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Maroti D, Dehdari B, von Below C. [Functional somatic symptoms - short-term psychodynamic therapy can be helpful]. Lakartidningen 2023; 120:23073. [PMID: 37721392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Patients with functional somatic symptoms or medically unexplained symptoms are very common in the healthcare system but they do not always receive adequate care or treatment. These patients struggle with a low quality of life and constitute a high cost to the healthcare system. Cognitive Behavioral Therapy is a relatively common treatment intervention and helps many patients, but not all. Short-term psychodynamic therapy has recently been evaluated in several meta-analysis and have been found to be clearly effective. A major focus of short-term psychodynamic therapy is on emotional processing of stressful or traumatic life events. At present, these psychodynamic short-term therapies are not offered in regular care, despite the solid research support that exists. Short-term psychodynamic therapy should be considered a complement to the range of treatments that already exist for patients with functional somatic symptoms.
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Affiliation(s)
- Daniel Maroti
- med dr, leg psyko-log, specialist i neuro-psyko-logi, Stockholms universitet
| | | | - Camilla von Below
- fil dr, leg psykolog, leg psykoterapeut, lektor, Stockholms universitet
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Maroti D, Lumley MA, Schubiner H, Lilliengren P, Bileviciute-Ljungar I, Ljótsson B, Johansson R. Internet-based emotional awareness and expression therapy for somatic symptom disorder: A randomized controlled trial. J Psychosom Res 2022; 163:111068. [PMID: 36327532 DOI: 10.1016/j.jpsychores.2022.111068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 09/11/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Somatic symptom disorder (SSD) is commonly encountered in health care settings. Cognitive-behavioural treatments have been most extensively studied, but they tend to have small effects of temporary duration. Emotional awareness and expression therapy (EAET) is a newly developed treatment for SSD, targeting emotional processing of trauma and conflict as a mechanism of symptom change. In an earlier uncontrolled study of self-guided, internet-administrated EAET (I-EAET), we found substantial reductions in somatic symptoms, prompting the need for a randomized controlled trial of I-EAET. METHODS We conducted a 2-arm RCT, comparing 10-week I-EAET (n = 37) to a waitlist control (WL; n = 37). Primary outcomes were reductions of somatic symptoms (PHQ-15) and pain intensity (BPI-4) at post-treatment, with a 4-month evaluation of effect duration. We also analysed emotional processing (EPS-25) and depression (PHQ-9) as possible mediators of I-EAET's effects. RESULTS Compared to controls, I-EAET significantly reduced somatic symptoms at both post-treatment and follow-up. I-EAET also reduced pain, depression, insomnia, and anxiety at post-treatment, but these effects were not retained at follow-up. As hypothesized, a facet of emotional processing partially mediated the treatment effect on somatic symptoms, even when controlling for depression. CONCLUSIONS Although treatment effects were smaller than in the previous uncontrolled trial, I-EAET is a promising treatment for SSD, with a minority of patients (around 20%) experiencing substantial clinical improvement. The benefits of I-EAET are partially mediated by improved emotional processing. Future research should identify and target patients who respond best to I-EAET and develop tailored treatment to enhance treatment effects. (Preregistered at clinicaltrials.gov: NCT04751825.).
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Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, MI, USA..
| | - Howard Schubiner
- Department of Internal Medicine, Ascension Providence-Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Peter Lilliengren
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden..
| | - Indre Bileviciute-Ljungar
- Department of Clinical Sciences, Karolinska Institute and Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden..
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
| | - Robert Johansson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Psychology, Stockholm University, Stockholm, Sweden..
