One-Week Self-Guided Internet Cognitive Behavioral Treatments for Insomnia in Adults With Situational Insomnia During the COVID-19 Outbreak

Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study

BACKGROUND

Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population's mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely.

OBJECTIVE

The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic.

METHODS

The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed.

RESULTS

Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period.

CONCLUSIONS

e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24913.

Baseline symptoms of depression and anxiety negatively impact the effectiveness of CBTi in treating acute insomnia among young adults

Background

Cognitive-behavioural therapy for insomnia (CBTi) is the first-line treatment for those with this sleep disorder. However, depressive and anxiety symptoms often co-occur with acute insomnia, which may affect the effectiveness of CBTi treatment.

Aims

This study aimed to determine the impact of depressive and anxiety symptoms on the efficacy of CBTi in treating acute insomnia.

Methods

A single-arm clinical trial was conducted among individuals who have acute insomnia. Participants underwent self-guided CBTi for 1-week. Their insomnia, depressive symptoms and anxiety symptoms were evaluated using the Insomnia Severity Index and the Hospital Anxiety and Depression Scale at baseline, post-treatment and 3-month follow-up. Repeated measures analysis of variance was used to assess the effectiveness of CBTi in treating insomnia, depressive symptoms and anxiety symptoms. A multivariate Cox regression model was used to determine the impact of depressive and anxiety symptoms on insomnia.

Results

The study found significant reductions in insomnia, depressive symptoms and anxiety symptoms at both post-treatment and 3-month follow-up (F=17.45, p<0.001; F=36.37, p=0.001; and F=81.51, p<0.001, respectively). The duration of CBTi treatment had a positive impact on insomnia recovery (hazard ratio (HR)=0.94, p=0.018). However, baseline depressive symptoms (HR=1.83, p=0.004) and baseline anxiety symptoms (HR=1.99, p=0.001) had significant negative effects on insomnia recovery.

Conclusions

The study showed that a 1-week self-guided CBTi treatment is effective in treating acute insomnia and comorbid depressive and anxiety symptoms. However, baseline depressive and anxiety symptoms negatively impact treatment effectiveness. Therefore, clinicians should assess for depressive and anxiety symptoms before treating acute insomnia with monotherapy CBTi.

The effect of cognitive behavior therapy on anxiety and depression during COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

The global spread of coronavirus has caused many physical and mental health problems throughout the world. Depression and anxiety are among the issues that people are experiencing abundantly, along with other mental health disorders, during this period. Cognitive behavior therapy (CBT) is one of the approaches that is effective on improving most of the psychological issues including depression and anxiety. The objective of this systematic review and meta-analysis was to assess the effects of CBT on depression and anxiety during COVID-19 pandemic period.

METHODS

English databases such as Cochrane, PubMed, Google Scholar, Web of Science and Persian databases such as SID, MagIran and IranDoc were searched with a time limit of 2019 to 2022. Two researchers independently evaluated the quality of the entered studies based on Cochrane handbook. Subgroup analysis was conducted separately on the basis of being infected with coronavirus, not being infected with coronavirus, and having a history of depression or anxiety before the intervention and internet-based CBT for depression and anxiety. Meta-analysis results were reported using standardized mean difference (SMD) and 95% confidence interval (95% CI). Heterogeneity of studies was analyzed by means of I2 index; and in the case of heterogeneity presence, random effects model was used instead of fixed effects model. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used for evaluating the quality of evidence.

RESULTS

Totally, 2015 articles were analyzed of which 11 articles entered meta-analysis. The overall results of meta-analysis showed that mean score of anxiety in the group receiving CBT was significantly lower than the control group (SMD: - 0.95, 95% CI - 1.29 to - 0.62; P < 0.00001, I2 = 94%). In addition, mean score of depression in the intervention group was significantly lower than the control group (SMD: - 0.58; 95% CI - 1.00 to - 0.16, P < 0.00001, I2 = 94%). In addition, the results of subgroup meta-analysis showed that internet-based CBT was effective in reducing of depression (SMD - 0.35; 95% CI - 0.50 to - 0.20; P < 0.00001; I2 = 0%) and anxiety (SMD - 0.90; 95%CI - 1.47 to - 0.33; P = 0.002; I2 = 94%). The evidence about the effectiveness of CBT on depression and anxiety compared with control group on the basis of GRADE approach had low quality.

