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Manber R, Simpson N, Gumport NB. Perspectives on increasing the impact and reach of CBT-I. Sleep 2023; 46:zsad168. [PMID: 37903637 PMCID: PMC10710991 DOI: 10.1093/sleep/zsad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/06/2023] [Indexed: 11/01/2023] Open
Abstract
Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.
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Affiliation(s)
- Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Norah Simpson
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
| | - Nicole B Gumport
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. 94305USA
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McCall WV, Looney SW, Zulfiqar M, Ketcham E, Jones M, Mixson C, McCloud L, Miller BJ, Rosenquist PB. Daytime autonomic nervous system functions differ among adults with and without insomnia symptoms. J Clin Sleep Med 2023; 19:1885-1893. [PMID: 37421322 PMCID: PMC10620659 DOI: 10.5664/jcsm.10704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
STUDY OBJECTIVES We gathered data to determine whether daytime assays of the autonomic nervous system would differ between persons with no vs modest insomnia symptoms and would correlate with the severity of insomnia symptoms in patients. METHODS This report is composed of 2 studies. Study 1 conducted pupillary light reflex (PLR) measurements in community volunteers who were not seeking medical care. Study 2 contrasted PLR and heart rate variability in a different sample of community volunteers and a comparison sample of adults seeking outpatient care for insomnia and psychiatric problems. All measurements were taken between 3 and 5 pm. RESULTS In Study 1, volunteers with modest insomnia symptom severity had a more rapid PLR average constriction velocity compared with those with no symptoms. In Study 2, lower heart rate variability, indicating higher levels of physiologic arousal, generally were in agreement with faster PLR average constriction velocity, both of which indicate higher levels of arousal. Insomnia symptom severity was highly correlated with faster average constriction velocity in the patient sample. CONCLUSIONS These studies suggest that (1) daytime measurements of the autonomic nervous system differ between persons with modest vs no insomnia symptoms and (2) insomnia symptom severity is highly correlated with PLR. Daytime measurement of autonomic nervous system activity might allow for daytime point-of-care measurement to characterize the level of physiologic arousal to define a hyperarousal subtype of insomnia disorder. CITATION McCall WV, Looney SW, Zulfiqar M, et al. Daytime autonomic nervous system functions differ among adults with and without insomnia symptoms. J Clin Sleep Med. 2023;19(11):1885-1893.
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Affiliation(s)
- William V. McCall
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Stephen W. Looney
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Maria Zulfiqar
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Evan Ketcham
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Megan Jones
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Carter Mixson
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Laryssa McCloud
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Brian J. Miller
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Peter B. Rosenquist
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
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Feng F, Zhang C, Liang H, Xu G, Luo X, Liu S, Xu Y, Yang L, Zhang L, Lin L, Zhang B. Decreased Transition Rate From Situational Insomnia to Chronic Insomnia by One-Week Internet Cognitive Behavioral Treatments for Insomnia During the COVID-19 Pandemic. Front Psychiatry 2022; 13:837399. [PMID: 35392382 PMCID: PMC8981203 DOI: 10.3389/fpsyt.2022.837399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Fei Feng
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China.,Shenzhen Kangning Hospital, Shenzhen, China
| | - Chenxi Zhang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Hanwen Liang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Guojian Xu
- Shenzhen Kangning Hospital, Shenzhen, China
| | - Xian Luo
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Shuai Liu
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Yan Xu
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Lulu Yang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China.,Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li Zhang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Lianhong Lin
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
| | - Bin Zhang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
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Dietch JR, Manber R. Insomnia and cognitive arousal are important potential targets to reduce perinatal depression risk. Sleep 2021; 44:6219632. [PMID: 33837426 PMCID: PMC8193559 DOI: 10.1093/sleep/zsab091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jessica R Dietch
- School of Psychological Science, Oregon State University, Corvallis, OR
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA
- Corresponding author. Jessica R. Dietch, School of Psychological Science, Oregon State University, Corvallis, OR 97331.
| | - Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA
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How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change. Clin Psychol Rev 2021; 86:102027. [PMID: 33887655 DOI: 10.1016/j.cpr.2021.102027] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/11/2021] [Accepted: 03/22/2021] [Indexed: 12/23/2022]
Abstract
Insomnia is prevalent and debilitating, comprising sustained difficulties initiating or maintaining sleep. Cognitive-behavioural therapy for insomnia (CBT-I) is a multicomponent intervention recommended as the first-line treatment, but the mediators of change remain unclear. This systematic review and meta-analysis aimed to synthesise and evaluate the evidence for potential mediators of CBT-I. Searches were performed for studies published until February 2021, reporting on mediation analyses with CBT-I. Seventeen unique samples of adults with insomnia (20 studies, N = 3125) were included. Two-stage structural equation modelling was applied to the available data, where 7 studies examined the cognitive mediator, 'dysfunctional beliefs about sleep', 5 studies examined a hyperarousal mediator, and 3 studies examined the behavioural mediator, 'time in bed'. There was evidence in support of changes in dysfunctional beliefs as a cognitive mediator of insomnia symptom improvement following CBT-I. There was more limited evidence in support of changes in hyperarousal-related mediators, and no significant effect of time in bed as a mediator. Numerous studies recorded diary-based measures of potential behavioural mediators, but analyses of these variables were not typically conducted. The most serious limitation of the evidence base is that the temporal precedence of mediator changes cannot be established. Future studies should consider: i) using mid-treatment measurements of mediator changes; ii) reporting on mediator psychometric properties; and iii) explicitly stating analyses as pre-specified or exploratory.
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Cognitive processes mediate the effects of insomnia treatment: evidence from a randomized wait-list controlled trial. Sleep Med 2019; 54:86-93. [DOI: 10.1016/j.sleep.2018.09.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/13/2018] [Accepted: 09/27/2018] [Indexed: 11/22/2022]
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Norell-Clarke A, Tillfors M, Jansson-Fröjmark M, Holländare F, Engström I. How Does Cognitive Behavioral Therapy for Insomnia Work? An Investigation of Cognitive Processes and Time in Bed as Outcomes and Mediators in a Sample With Insomnia and Depressive Symptomatology. Int J Cogn Ther 2017. [DOI: 10.1521/ijct.2017.10.4.304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Annika Norell-Clarke
- Centre for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad, Sweden
| | - Maria Tillfors
- Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden
| | - Markus Jansson-Fröjmark
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Fredrik Holländare
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- University Health Care Research Centre, Region Örebro County, Örebro, Sweden
| | - Ingemar Engström
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Hayes AF, Rockwood NJ. Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behav Res Ther 2017; 98:39-57. [DOI: 10.1016/j.brat.2016.11.001] [Citation(s) in RCA: 783] [Impact Index Per Article: 111.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 02/03/2023]
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9
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Harvey AG, Dong L, Bélanger L, Morin CM. Mediators and treatment matching in behavior therapy, cognitive therapy and cognitive behavior therapy for chronic insomnia. J Consult Clin Psychol 2017; 85:975-987. [PMID: 28956950 PMCID: PMC5679013 DOI: 10.1037/ccp0000244] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To examine the mediators and the potential of treatment matching to improve outcome for cognitive behavior therapy (CBT) for insomnia. METHOD Participants were 188 adults (117 women; Mage = 47.4 years, SD = 12.6) meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) diagnostic criteria for chronic insomnia (Mduration: 14.5 years, SD: 12.8). Participants were randomized to behavior therapy (BT; n = 63), cognitive therapy (CT; n = 65), or CBT (n = 60). The outcome measure was the Insomnia Severity Index (ISI). Hypothesized BT mediators were sleep-incompatible behaviors, bedtime variability (BTv), risetime variability (RTv) and time in bed (TIB). Hypothesized CT mediators were worry, unhelpful beliefs, and monitoring for sleep-related threat. RESULTS The behavioral processes mediated outcome for BT but not CT. The cognitive processes mediated outcome in both BT and CT. The subgroup scoring high on both behavioral and cognitive processes had a marginally significant better outcome if they received CBT relative to BT or CT. The subgroup scoring relatively high on behavioral but low on cognitive processes and received BT or CBT did not differ from those who received CT. The subgroup scoring relatively high on cognitive but low on behavioral processes and received CT or CBT did not differ from those who received BT. CONCLUSION The behavioral mediators were specific to BT relative to CT. The cognitive mediators were significant for both BT and CT outcomes. Patients exhibiting high levels of both behavioral and cognitive processes achieve better outcome if they receive CBT relative to BT or CT alone. (PsycINFO Database Record
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Affiliation(s)
| | - Lu Dong
- Psychology Department, University of California, Berkeley