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Maroti D, Hallberg H, Lindqvist K, Mechler J. Using psychodynamic principles in guided internet-delivered therapy (IPDT). Psychoanalytic Psychotherapy 2022. [DOI: 10.1080/02668734.2022.2124441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2022]
Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Henrik Hallberg
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Karin Lindqvist
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Jakob Mechler
- Department of Psychology, Stockholm University, Stockholm, Sweden
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Maroti D, Ljótsson B, Lumley MA, Schubiner H, Hallberg H, Olsson PÅ, Johansson R. Emotional Processing and Its Association to Somatic Symptom Change in Emotional Awareness and Expression Therapy for Somatic Symptom Disorder: A Preliminary Mediation Investigation. Front Psychol 2021; 12:712518. [PMID: 34690868 PMCID: PMC8528965 DOI: 10.3389/fpsyg.2021.712518] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: The aim of this study was to investigate emotional processing as a potential mediator in therapist-guided, internet-based Emotional Awareness and Expression Therapy (I-EAET) for somatic symptom disorder, using data from a previously published pilot study. Methods: Participants (N = 52) engaged in a 9-week I-EAET treatment. Before treatment and each week during treatment (i.e., 10 weekly measurements), emotional processing was assessed with the Emotional Processing Scale-25 (EPS-25), which contains five subscales, and somatic symptoms were assessed with the Patient Health Questionnaire-15 (PHQ-15). Results: Mediation analyses using linear mixed models showed that two EPS-25 subscales—Signs of Unprocessed Emotions and Impoverished Emotional Experience—were uniquely associated with somatic symptom reduction. The proportion of the mediated effect was 0.49, indicating that about half of the total association of the PHQ-15 with symptoms was accounted for by the two EPS-25 subscales. Conclusion: This preliminary mediation analysis suggests that improved emotional processing is associated with change in somatic symptoms in I-EAET. However, randomized controlled and comparison trials are needed to establish that I-EAET creates the change in emotional processing and that such changes are specific to I-EAET.
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Affiliation(s)
- Daniel Maroti
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, MI, United States
| | - Howard Schubiner
- Department of Internal Medicine, Ascension Providence-Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI, United States
| | - Henrik Hallberg
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Per-Åke Olsson
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Robert Johansson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Psychology, Stockholm University, Stockholm, Sweden
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Maroti D, Johansson R. Is Cognitive Change Necessary to Alleviate Symptoms in Patients With Functional Somatic Syndrome? Front Psychiatry 2021; 12:781083. [PMID: 34795604 PMCID: PMC8593391 DOI: 10.3389/fpsyt.2021.781083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robert Johansson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Psychology, Stockholm University, Stockholm, Sweden
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Maroti D, Ek J, Widlund RM, Schubiner H, Lumley MA, Lilliengren P, Bileviciute-Ljungar I, Ljótsson B, Johansson R. Internet-Administered Emotional Awareness and Expression Therapy for Somatic Symptom Disorder With Centralized Symptoms: A Preliminary Efficacy Trial. Front Psychiatry 2021; 12:620359. [PMID: 33679478 PMCID: PMC7928393 DOI: 10.3389/fpsyt.2021.620359] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/20/2021] [Indexed: 01/04/2023] Open
Abstract
Background: There is growing evidence that trauma, psychosocial conflict, and difficulties with emotional processing contribute to centralized somatic symptoms. Emotional Awareness and Expression Therapy (EAET) was developed to address these factors and reduce symptoms, and EAET has shown efficacy in face-to-face formats. No trial of an internet-delivered EAET (I-EAET) exists, however, so we developed such an intervention and conducted an uncontrolled feasibility and potential efficacy trial of I-EAET for patients with Somatic Symptom Disorder (SSD) with centralized symptoms (SSD-CS). Method: After screening potential participants, a sample of 52 patients (50 women, two men; age M = 49.6, SD = 11.9) diagnosed with SSD-CS initiated treatment. I-EAET consisted of nine weekly modules focused on psychoeducation, emotional awareness and exposure, and anxiety regulation with self-compassion. Therapists communicated with each patient by email for about 20 min per week during treatment, answering questions and giving feedback on homework assignments. Patients completed measures of somatic symptoms, depression, anxiety, trauma-related symptoms, and functional disability before treatment and again at post-treatment and 4-month follow-up. Results: A large reduction in somatic symptoms (PHQ-15) occurred pre-to post-treatment (d = 1.13; 95% CI: 0.84-1.47) which was fully maintained at 4-month follow-up (d = 1.19; 95% CI: 0.88-1.56). Twenty-three percent of the patients at post-treatment and 27% at follow-up achieved a 50% or greater reduction in somatic symptoms, and about 70% achieved a minimally important clinical difference. In addition, at post-treatment, there were small to medium reductions (d's from 0.33 to 0.72) in anxiety (GAD-7), depression (PHQ-9), trauma-related symptoms (PCL-5), and functional disability (Sheehan Disability Scale). For all of these secondary outcomes, improvements were slightly to substantially larger at follow-up than at post-treatment (d's from 0.46 to 0.80). Conclusion: I-EAET appears to be a feasible treatment for adults with SSD and centralized symptoms, resulting in substantial and durable improvement not only in somatic symptoms but in other psychiatric symptoms and functioning. Controlled trials are needed determine the effects of I-EAET specifically and how this approach compares to face-to-face EAET and to other internet-delivered treatments, such as cognitive-behavioral interventions. Research should also identify treatment responders and mechanisms of change in EAET. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04122846.