CONCLUSIONS

Meta-analysis results showed that CBT reduced the mean scores of anxiety and depression significantly during COVID-19 pandemic period. Due to the low quality of evidence, conducting more randomized controlled trials with rigorous design is suggested. Prospero registration This systematic review has been registered in Prospero (ID: CRD42021277213).

Mental health professionals views and the impact of COVID-19 pandemic on implementing digital mental health in China: A nationwide survey study

BACKGROUND

Using digital health technologies (DHTs) to deliver and augment healthcare is an innovative way to solve common challenges that the mental healthcare setting faces. Despite China's rapid development of DHT, a comprehensive understanding of staff views of DHTs is lacking, which limited the evidence to support implementation strategies. In the current study, we aim to: (i) investigate staff attitudes towards digital technology for mental health problems in China; (ii) explore staff's views on the facilitators and barriers regarding uptake and adoption of digital technology in mental health services in China; and (iii) understand how the COVID-19 pandemic has changed staff views on digital mental health.

METHODS

An online survey was conducted to explore staff attitudes towards implementing DHTs in China. Descriptive statistics were conducted to summarise quantitative data. Free-text data were analysed using qualitative content analysis.

RESULTS

1270 mental health professionals completed the survey. Respondents reported low levels of knowledge of DHTs and moderate levels of accessibility of DHTs in their hospitals. Respondents expressed positive attitudes towards DHTs and demonstrated moderate levels of perceived feasibility and acceptability of implementing DHTs in clinical services. As expected, respondents reported that the COVID-19 pandemic caused significant impacts on their clinical services, and almost all respondents deemed DHTs useful for services provision during the pandemic and were willing to apply such technologies in clinical services after the pandemic.

CONCLUSIONS

Despite the Chinese mental health staff expressed positive attitudes towards implementing DHTs in clinical practice, most of the staff lacked sufficient knowledge to provide such services. These findings highlight the need to develop implementation strategies such as training programmes and dissemination of research evidence to support the translation of research.

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.

Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All?

Purpose

Insomnia is a highly prevalent disorder that is seen across all age groups causing significant morbidity to the patients. Its prevalence has further risen during COVID-19 pandemic. It is widely acknowledged that untreated insomnia can lead to significant health risks and socio-occupational dysfunction.

Methods

A narrative review was conducted following focused search of databases.

Results

Available guidelines mention two different approaches for the management of insomnia-pharmacological and non-pharmacological. Non-pharmacological therapies like multicomponent cognitive behavior therapy for insomnia (CBT-I) have been advocated for the management of acute as well as chronic insomnia in the literature as it has been found efficacious and useful. Multiple variants of CBT-I, e.g., digitally delivered CBT-I, brief CBT-I have been tested during pandemic owing to closure of clinics. However, there are certain issues to be considered while choosing CBT-I as therapy. For example, like other forms of psychotherapies, is there a need for assessing the candidature of patient before administering CBT-I; is CBT-I free of adverse effects as commonly thought; is CBT-I more efficacious than hypnotics; and at last, how to manage cases that are not candidate for CBT-I.

Conclusion

This narrative review addresses the scientific robustness of evidence for issues related to adherence, efficacy and adverse effects of non-pharmacological therapies. Available literature suggests that data related to adherence and efficacy of CBT-I suffer from methodological shortcomings and careful selection of patient is important for the successful therapy. At the same time, attempts have been made to shed light to the areas where CBT-I can be helpful in the management of insomnia.

Let’s color: An online coloring game improves subjective well-being and reduces anxiety during the COVID-19 pandemic (Preprint)

Background

COVID-19 has spread worldwide and generated tremendous stress on human beings. Unfortunately, it is often hard for distressed individuals to access mental health services under conditions of restricted movement or even lockdown.