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Ye YY, Chen NK, Chen J, Liu J, Lin L, Liu YZ, Lang Y, Li XJ, Yang XJ, Jiang XJ. Internet-based cognitive-behavioural therapy for insomnia (ICBT-i): a meta-analysis of randomised controlled trials. BMJ Open 2016; 6:e010707. [PMID: 27903557 PMCID: PMC5168528 DOI: 10.1136/bmjopen-2015-010707] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of internet-based cognitive-behavioural therapy for insomnia (ICBT-i) in adults. DESIGN A meta-analysis of ICBT-i. DATA SOURCES Systematic searches of randomised controlled trials of ICBT-i were performed in the PubMed, EMBASE, PsycINFO and Cochrane Library databases up to 19 June 2016. REVIEW METHOD 2 reviewers independently performed study selection, quality assessment and data extraction. Outcomes of interest included sleep onset latency (SOL), total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), number of nocturnal awakenings (NWAK), and Insomnia Severity Index (ISI). RevMan 5.2 and Stata 13.0 meta-analysis software were used to perform statistical analysis. RESULTS 14 records for 15 studies (1013 experimental group participants, 591 waiting list group participants) were included. The meta-analysis indicated that, at the post-test time point, SOL decreased by 18.41 min (95% CI 13.60 to 23.21), TST increased by 22.30 min (95% CI 16.38 to 28.23), SE increased by 9.58% (95% CI 7.30% to 11.85%), WASO decreased by 22.31 min (95% CI 13.50 to 31.11), NWAK decreased by 0.52 (95% CI 0.28 to 0.76), and ISI decreased by 5.88 points (95% CI 4.29 to 7.46). Additionally SOL, TST, SE, and WASO exhibited statistically significant improvements at follow-up versus before treatment. CONCLUSIONS ICBT-i is an effective treatment for adults with insomnia. This conclusion should be verified in further studies.
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Affiliation(s)
- Yuan-yuan Ye
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ni-ka Chen
- Department of Neurology, PLA 187 Hospital, Haikou, China
| | - Jia Chen
- Department of Neurology, PLA 123 Hospital, Bengbu, China
| | - Juan Liu
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ling Lin
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ya-zhen Liu
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ying Lang
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xun-jun Li
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xin-ju Yang
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xiao-jiang Jiang
- Department of Neurology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
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Lommen MJJ, Grey N, Clark DM, Wild J, Stott R, Ehlers A. SLEEP AND TREATMENT OUTCOME IN POSTTRAUMATIC STRESS DISORDER: RESULTS FROM AN EFFECTIVENESS STUDY. Depress Anxiety 2016; 33:575-83. [PMID: 26393429 PMCID: PMC4934137 DOI: 10.1002/da.22420] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/05/2015] [Accepted: 08/16/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most patients with posttraumatic stress disorder (PTSD) suffer from sleep problems. Concerns have been raised about possible detrimental effects of sleep problems on the efficacy of psychological treatments for PTSD. In this study, we investigated the relation of session-to-session changes in PTSD symptoms and sleep, and tested whether sleep problems predicted poorer short- and long-term treatment outcome. METHODS Self-reported sleep quality, sleep duration, and PTSD symptoms were assessed weekly in a consecutive sample of 246 patients who received cognitive therapy for PTSD (CT-PTSD; Ehlers & Clark, 2000), and at follow-up (mean = 247 days posttreatment). Additionally, moderating effects of medication use and comorbid depression were assessed. RESULTS Sleep and PTSD symptoms improved in parallel. The relation was moderated by depression: Sleep problems at the start of therapy did not predict improvement in PTSD symptoms during treatment for patients without comorbid depression. Patients with comorbid depression, however, showed less rapid decreases in PTSD symptoms, but comparable overall outcome, if their sleep quality was poor. Residual sleep problems at the end of treatment did not predict PTSD symptoms at follow-up once residual PTSD symptoms were taken into account. CONCLUSIONS CT-PTSD leads to simultaneous improvement in sleep and PTSD symptoms. Sleep problems may reduce the speed of recovery in PTSD patients with comorbid depression. For these patients, additional treatment sessions are indicated to achieve comparable outcomes, and additional interventions targeting sleep may be beneficial. For those without comorbid depression, self-reported sleep problems did not interfere with response to trauma-focused psychological treatment.
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Affiliation(s)
- Miriam J J Lommen
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Nick Grey
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK.,National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK
| | - Richard Stott
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford NIHR Cognitive Health Clinical Research Facility, Oxford, UK.,National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
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12
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Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study. COGNITIVE THERAPY AND RESEARCH 2015. [DOI: 10.1007/s10608-015-9698-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Gilbert KS, Kark SM, Gehrman P, Bogdanova Y. Sleep disturbances, TBI and PTSD: Implications for treatment and recovery. Clin Psychol Rev 2015; 40:195-212. [PMID: 26164549 DOI: 10.1016/j.cpr.2015.05.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 04/27/2015] [Accepted: 05/13/2015] [Indexed: 12/26/2022]
Abstract
Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.