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Affiliation(s)
- Daniel Maroti
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Josefine Ek
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | | | - Howard Schubiner
- Department of Internal Medicine, Ascension Providence-Providence Hospital, Michigan State University College of Human Medicine, Southfield, MI, United States
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, MI, United States
| | - Peter Lilliengren
- Department of Health Care Sciences, St. Lukas Educational Institute, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Indre Bileviciute-Ljungar
- Department of Clinical Sciences, Karolinska Institutet and Multidisciplinary Pain Unit, St Göran Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Robert Johansson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Psychology, Stockholm University, Stockholm, Sweden
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Bileviciute-Ljungar I, Maroti D, Bejerot S. Patients with chronic fatigue syndrome do not score higher on the autism-spectrum quotient than healthy controls: Comparison with autism spectrum disorder. Scand J Psychol 2018; 59:428-432. [DOI: 10.1111/sjop.12451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/14/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Indre Bileviciute-Ljungar
- Department of Clinical Sciences; Danderyd University Hospital; Karolinska Institutet; and ME/CFS-rehabilitation, Department of Rehabilitation Medicine; Danderyd University Hospital; Stockholm Sweden
- ME/CFS-unit; Pain and Rehabilitation Center; Region Östergotland; Linköping Sweden
| | - Daniel Maroti
- Department of Clinical Sciences; Danderyd University Hospital; Karolinska Institutet; and ME/CFS-rehabilitation, Department of Rehabilitation Medicine; Danderyd University Hospital; Stockholm Sweden
| | - Susanne Bejerot
- Department of Medical Sciences; Örebro University; Örebro Sweden
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Maroti D, Lilliengren P, Bileviciute-Ljungar I. The Relationship Between Alexithymia and Emotional Awareness: A Meta-Analytic Review of the Correlation Between TAS-20 and LEAS. Front Psychol 2018; 9:453. [PMID: 29713295 PMCID: PMC5911526 DOI: 10.3389/fpsyg.2018.00453] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/19/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Alexithymia and emotional awareness may be considered overlapping constructs and both have been shown to be related to psychological and emotional well-being. However, it is not clear how the constructs relate to each other empirically or if they may overlap more or less in different populations. The aim of this review was therefore to conduct a meta-analysis of correlations between the most commonly used measures of alexithymia (i.e., the self-report instrument Toronto Alexithymia Scale; TAS-20) and emotional awareness (i.e., the observer-rated instrument Level of Emotional Awareness Scale; LEAS) and to explore potential moderators of their relationship. Methods: Electronic databases were searched for studies published until the end of February 2018. Study samples were coded as medical conditions, psychiatric disorders and/or healthy controls and sample mean age and gender distribution were extracted. Correlations between the TAS-20 and the LEAS were subjected to a random effect of meta-analysis and moderators were explored in subgroup analyses and meta-regressions. Publication bias was considered. Results: 21 studies reporting on 28 independent samples on correlation analysis were included, encompassing a total of 2857 subjects (57% women). The aggregated correlation between TAS-20 and LEAS was r = −0.122 (95% CI [−0.180, −0.064]; Z = −4.092; p < 0.001), indicating a significant, but weak, negative relationship between the measures. Heterogeneity was moderate, but we found no indication of significant differences between patients with medical conditions, psychiatric disorders or healthy controls, nor that mean age or percentage of female subjects moderated the relationship. The overall estimate became somewhat weaker after adjusting for possible publication bias. Conclusions: Our results indicate that TAS-20 and LEAS measure different aspects of emotional functioning. The small overlap suggests that alexithymia and emotional awareness are distinct constructs of emotional well-being. Clinicians need to assess both aspects when considering treatment options for individual patients. Moreover, from the clinical standpoint, an easy reliable and valid way of measuring emotional awareness is still needed. More research should be focus on the differences between alexithymia and emotional awareness in specific conditions, but also how to integrate self-report instrument and observed based measures in a clinical situation.
