Do evidence based interventions for chronic fatigue syndrome improve sleep? A systematic review and narrative synthesis

Digital cognitive behaviour therapy for insomnia in individuals with self-reported insomnia and chronic fatigue: A secondary analysis of a large scale randomized controlled trial

Insomnia is associated with fatigue, but it is unclear whether response to cognitive behaviour therapy for insomnia is altered in individuals with co-occurring symptoms of insomnia and chronic fatigue. This is a secondary analysis using data from 1717 participants with self-reported insomnia in a community-based randomized controlled trial of digital cognitive behaviour therapy for insomnia compared with patient education. We employed baseline ratings of the Chalder Fatigue Questionnaire to identify participants with more or fewer symptoms of self-reported chronic fatigue (chronic fatigue, n = 592; no chronic fatigue, n = 1125). We used linear mixed models with Insomnia Severity Index, Short Form-12 mental health, Short Form-12 physical health, and the Hospital Anxiety and Depression Scale separately as outcome variables. The main covariates were main effects and interactions for time (baseline versus 9-week follow-up), intervention, and chronic fatigue. Participants with chronic fatigue reported significantly greater improvements following digital cognitive behaviour therapy for insomnia compared with patient education on the Insomnia Severity Index (Cohen's d = 1.36, p < 0.001), Short Form-12 mental health (Cohen's d = 0.19, p = 0.029), and Hospital Anxiety and Depression Scale (Cohen's d = 0.18, p = 0.010). There were no significant differences in the effectiveness of digital cognitive behaviour therapy for insomnia between chronic fatigue and no chronic fatigue participants on any outcome. We conclude that in a large community-based sample of adults with insomnia, co-occurring chronic fatigue did not moderate the effectiveness of digital cognitive behaviour therapy for insomnia on any of the tested outcomes. This may further establish digital cognitive behaviour therapy for insomnia as an adjunctive intervention in individuals with physical and mental disorders.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Neurologic Manifestations of Systemic Disease: Sleep Disorders

Purpose of review

Sleep is intimately involved in overall health and wellbeing. We provide a comprehensive report on the interplay between systemic diseases and sleep to optimize the outcomes of systemic disorders.

Recent findings

Spanning the categories of endocrinologic disorders, metabolic/toxic disturbances, renal, cardiovascular, pulmonary, gastrointestinal, infectious diseases, autoimmune disorders, malignancy, and critical illness, the review highlights the prevalent coexisting pathology of sleep across the spectrum of systemic disorders. Although it is rare that treating a sleep symptom can cure disease, attention to sleep may improve quality of life and may mitigate or improve the underlying disorder. Recent controversies in assessing the cardiovascular relationship with sleep have called into question some of the benefits of treating comorbid sleep disorders, thereby highlighting the need for an ongoing rigorous investigation into how sleep interplays with systemic diseases.

Summary

Systemic diseases often have sleep manifestations and this report will help the clinician identify key risk factors linking sleep disorders to systemic diseases so as to optimize the overall care of the patient.

The Relationship Between Improvement in Insomnia Severity and Long-Term Outcomes in the Treatment of Chronic Fatigue

Background: The current treatments of choice for patients with chronic fatigue are moderately effective. One way to advance treatments is identifying process variables associated with good treatment outcomes. There is little knowledge regarding a possible association between insomnia and long-term outcomes in the treatment of chronic fatigue.

Aims: Testing whether (1) improvement in insomnia is associated with improvement in levels of fatigue at 1-year follow-up, and (2) if such a relationship remains when controlling for improvement in levels of anxiety and depression, and pain in patients with chronic fatigue.

Methods: Patients having been on sick leave 8 weeks or more due to chronic fatigue were referred to a return-to-work program. They received an intensive 3.5-week inpatient treatment program based on acceptance and commitment therapy (ACT). Before treatment and at 1-year follow-up the patients completed questionnaires assessing levels of insomnia severity, pain, anxiety and depression, and fatigue.

Results: A regression analysis found that changes in insomnia-severity were associated with changes in fatigue-levels at 1-year follow-up. When changes in levels of anxiety and depression were entered in the regression analysis, anxiety and depression was significantly associated with levels of fatigue but insomnia was not. The association between anxiety and depression and fatigue was at a trend level when pain was entered into the model.

Conclusion: Long-term improvement in insomnia severity was significantly associated with long-term improvement in chronic fatigue, but not independently of long-term improvement in anxiety and depression, and pain.

Trial Registration:https://clinicaltrials.gov/, identifier NCT01568970.