Effects of Telephone-Delivered Cognitive-Behavioral Therapy and Nondirective Supportive Therapy on Sleep, Health-Related Quality of Life, and Disability

Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial

BACKGROUND

Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population.

OBJECTIVE

To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis.

DESIGN

Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284).

SETTING

26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington.

PARTICIPANTS

Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months.

INTERVENTION

Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo.

MEASUREMENTS

The primary outcome was the ISI score at 7 and 25 weeks from randomization.

RESULTS

A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]).

LIMITATION

Modest sample size and most participants had mild or moderate insomnia.

CONCLUSION

In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone.

PRIMARY FUNDING SOURCE

National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

The Impact of Cognitive-Behavioral Interventions on Sleep Disturbance in Depressed and Anxious Community-dwelling Older Adults: A Systematic Review

INTRODUCTION

Depression and anxiety are prevalent mental health conditions in older adulthood. Despite sleep disturbance being a common comorbidity in late-life depression and anxiety, it is often discounted as a target for treatment. The current review aims to establish whether cognitive-behavioral therapy (CBT) is effective in treating concomitant sleep disturbance in depressed and anxious older adults and to review evidence supporting whether CBT interventions targeting anxiety and depression, or concurrent sleep disturbance, have the greatest effectiveness in this client group.

METHOD

A systematic database search was conducted to identify primary research papers evaluating the effectiveness of CBT interventions, recruiting older adults with symptoms of depression and/or anxiety, and employing a validated measure of sleep disturbance. The identified papers were included in a narrative synthesis of the literature.

RESULTS

Eleven identified studies consistently support reductions in sleep disturbance in elderly participants with depression and anxiety in response to CBT. Most CBT interventions in the review included techniques specifically targeting sleep, and only one study directly compared CBT for insomnia (CBT-I) with a CBT-I intervention also targeting depressive symptoms, limiting the ability of the review to comment on whether interventions targeting sleep disturbance or mental health symptoms have superior effectiveness.

CONCLUSION

The extant research indicates that CBT interventions are effective in ameliorating sleep disturbance in late-life depression and anxiety. Future high-quality research is required to substantiate this finding and to compare the effectiveness of CBT-I and CBT for depression and anxiety in this group to inform clinical practice.

The Efficacy of a Smartphone-Based App on Stress Reduction: Randomized Controlled Trial

Background

Stress management in the workplace is essential for a healthy mental and physical state. Due to technological advancements, individually tailored therapy and online cognitive behavioral therapy (CBT) are on the rise.

Objective

This study analyzed the efficacy of a smartphone app based on third-wave CBT tailored to an individual.

Methods

A randomized controlled trial was conducted with 126 participants who were divided into 2 groups. The intervention group used the smartphone app BetterLife for 10 weeks, while the control group was placed on a waiting list for the same duration. The Perceived Stress Scale–10 (PSS), Korean Utrecht Work Engagement Scale–9 (UWES), World Health Organization Quality of Life Assessment (WHOQOL), Beck Depression Inventory–II (BDI), and Beck Anxiety Inventory (BAI) were administered at baseline and after 10 weeks to both groups.

Results

Of the 126 participants, 11 dropped out during the trial. A 2-way repeated measure analysis of covariance was conducted, controlling for baseline BDI. There were greater improvements in PSS (F=24.33, P<.001, η²=0.17) and UWESK scores (F=8.32, P=.0046, η²=0.06) in the intervention group than in the control group. WHOQOL scores exhibited statistically significant improvement in the intervention group in the overall quality of life (F=8.19, P=.0049, η²=0.06), physical health (F=8.87, P=.003, η²=0.07), psychological health (F=13.32, P<.001, η²=0.10), social relationships (F=19.43, P<.001, η²=0.14), and environmental domains (F=10.14, P=.002, η²=0.08) but not overall health (F=1.68, P=.20). BDI (F=7.17, P=.008, η²=0.06) and BAI (F=6.00, P=.02, η²=0.05) showed a statistically significant improvement in the intervention group, but this significance did not survive the Bonferroni correction (P<.005).

