most common sleep disorder. It disrupts the patient’s life and work, increases the risk of various health issues, and often requires long-term intervention. The financial burden and inconvenience of treatments discourage patients from complying with them, leading to chronic insomnia.

AIM

To investigate the long-term home-practice effects of mindful breathing combined with a sleep-inducing exercise as adjunctive insomnia therapy.

METHODS

A quasi-experimental design was used in the present work, in which the patients with insomnia were included and grouped based on hospital admission: 40 patients admitted between January and April 2020 were assigned to the control group, and 40 patients admitted between May and August 2020 were assigned to the treatment group. The control group received routine pharmacological and physical therapies, while the treatment group received instruction in mindful breathing and a sleep-inducing exercise in addition to the routine therapies. The Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Insomnia Severity Index (ISI) were utilized to assess sleep-quality improvement in the patient groups before the intervention and at 1 wk, 1 mo, and 3 mo postintervention.

RESULTS

The PSQI, GAD-7, and ISI scores before the intervention and at 1 wk postintervention were not significantly different between the groups. However, compared with the control group, the treatment group exhibited significant improvements in sleep quality, daytime functioning, negative emotions, sleep latency, sleep duration, sleep efficiency, anxiety level, and insomnia severity at 1 and 3 mo postintervention (P < 0.05). The results showed that mindful breathing combined with the sleep-inducing exercise significantly improved the long-term effectiveness of insomnia treatment. At 3 mo, the PSQI scores for the treatment vs the control group were as follows: Sleep quality 0.98 ± 0.48 vs 1.60 ± 0.63, sleep latency 1.98 ± 0.53 vs 2.80 ± 0.41, sleep duration 1.53 ± 0.60 vs 2.70 ± 0.56, sleep efficiency 2.35 ± 0.58 vs 1.63 ± 0.49, sleep disturbance 1.68 ± 0.53 vs 2.35 ± 0.53, hypnotic medication 0.53 ± 0.64 vs 0.93 ± 0.80, and daytime dysfunction 1.43 ± 0.50 vs 2.48 ± 0.51 (all P < 0.05). The GAD-7 scores were 2.75 ± 1.50 vs 7.15 ± 2.28, and the ISI scores were 8.68 ± 2.26 vs 3.38 ± 1.76 for the treatment vs the control group, respectively (all P < 0.05).

CONCLUSION

These simple, cost-effective, and easy-to-implement practices used in clinical or home settings could have profound significance for long-term insomnia treatment and merit wide adoption in clinical practice.

The Impact of COVID-19 on Individuals with Hearing and Visual Disabilities during the First Pandemic Wave in Italy

BACKGROUND

The COVID-19 pandemic has imposed radical behavioral and social changes in the general population, significantly impacting the lives of individuals affected by disabilities. The aim of this study was to investigate the impact of COVID-19 on non-institutionalized subjects with sensorineural disabilities during the first COVID-19 wave in Italy.

METHODS

A 39-item online national survey was disseminated from 1 April 2020 to 31 June 2020 via social media throughout Italy to communities of individuals with proven severe sensorineural disabilities, affiliated to five national patient associations. The survey collected extensive information on the socio-demographic profile, health, everyday activities, and lifestyle of individuals with hearing and visual disabilities.

RESULTS

One hundred and sixty-three respondents with hearing (66.9%) and visual (33.1%) disabilities returned a usable questionnaire. The mean age of interviewees was 38.4 ± 20.2 years and 56.3% of them were females. Despite the vast majority of respondents (77.9%) perceiving their health status as unchanged (68.8% of interviewees with hearing deficits vs. 96.3% of those with visual impairments), about half the interviewees reported sleep disorders during lock-down, more likely those with visual deficits. Remote services were seemingly more effective for business than school activities. Furthermore, although just 18.8% of respondents rated remote rehabilitation care unsatisfactory, only 12.8% of interviewees felt supported by health and social services during the COVID-19 emergency. The vast majority of respondents were concerned about the future and the risk of SARS-CoV-2 contagion, particularly individuals with hearing impairments. Among the various risk mitigation measures, facemasks caused the greatest discomfort due to communication barriers, particularly among interviewees affected by hearing disabilities (92.2% vs. 45.7%). The most common request (46.5%) of respondents to reduce the inconveniences of the COVID-19 emergency country lock-down was improving the access to and delivery of health and social services for individuals with sensorineural disabilities (19.3%), followed by the use of transparent masks (17.5%).