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Affiliation(s)
- Daniel Maroti
- Department of Clinical Sciences, Rehabilitation Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Peter Lilliengren
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Indre Bileviciute-Ljungar
- Department of Clinical Sciences, Rehabilitation Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Maroti D, Molander P, Bileviciute-Ljungar I. Differences in alexithymia and emotional awareness in exhaustion syndrome and chronic fatigue syndrome. Scand J Psychol 2016; 58:52-61. [PMID: 27686801 DOI: 10.1111/sjop.12332] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/03/2016] [Indexed: 11/27/2022]
Abstract
Symptoms of Exhaustion Syndrome (ES) and Chronic Fatigue Syndrome (CFS) are overlapping and create difficulties of differential diagnosis. Empirical studies comparing ES and CFS are scarce. This study aims to investigate if there are any emotional differences between ES and CFS. This cross-sectional study compared self-reported alexithymia and observer-rated emotional awareness in patients with ES (n = 31), CFS (n = 38) and healthy controls (HC) (n = 30). Self-reported alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20) and emotional awareness with an observer-rated performance test, the Level of Emotional Awareness Scale (LEAS). Additionally, depression and anxiety were scored by the Hospital Anxiety and Depression Scale (HADS). Results show that patients with ES expressed higher self-reported alexithymia in the TAS-20 compared to HC, but had similar emotional awareness capacity in the observer-rated performance test, the LEAS. Patients with CFS expressed more difficulties in identifying emotions compared to HCs, and performed significantly worse in the LEAS-total and spent more time completing the LEAS as compared to HC. Correlation and multiple regressions analyses revealed that depression and anxiety positively correlated with and explained part of the variances in alexithymia scores, while age and group explained the major part of the variance in LEAS. Findings of this study indicate that emotional status is different in patients with ES and CFS with respect to both self-reported alexithymia and observer-rated emotional awareness. Emotional parameters should be approached both in clinical investigation and psychotherapy for patients with ES and CFS.
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Affiliation(s)
- Daniel Maroti
- Department of Clinical Sciences, Karolinska Institutet and Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Peter Molander
- Department of Medical and Health Sciences, Linköping University and Region Östergotland, Linköping, Sweden.,Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Indre Bileviciute-Ljungar
- Department of Clinical Sciences, Karolinska Institutet and Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden.,Department of Medical and Health Sciences, Linköping University and Region Östergotland, Linköping, Sweden
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Maroti D, Westerberg A, Saury J, Bileviciute-Ljungar I. Computerized training improves verbal working memory in patients with myalgic encephalomyelitis/chronic fatigue syndrome: A pilot study. J Rehabil Med 2015; 47:665-8. [DOI: 10.2340/16501977-1976] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Maroti D, Folkeson P, Jansson-Fröjmark M, Linton SJ. Does Treating Insomnia With Cognitive–Behavioural Therapy Influence Comorbid Anxiety and Depression? An Exploratory Multiple Baseline Design With Four Patients. Behav change 2012. [DOI: 10.1375/bech.28.4.195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectives:Although cognitive–behaviour therapy for insomnia (CBT-I) has been shown to be effective for primary insomnia, the impact of CBT-I on insomnia comorbid with psychiatric conditions is largely unknown.Design:A multiple baseline design with 2–3 weeks of baseline, 6 weeks of CBT-I, and a 3-week follow-up was employed.Methods:Four patients with insomnia comorbid with both anxiety and depressive disorders participated. Sleep onset latency (SOL), wake time after sleep onset (WASO), total sleep time (TST), the Insomnia Severity Index (ISI), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI-II) were used as outcome measures.Results:Improvements in SOL, WASO, and TST were observed for all the four patients. Based on ISI, there were reductions for all the patients (32–92%), three patients responded to treatment, and two patients remitted. Based on BAI, reductions on anxiety were observed for all the patients (40–76%), three patients were treatment responders, and two patients remitted. Based on BDI-II, all the patients experienced reductions in depression (36–53%), three patients responded to treatment, and one patient remitted.Conclusions:CBT-I was able to reduce insomnia and co-morbid anxiety and depression, thus providing preliminary evidence for using CBT-I on insomnia co-morbid with psychiatric conditions.
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