Conclusions

These results provide evidence that smartphone-based CBT is a viable option for reducing stress in the workplace.

Trial Registration

Clinical Research Information Service KCT0003231; https://cris.nih.go.kr/cris/search/detailSearch.do/15137

Comparative efficacy of digital cognitive behavioral therapy for insomnia: A systematic review and network meta-analysis

The comparative efficacy of various approaches of digital cognitive behavioral therapy for insomnia (CBTi) is still unclear. This network meta-analysis explored the comparative efficacy of digital CBTi approaches in adults with insomnia. Four electronic databases were searched from inception to June 27, 2020. Primary outcomes were self-reported total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), and insomnia symptoms; these were measured using sleep diaries or valid questionnaires. A random-effects network meta-analysis in a frequentist framework was used. Fifty-four randomized controlled trials comprising 11,815 participants were included. Compared with usual care, web-based CBTi with a therapist demonstrated significantly longer TST (mean difference [MD]: 23.19 min, 95% confidence interval [CI]: 18.98-27.39 min), shorter SOL (MD: -18.76 min, 95% CI -24.20 to -13.31 min), lower WASO (MD: -31.40 min, 95% CI: -36.26 to -26.55 min), and greater SE (MD: 10.37%, 95% CI: 8.08%-12.65%). The surface under the cumulative ranking curve indicates that web-based CBTi with therapists is most likely to be ranked the highest among all treatments, and thus, this network meta-analysis suggests that such a treatment is the optimal intervention for improving sleep duration and SE as well as the reductions in SOL and WASO. PROSPERO REGISTRATION NUMBER: CRD42020171134.

Effectiveness of Information and Communication Technology (ICT) Interventions in Elderly's Sleep Disturbances: A Systematic Review and Meta-Analysis

Sleep is a crucial factor for human health and is closely related to quality of life. Sleep disturbances constitute a health problem that should be solved, especially when it affects the elderly. This study aims to examine the effectiveness of information and communication technologies (ICT) interventions in managing sleep disturbances in the elderly. The study used a systematic review of three databases: Ovid-Medline, Ovid-EMBASE, and the Cochrane library database for papers published till 15 April 2021. Two authors independently selected and screened relevant studies based on predefined inclusion criteria. The meta-analysis of randomized controlled trials (RCTs) was carried out using Review Manager 5.4. Two authors independently screened the titles and abstracts of 4297 studies considering both inclusion and exclusion criteria. The complete texts of 47 articles were then evaluated, 31 articles were excluded, and finally, 16 articles were selected. Our meta-analysis showed that the cognitive-behavioral therapy for insomnia (CBT-I) group had a significantly reduced Insomnia Severity Index (ISI) compared to the control group (−4.81 [−5.56, −4.06], p < 0.00001, I² = 83%) in RCTs, with a significant reduction in ISI (3.47 [1.58, 5.35], p = 0.0003) found in quasi-experimental studies. A significant improvement was found in total sleep time in the CBT-I group compared to the control group (29.24 [15.41, 43.07], p <0.0001) in RCTs, while the CBT-I group showed significantly reduced wake time after sleep onset compared to the control group (−20.50 [−26.60, −14.41], p < 0.00001). In addition, a significant reduction in depression was found in the CBT-I group compared to the control group (−2.11 [−2.85, −1.37], p < 0.00001, I² = 0%) in RCTs. The quality of life–mental component score (5.75 [1.64, 9.87], p = 0.006, I² = 0%) and the quality of life–physical component score (5.19 [0.76, 9.62], p = 0.02, I² = 0%) showed significant improvement in the CBT-I group compared to the control group. ICT interventions showed positive effects on sleep disturbances of the elderly, specifically confirming the positive effect on depression and quality of life as well as the indicators directly related to sleep such as ISI and quality of sleep. Thus, the application of ICT in the healthcare sector will be greater in the future, with changes in the nursing education and practice guidelines so that nurses can play a pivotal role in promoting health behaviors such as sleep-related quality of life and daily activities of the elderly.