CONCLUSIONS

Although health protection measures such as face masks and social distancing play a key role in preventing and controlling the spread of SARS-CoV-2, the unmet needs of disabled individuals should be carefully considered, especially those affected by sensory disabilities. Tailored access to health and social services for individuals affected by sensorineural disabilities should be implemented. Additional actions should include the use of to face masks to reduce communication barriers linked to hearing-impairment, as well as the improvement of remote services, especially distance learning at school.

Self-help cognitive behavioral therapy application for COVID-19-related mental health problems: A longitudinal trial

BACKGROUND AND AIM

Recently, the availability and usefulness of mobile self-help mental health applications have increased, but few applications deal with COVID-19-related psychological problems. This study explored the intervention efficacy of a mobile application on addressing psychological problems related to COVID-19.

METHODS

A longitudinal control trial involving 129 Chinese participants with depression symptoms was conducted through the mobile application "Care for Your Mental Health and Sleep during COVID-19" (CMSC) based on WeChat. Participants were divided into two groups: mobile internet cognitive behavioral therapy (MiCBT) and wait-list. The primary outcome was improvement in depression symptoms. Secondary outcomes included improvement in anxiety and insomnia. The MiCBT group received three self-help CBT intervention sessions in one week via CMSC.

RESULTS

The MiCBT group showed significant improvement in depression and insomnia (allP < 0.05) compared with the wait-list group. Although both groups showed significant improvement in anxiety at the intervention's end, compared with the wait-list group, the MiCBT group had no significant advantage. Correlation analysis showed that improvement in depression and anxiety had a significant positive association with education level. Changes in insomnia were significantly negatively correlated with anxiety of COVID-19 at the baseline. CMSC was considered helpful (n=68, 81.9 %) and enjoyable (n=54, 65.9 %) in relieving depression and insomnia during the COVID-19 outbreak.

CONCLUSIONS

CMSC is verified to be effective and convenient for improving COVID-19-related depression and insomnia symptoms. A large study with sufficient evidence is required to determine its continuous effect on reducing mental health problems during the pandemic.

Sleep problems during COVID-19 pandemic and its' association to psychological distress: A systematic review and meta-analysis

BACKGROUND

The emerging novel coronavirus disease 2019 (COVID-19) has become one of the leading cause of deaths worldwide in 2020. The present systematic review and meta-analysis estimated the magnitude of sleep problems during the COVID-19 pandemic and its relationship with psychological distress.

METHODS

Five academic databases (Scopus, PubMed Central, ProQuest, ISI Web of Knowledge, and Embase) were searched. Observational studies including case-control studies and cross-sectional studies were included if relevant data relationships were reported (i.e., sleep assessed utilizing the Pittsburgh Sleep Quality Index or Insomnia Severity Index). All the studies were English, peer-reviewed papers published between December 2019 and February 2021. PROSPERO registration number: CRD42020181644.

FINDINGS

168 cross-sectional, four case-control, and five longitudinal design papers comprising 345,270 participants from 39 countries were identified. The corrected pooled estimated prevalence of sleep problems were 31% among healthcare professionals, 18% among the general population, and 57% among COVID-19 patients (all p-values < 0.05). Sleep problems were associated with depression among healthcare professionals, the general population, and COVID-19 patients, with Fisher's Z scores of -0.28, -0.30, and -0.36, respectively. Sleep problems were positively (and moderately) associated with anxiety among healthcare professionals, the general population, and COVID-19 patients, with Fisher's z scores of 0.55, 0.48, and 0.49, respectively.

INTERPRETATION

Sleep problems appear to have been common during the ongoing COVID-19 pandemic. Moreover, sleep problems were found to be associated with higher levels of psychological distress. With the use of effective programs treating sleep problems, psychological distress may be reduced. Vice versa, the use of effective programs treating psychological distress, sleep problems may be reduced.

FUNDING

The present study received no funding.