Objective

The study first aims to develop an online digital intervention package based on a commercially released coloring game. The second aim is to test the effectiveness of difference intervention packages for players to increase subjective well-being (SWB) and reduce anxiety during the pandemic.

Methods

An evidence-based coloring intervention package was developed and uploaded to an online coloring game covering almost 1.5 million players worldwide in January 2021. Players worldwide participated to color either 4 rounds of images characterized by awe, pink, nature, and blue or 4 rounds of irrelevant images. Participants' SWB and anxiety and the perceived effectiveness of the game in reducing anxiety (subjective effectiveness [SE]) were assessed 1 week before the intervention (T1), after the participants completed pictures in each round (T2-T5), and after the intervention (T6). Independent 2-tailed t tests were conducted to examine the general intervention (GI) effect and the intervention effect of each round. Univariate analysis was used to examine whether these outcome variables were influenced by the number of rounds completed.

Results

In total, 1390 players worldwide responded and completed at least 1 assessment. Overall, the GI group showed a statistical significantly greater increase in SWB than the general control (GC) group (N=164, t162=3.59, Cohen d=0.59, 95% CI 0.36-1.24, P<.001). Compared to the control group, the best effectiveness of the intervention group was seen in the awe round, in which the increase in SWB was significant (N=171, t169=2.51, Cohen d=0.39, 95% CI 0.10-0.82, P=.01), and players who colored all 4 pictures had nearly significant improvements in SWB (N=171, F4,170=2.34, partial ŋ2=0.053, P=.06) and a significant decrease in anxiety (N=171, F4,170=3.39, partial ŋ2=0.075, P=.01).

Conclusions

These data indicate the effectiveness of online psychological interventions, such as coloring games, for mental health in the specific period. They also show the feasibility of applying existing commercial games embedded with scientific psychological interventions that can fill the gap in mental crises and services for a wider group of people during the pandemic. The results would inspire innovations to prevent the psychological problems caused by public emergencies and encourage more games, especially the most popular ones, to take more positive action for the common crises of humankind.

Decreased Transition Rate From Situational Insomnia to Chronic Insomnia by One-Week Internet Cognitive Behavioral Treatments for Insomnia During the COVID-19 Pandemic

PURPOSE

The purpose of the study was to determine the long-term effects of one-week self-guided internet cognitive behavioral treatments for insomnia (CBTI) on situational insomnia during the COVID-19 pandemic.

PATIENTS AND METHODS

The participants with situational insomnia (n = 194) were recruited from March 2020 to April 2020 in Guangzhou, China. The insomnia severity index (ISI), pre-sleep arousal scale (PSAS), and hospital anxiety and depression scale (HADS) were evaluated at baseline and a one-week internet CBTI program was delivered to all individuals. The participants were divided into the complete treatment group (the participants completed all seven modules of the CBTI course, n = 75), and the incomplete treatment group (the participants completed 0-6 modules of the CBTI course, n = 119). A total of 135 participants completed the post-intervention assessments. At 3 months follow-up, a total of 117 participants (complete treatment group: n = 51; incomplete treatment group: n = 66) completed the assessments of the ISI, PSAS and HADS. The transition rate from situational insomnia to chronic insomnia (duration of insomnia ≥ 3 months and ISI ≥ 8) was calculated in the two groups. Linear mixed effect model was used to investigate the effect of group (between the two groups), time (baseline vs. follow-up), and interaction (group x time) on various questionnaire score.

RESULTS

The transition rate from situational insomnia to chronic insomnia was significantly lower in the complete treatment group compared to the incomplete treatment group (27.5%, 14/51 vs. 48.5%, 32/66, p = 0.023). There were significant differences in group effect (p = 0.032), time effect (p = 0.000) and group × time effect (p = 0.048) between the two groups in the ISI total score. The ISI total scores decreased in both groups during follow-up compared to their baseline values, with a greater magnitude of decrease in the complete treatment group. There were no significant group x time effects between the two groups in the PSAS-total score, PSAS-somatic, PSAS-cognitive score, HADS total score, HADS anxiety score or HADS depression score.