Peer-delivered Cognitive Behavioral Therapy-based Intervention Reduced Depression and Stress in Community Dwelling Adults With Diabetes and Chronic Pain: A Cluster Randomized Trial

BACKGROUND

Finding effective, accessible treatment options such as professional-delivered cognitive behavioral therapy (CBT) for medically complex individuals is challenging in rural communities.

PURPOSE

We examined whether a CBT-based program intended to increase physical activity despite chronic pain in patients with diabetes delivered by community members trained as peer coaches also improved depressive symptoms and perceived stress.

METHODS

Participants in a cluster-randomized controlled trial received a 3-month telephonic lifestyle modification program with integrated CBT elements. Peer coaches assisted participants in developing skills related to adaptive coping, diabetes self-management goal-setting, stress reduction, and cognitive restructuring. Attention controls received general health advice with an equal number of contacts but no CBT elements. Depressive symptoms and stress were assessed using the Centers for Epidemiologic Studies Depression and Perceived Stress scales. Assessments occurred at baseline, 3 months, and 1 year.

RESULTS

Of 177 participants with follow-up data, 96% were African Americans, 79% women, and 74% reported annual income <$20,000. There was a significant reduction in perceived stress in intervention compared to control participants at 3-months (β = -2.79, p = .002 [95% CI -4.52, -1.07]) and 1 year (β = -2.59, p < .0001 [95% CI -3.30, -1.87]). Similarly, intervention participants reported significant decreases in depressive symptoms at 3-months (β = -2.48, p < .0001 [95% CI -2.48, -2.02]) and at 1 year (β = -1.62, p < .0001 [95% CI -2.37, -0.86]).

CONCLUSIONS

This peer-delivered CBT-based program improved depressive symptoms and stress in individuals with diabetes and chronic pain. Training community members may be a feasible strategy for offering CBT-based interventions in rural and under-resourced communities.

CLINICAL TRIAL REGISTRATION

NCT02538055.

Application of Mobile Call-Based Integrative Body-Mind-Spirit (IBMS) Intervention to Deal With Psychological Issues of COVID-19 Patients: A Case Study in India

Aim: The aim of this case study was to assess whether 8 sessions of mobile call based integrated Body-Mind-Spirit (IBMS) intervention could help COVID-19 patient to deal with psychological issues. Methods: This article is based on a practical example of working with COVID-19 patient using the IBMS model. It is a single subject study involving a 50 year old south Indian male living in a Covid Care Center (CCC). Mobile call interviews and brief symptom inventory were used for evaluation. Subject underwent 8 sessions of integrated body-mind-spirit Intervention through video/mobile calls of 45 minutes each time for 8 sessions offered on alternative days over a period of 15 days with pre-post assessments. Results: The results indicate that there was a reduction in somatic symptoms, anxiety and depression on 15th day. Conclusion: Illustrations of real life cases may help psychiatric nurses to gain insight into the application of psycho-social-spiritual interventions through mobile phone during isolation and lockdown.

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

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

Cognitive behavioral therapy for insomnia in veterans with gulf war illness: Results from a randomized controlled trial

Aims:

To examine whether cognitive behavioral therapy for insomnia (CBT-I), delivered by telephone, improves sleep and non-sleep symptoms of Gulf War Illness (GWI).

Main methods:

Eighty-five Gulf War veterans (21 women, mean age: 54 years, range 46–72 years) who met the Kansas GWI case definition, the Centers for Disease Control and Prevention (CDC) case definition for Chronic Multisymptom Illness (CMI), and research diagnostic criteria for insomnia disorder were randomly assigned to CBT-I or monitor-only wait list control. Eight weekly sessions of individual CBT-I were administered via telephone by Ph.D. level psychologists to study participants. Outcome measures included pre-, mid-, and post-treatment assessments of GWI and insomnia symptoms, subjective sleep quality, and continuous sleep monitoring with diary. Outcomes were re-assessed 6-months post-treatment in participants randomized to CBT-I.