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Affiliation(s)
- Karina Stavitsky Gilbert
- Psychology Research, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States
| | - Sarah M Kark
- Psychology Research, VA Boston Healthcare System, Boston, MA, United States
| | - Philip Gehrman
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States; Philadelphia VA Medical Center, Philadelphia, PA, United States
| | - Yelena Bogdanova
- Psychology Research, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
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14
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Lancee J, Eisma MC, van Straten A, Kamphuis JH. Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial. Cogn Behav Ther 2015; 44:406-22. [DOI: 10.1080/16506073.2015.1026386] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Beaulac J, Vincent N, Walsh K. Dissemination of an Internet-based treatment for chronic insomnia into primary care. Behav Sleep Med 2015; 13:124-39. [PMID: 24564299 DOI: 10.1080/15402002.2013.845780] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study evaluated the effectiveness of two strategies (provider-targeted, consumer-targeted) in the dissemination of an insomnia treatment into primary care. Results of the study indicated that more patients from the provider-targeted, than the consumer-targeted, clinic followed up on the referral for insomnia treatment, but that overall there was limited uptake. These results did not seem to be associated with low levels of provider interest, although providers expressed need for more education about the insomnia program. Implications of these results are that future research efforts would benefit from expanding upon the education of providers in terms of treatment offered, perhaps teaching providers how to better motivate their patients for behavior change.
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Affiliation(s)
- Julie Beaulac
- a Department of Clinical Health Psychology University of Manitoba
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16
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Brooks AT, Wallen GR. Sleep Disturbances in Individuals with Alcohol-Related Disorders: A Review of Cognitive-Behavioral Therapy for Insomnia (CBT-I) and Associated Non-Pharmacological Therapies. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2014; 8:55-62. [PMID: 25288884 PMCID: PMC4179428 DOI: 10.4137/sart.s18446] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 12/11/2022]
Abstract
Sleep disturbances are common among alcohol-dependent individuals and are often associated with relapse. The utility of behavioral therapies for sleep disturbances, including cognitive-behavioral therapy for insomnia (CBT-I), among those with alcohol-related disorders is not well understood. This review systematically evaluates the evidence of CBT-I and related behavioral therapies applied to those with alcohol-related disorders and accompanying sleep disturbances. A search of four research databases (PubMed, PsycINFO, Embase, and CINAHL Plus) yielded six studies that met selection criteria. Articles were reviewed using Cochrane's Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) scoring system. A majority of the studies demonstrated significant improvements in sleep efficiency among behavioral therapy treatment group(s), including but not limited to CBT-I. While behavioral sleep interventions have been successful in varied populations, they may not be utilized to their full potential among those with alcohol-related disorders as evidenced by the low number of studies found. These findings suggest a need for mixed-methods research on individuals' sleep experience to inform interventions that are acceptable to the target population.
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Affiliation(s)
- Alyssa T Brooks
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Gwenyth R Wallen
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Ferri R, Cosentino FI, Manconi M, Rundo F, Bruni O, Zucconi M. Increased electroencephalographic high frequencies during the sleep onset period in patients with restless legs syndrome. Sleep 2014; 37:1375-81. [PMID: 25083018 PMCID: PMC4096207 DOI: 10.5665/sleep.3934] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To analyze the electroencephalographic (EEG) spectral content in untreated patients with restless legs syndrome (RLS) during the sleep onset period (SOP) and during the quiet wakefulness preceding sleep, in order to test the hypothesis that a state of hyperarousal might be present during the SOP with RLS. SETTING Sleep Research Centre. PATIENTS Twenty-seven untreated consecutive patients with RLS (mean age = 53.6 y), 11 untreated consecutive patients with primary insomnia (mean age = 58.9 y), and 14 normal controls (mean age = 50.3 y). METHODS SOP was defined as the 10-min period centered with the occurrence of the first sleep spindle in the EEG, and then subdivided into SOP-1 (period of 5 min before the first spindle) and SOP-2 (period of 5 min following). Leg movements occurring during SOP were counted and used as a covariate in the statistical analysis. Also, one period of 1 min of artifact-free quiet wakefulness after lights off was identified. EEG spectral analysis was run during these periods using the C3/A2 or C4/A1 channel. MEASUREMENTS AND RESULTS Increased EEG alpha and beta bands and/or beta/delta ratio in RLS versus normal controls, during both wakefulness preceding sleep and SOP (both parts SOP-1 and SOP-2) were found, which were, however, smaller than the increases found in patients with insomnia. CONCLUSION The results of this study support the hypothesis of the presence of a state of hyperarousal in restless legs syndrome (RLS) during the sleep onset period. Treatment for RLS might need to take these findings into consideration. CITATION Ferri R, Cosentino FI, Manconi M, Rundo F, Bruni O, Zucconi M. Increased electroencephalographic high frequencies during the sleep onset period in patients with restless legs syndrome.