CONCLUSION

Our results suggested that one-week self-guided internet CBTI prevented the development of chronic insomnia from situational insomnia during the COVID-19 pandemic.

MAPPING MENTAL HEALTH INTERVENTIONS DURING THE COVID-19 PANDEMIC. A COMPARISON REVIEW OF CHINA AND WESTERN EUROPE

OBJECTIVE

The aim: To map and compare mental health interventions during the Covid-19 pandemic in China and Western-Europe. The focus was specifically on the availability, duration, target group, content, setting, and outcomes of the interventions.

PATIENTS AND METHODS

Materials and methods: A scoping review was conducted by utilising several scientific databases. A total of 479 articles were found after removing the duplicate records. After screening, 36 articles were included in the study. Relevant intervention characteristics were systematically mapped, and compared within and among countries.

CONCLUSION

Conclusions: All interventions had shared aims to improve the psychological resilience and to reduce psychological distress. In particular, anxiety- and depression-related symptoms were commonly addressed. On average, interventions in China were larger scaled, had longer durations, and often used combinations of strategies such as therapies and exercises both in-person and remotely. Interventions in Western-Europe tend to be locally implemented on a smaller scale, and often used a single strategy. Most Chinese interventions targeted adolescents, while all interventions in Western-Europe were meant for adults. Most interventions were assessed using quantitative methods using various mental health scales, showing statistically significant effects in improving mental health.

Insomnia, Pre-Sleep Arousal, Psychosocial Factors and Changes in Sleep Pattern during the Second Wave Lockdown of the COVID-19 Pandemic in Georgia

Studies performed across the COVID-19 pandemic waves point to the persistent impact of the pandemic on sleep and mental health. We expand these data by examining insomnia, pre-sleep arousal, psychosocial factors, and retrospective changes in sleep pattern during the COVID-19 second wave lockdown period in Georgia. Data were collected through an online survey (n = 1117). The prevalence rate of probable insomnia disorder was 24.2%. Clinically relevant somatic and cognitive pre-sleep arousal was present in 49.8% and 58.0% of participants, and high levels of anxiety, depression and social isolation were found in 47.0%, 37.3%, 47.2% of respondents, respectively. We observed high prevalence rates of worse sleep quality, delayed bedtimes and risetimes, longer sleep latencies, higher awakenings and shorter sleep durations, relative to the pre-pandemic period. COVID-19-infected participants showed more severe sleep and mental problems. Specific predictors differentially affected insomnia, somatic and cognitive pre-sleep arousal. Depression and COVID-19 infection emerged as vulnerability factors for pre-sleep arousal, which, in turn, was associated with a higher predisposition to insomnia disorder. We confirm the strong deteriorating impact of the COVID-19 pandemic on sleep and psychosocial well-being during the second wave lockdown period. The specific association between pre-sleep arousal, insomnia, and psychosocial factors is of clinical relevance for the prevention of severity and persistence of sleep and mental problems across the repeated lockdown/reopening waves. Modulation of pre-sleep arousal may prove beneficial to implement targeted interventions.

Pre-sleep arousal and sleep quality during the COVID-19 lockdown in Italy

Objective

The COVID-19 pandemic has strongly affected daily habits and psychological wellbeing, and many studies point to large modifications in several sleep and sleep-related domains. Nevertheless, pre-sleep arousal during the pandemic has been substantially overlooked. Since hyperarousal represents one of the main factors for the development and the perpetuation of chronic insomnia disorder, the assessment of variables associated with high levels of pre-sleep arousal during the pandemic is clinically relevant. The study aimed to assess the prevalence and predictors of perceived sleep quality and pre-sleep arousal in an Italian sample during the COVID-19 lockdown.

Methods

We used an online survey to collect self-reported sociodemographic, environmental, clinical, sleep, and sleep-related data. Our final sample included 761 participants.