Key findings:

Compared to wait list, CBT-I produced significant improvements in overall GWI symptom severity, individual measures of fatigue, cognitive dysfunction, depression and anxiety, insomnia severity, subjective sleep quality, and sleep diary outcome measures. The beneficial effects of CBT-I on overall GWI symptom severity and most individual GWI symptom measures were maintained 6-months after treatment.

Significance:

GWI symptoms have historically been difficult to treat. Because CBT-I, which is associated with low stigma and is increasingly readily available to veterans, improved both sleep and non-sleep symptoms of GWI, these results suggest that a comprehensive approach to the treatment of GWI should include behavioral sleep interventions.

Feasibility of an online cognitive behavioral therapy program to improve insomnia, mood, and quality of life in bereaved adults ages 55 and older

The aim of the current study was to assess the feasibility and preliminary efficacy of utilizing an online Cognitive Behavioral Therapy for Insomnia (CBT-I) program in bereaved older adults (ages 55 and older). Participants were randomized to receive either a 6-week online CBT-I program or six weeks of online psychoeducational modules on insomnia and grief. The sample included 30 adults with mild to severe symptoms of insomnia. Results suggest that the study was feasible to conduct, as evidenced by the brief 5-week recruitment time, 87% retention rate, and 100% completion rate of the intervention modules. There were no treatment effects by time difference shown in the study and no significant differences in study outcomes were found between the CBT-I and control groups, as both demonstrated similar improvements in insomnia. However, this study suggests that it is feasible to recruit bereaved older adults for an online educational program and successfully administer an online protocol targeting insomnia and well-being.

Insomnia in Older Adults

Purpose of Review

To evaluate and summarize recent research articles pertaining to insomnia in older adults that can guide healthcare providers on factors to consider when assessing and managing insomnia.

Recent Findings

Up to 75% of older adults experience symptoms of insomnia. Insomnia is associated with socioeconomic status, racial and ethnic classification, family relationships, medical and mental health disorders, cognitive function, and dementia. Although one-fifth of older adults are still prescribed sleep medications, cognitive behavioral therapy for insomnia is the first line treatment for insomnia, resulting in short-term and long-term benefits.

Summary

To manage insomnia safely and effectively, healthcare providers need to consistently assess for insomnia during baseline and annual assessments, evaluate medical and social factors associated with insomnia, minimize the use of sleep medications, and provide referrals to and/or collaborate with providers who perform cognitive behavioral therapy for insomnia. Insomnia screening is important as it facilitates early intervention with behavioral management, reduces the potential for pharmacological management, which increases fall risk in older adults, and enables further assessment and early identification of outcomes such as cognitive impairment.

Update of Recent Literature on Remotely Delivered Psychotherapy Interventions for Anxiety and Depression

Introduction: Anxiety and depression are harmful to individuals suffering from these disorders, their caregivers, and the economy. Remote delivery of psychotherapy has been established as a viable alternative to traditional in-person psychotherapy for treating anxiety and depression. However, literature comparing and evaluating the variety of remote delivery modalities of psychotherapy has not yet been integrated. This review examines the efficacy, practicality, and limitations of telephone, video, and online-administered psychotherapy for the treatment of anxiety and depression. Methods: A comprehensive literature search conducted using PubMed and PsycINFO included systematic reviews, randomized controlled trials, and cost-analysis studies focused on a remote delivery method of psychotherapy for anxiety and depression. Results: Overall, interventions delivered through telephone, video, and online modalities demonstrated good efficacy in treating anxiety and depression in general, and when presenting comorbid with other disorders. The literature also suggested that telehealth psychotherapy is accessible, convenient, and cost-effective. However, there is less evidence for video-delivered psychotherapy for anxiety and depression compared with telephone-administered and online-administered modalities. Despite this, overall, the efficacy and practical benefits of remote psychotherapy interventions in treating anxiety and depression across a diverse range of patient groups suggested that it is an appropriate alternative for those who cannot access in-person psychotherapy. Conclusions: Further research evaluating the efficacy and practical benefits of video-delivered psychotherapy for anxiety and depression is much needed for patients with limited access to in-person psychological care.