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Affiliation(s)
- Raffaele Ferri
- Department of Neurology IC, Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
| | - Filomena I.I. Cosentino
- Department of Neurology IC, Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital (EOC) of Lugano, Lugano, Switzerland
| | - Francesco Rundo
- Department of Neurology IC, Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Marco Zucconi
- Sleep Disorders Center, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Vita-Salute University, Institute and Ospedale San Raffaele, Milan, Italy
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18
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Ho FYY, Chung KF, Yeung WF, Ng TH, Kwan KS, Yung KP, Cheng SK. Self-help cognitive-behavioral therapy for insomnia: a meta-analysis of randomized controlled trials. Sleep Med Rev 2014; 19:17-28. [PMID: 25104471 DOI: 10.1016/j.smrv.2014.06.010] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 06/24/2014] [Accepted: 06/26/2014] [Indexed: 11/29/2022]
Abstract
Self-help cognitive-behavioral therapy (CBT) is an increasingly popular treatment option for insomnia. The objective of this meta-analysis was to compile an up-to-date evaluation on the efficacy, adherence, acceptability and dropout rate of self-help CBT for insomnia. We systematically searched six key electronic databases up until May 2013. Two researchers independently selected relevant publications, extracted data, and evaluated methodological quality according to the Cochrane criteria. Twenty randomized controlled trials were included; 10 of which were published after the last review up until January 2007. Meta-analysis of self-help CBT vs. waiting-list, routine care or no treatment was performed. Results showed that self-help CBT improved sleep, sleep-related cognitions and anxiety and depressive symptoms. Effect sizes for sleep-diary-derived sleep efficiency, sleep onset latency, and wake after sleep onset at immediate posttreatment were 0.80, 0.66, and 0.55, respectively. The average dropout rate of self-help CBT at immediate posttreatment was 14.5%, which was not significantly different from the 16.7% in therapist-administered CBT. Subgroup analyses supported the added benefit of telephone consultation. In conclusion, self-help CBT is efficacious and acceptable as an entry level of a stepped care model for insomnia. In places where face-to-face treatments are unavailable or too costly, self-help CBT can be considered as a compromise.
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Affiliation(s)
- Fiona Yan-Yee Ho
- Department of Psychiatry, The University of Hong Kong, Hong Kong
| | - Ka-Fai Chung
- Department of Psychiatry, The University of Hong Kong, Hong Kong.
| | - Wing-Fai Yeung
- School of Chinese Medicine, The University of Hong Kong, Hong Kong
| | - Tommy H Ng
- Department of Psychiatry, The University of Hong Kong, Hong Kong
| | - Ka-Shing Kwan
- Department of Psychiatry, The University of Hong Kong, Hong Kong
| | - Kam-Ping Yung
- Department of Psychiatry, The University of Hong Kong, Hong Kong
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Ramirez JM. The integrative role of the sigh in psychology, physiology, pathology, and neurobiology. PROGRESS IN BRAIN RESEARCH 2014; 209:91-129. [PMID: 24746045 DOI: 10.1016/b978-0-444-63274-6.00006-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
"Sighs, tears, grief, distress" expresses Johann Sebastian Bach in a musical example for the relationship between sighs and deep emotions. This review explores the neurobiological basis of the sigh and its relationship with psychology, physiology, and pathology. Sighs monitor changes in brain states, induce arousal, and reset breathing variability. These behavioral roles homeostatically regulate breathing stability under physiological and pathological conditions. Sighs evoked in hypoxia evoke arousal and thereby become critical for survival. Hypoarousal and failure to sigh have been associated with sudden infant death syndrome. Increased breathing irregularity may provoke excessive sighing and hyperarousal, a behavioral sequence that may play a role in panic disorders. Essential for generating sighs and breathing is the pre-Bötzinger complex. Modulatory and synaptic interactions within this local network and between networks located in the brainstem, cerebellum, cortex, hypothalamus, amygdala, and the periaqueductal gray may govern the relationships between physiology, psychology, and pathology. Unraveling these circuits will lead to a better understanding of how we balance emotions and how emotions become pathological.
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Affiliation(s)
- Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA; Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
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