Results

Beyond a high frequency of poor sleep quality, depressive and stress symptoms, our results show that almost half of the sample suffered from clinically relevant levels of at least one component (ie, cognitive, somatic) of pre-sleep arousal. Subjects with greater pre-sleep arousal exhibited poorer sleep quality. Also, sleep quality was strongly associated with somatic and cognitive pre-sleep arousal. Regarding the predictors of sleep and sleep-related measures, depressive and event-related stress symptoms were the main factors associated with both poor sleep quality and pre-sleep arousal components. Moreover, specific sociodemographic and environmental variables were uniquely related to sleep quality, cognitive or somatic pre-sleep arousal.

Conclusions

These findings suggest that the assessment of specific sleep-related factors (ie, pre-sleep arousal), together with more global measures of sleep quality, may be crucial to depict the complex impact of the pandemic on sleep, and to help prevent and counteract the spread of insomnia symptoms.

Digital mental health in China: a systematic review

Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.

Internet-based cognitive behavioral therapy for psychological distress in older adults without cognitive impairment living in nursing homes during the COVID-19 pandemic: A feasibility study

BACKGROUND

The COVID-19 pandemic has had a detrimental effect on the mental health of older adults living in nursing homes. Very few studies have examined the effects of Internet-based Cognitive Behavioral Therapy (ICBT) on older adults living in nursing homes during the pandemic. We conducted a feasibility study using a single-group design, to explore the effectiveness of ICBT on psychological distress in 137 older adults (without cognitive impairment) from 8 nursing homes in 4 southeast cities in China, between January and March 2020.

METHODS

Symptoms of depression, anxiety, general psychological distress, and functional disability were measured at baseline, post-treatment (5 weeks) and at a 1-month follow-up. Mixed-effects model was used to assess the effects of ICBT.

RESULTS

Statistically significant changes with large effect sizes were observed from pre- to post-treatment on the PHQ-9 (p < .001, Cohen's d = 1.74), GAD-7 (p < .001, d = 1.71), GDS (p < .001, d = 1.30), K-10 (p < .001, d = 1.93), and SDS (p < .001, d = 2.03). Furthermore, improvements in treatment outcomes were sustained at 1-month follow-up, and high levels of adherence and satisfaction were indicated.

CONCLUSION

ICBT was effective in reducing psychological distress in older adults without cognitive impairments living in nursing homes during the COVID-19 pandemic. Thus, it could be applied in improving the mental health of this vulnerable group during the pandemic.

Anxiety and Depression in Patients With Physical Diseases and Associated Factors: A Large-Scale Field Survey in General Hospitals in China

Introduction: To investigate the characteristic of anxiety and depression among patients in general hospitals, and explore the degree of the clinical symptoms and correlated social economic factors. Methods: This is a cross-sectional survey of anxiety and depression in patients with physical diseases, who were suspected of depression and anxiety based on their clinical performance by their physicians and PHQ ≧ 8, from various clinical departments of 57 general hospitals in China. Data regarding demographic characteristics and clinical characteristics were collected. Social and psychological factors and the severity of anxiety or depression were collected through self-rating scales. Finally, we used multivariate logistic regression to identify the factors associated with anxiety and depression in patients with physical diseases. Results: A total of 2,105 (84.6%) valid and completed questionnaires were returned. The proportion of anxiety, depression, combined depression and anxiety, either anxiety or depression among the patients with physical diseases from all clinical departments was 63.3, 75.1, 57.1, and 81.2% respectively. Further regression analysis indicated that gender, monthly income, specific physical diseases, personality traits, social supports and life negative events were related factors of both anxiety and depression. Conclusions: Anxiety and depression were common in patients with physical diseases, with a high proportion of co-morbidity of anxiety and depression. Females, patients with cancer, poor social support and negative life events reported more severe anxiety and depression. The results may help to understand the present situation of anxiety and depression in general hospitals in china, and identify the patients with high risk of depression and anxiety.