Assessing the Efficacy of Mobile Health Apps Using the Basic Principles of Cognitive Behavioral Therapy: Systematic Review

BACKGROUND

Cognitive behavioral therapy (CBT) in its basic principle has developed itself as a stand-alone, substantial method of therapy. With effective application in therapy for a range of mental health issues, the spread of CBT methods to Web-based therapy sources is evident. The development of mobile phone apps using CBT principles is increasing within the research area. Despite the move to Web-based methods of therapy, it is argued that these methods lack the same efficacy of face-to-face therapy sessions.

OBJECTIVE

The aim of this review was to assess extent research findings with regard to the effectiveness of CBT-related mobile health (mHealth) apps. By assessing only studies employing a randomized controlled trial design, the review aimed to determine app efficacy within the highly regarded method of investigation.

METHODS

A comprehensive literature search was conducted across several databases. Search results were filtered, and results were subject to strict inclusion and exclusion criteria because of the nature of the review. Where possible, analysis of effect size was calculated and results reported.

RESULTS

A total of 8 studies investigating the effectiveness of mHealth CBT-related apps across a range of mental health issues were reviewed. Three studies used the app against a control group, and 5 studies used the app intervention against another form of treatment or intervention. A range of effect sizes were seen across all included studies (d=-0.13 to 1.83; 0.03-1.44), with the largest effects often being seen when comparing the data from pre- to posttest for the app engaged group.

CONCLUSIONS

The studies reviewed support the use of mHealth apps containing CBT principles for a range of mental health issues. However, the effectiveness over longer time periods should be assessed. Researchers and professionals should seek to collaborate effectively when creating new apps to enhance their effectiveness as a treatment for the general public.

Effectiveness and cost-effectiveness of telephone-based cognitive-behavioural therapy in primary care: study protocol of TIDe - telephone intervention for depression

BACKGROUND

Despite the availability of evidence-based treatments for depression, a large proportion of patients remains untreated or adequate treatment is initiated with delay. This situation is particularly critical in primary care, where not only most individuals first seek help for their mental health problems, but also depressive disorders - particularly mild to moderate levels of severity - are highly prevalent given the high comorbidity of chronic somatic conditions and depression. Improving the access for evidence-based treatment, especially in primary care, is hence a priority challenge in the mental health care agenda. Telephone usage is widespread and has the potential of overcoming many barriers that individuals suffering from mental health problems are facing: Its implementation for treatment delivery presents an option for optimisation of treatment pathways and outcomes.

METHODS/DESIGN

This paper details the study protocol for a randomised controlled trial (RCT) evaluating the effectiveness of a telephone-administered short-term cognitive-behavioural therapy (T-CBT) for depression as compared to treatment as usual (TAU) in the Swiss primary care setting. The study aims at randomising a total of 216 mildly to moderately depressed patients, which are either identified by their General Practitioners (GPs) or who self-refer to the study programme in consultation with their GP. The trial will examine whether telephone-delivered, manualised treatment leads to clinically significant reduction in depression at follow-up. It will further investigate the cost-effectiveness and acceptability of the intervention in the primary care setting.

DISCUSSION

Conducting a low-intensity treatment on the telephone allows for greater flexibility for both patient and therapist, can grant more anonymity and can thus lead to less hesitation in the patient about whether to attempt treatment or not. In order to benefit from this approach, large-scale studies need to prove superior effectiveness and cost-effectiveness of telephone-delivered therapy over routine care for patients with mild to moderate depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02667366 . Registered on 3 December 2015.