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Computerized Cognitive Behavioral Therapy for Insomnia in a Community Health Setting.

ABSTRACT: Insomnia, though quite common in the general population, is especially prevalent among individuals with co-occurring mental illnesses, patients whose condition can be further exacerbated by insomnia and vice versa. For individuals taking one or more psychotropic medications, cognitive behavioral therapy for insomnia (CBT-I), the gold standard in insomnia treatment, is a particularly favorable option (vis-à-vis pharmacotherapy). However, CBT-I can be inaccessible for persons with low socioeconomic status, a group that includes many with psychiatric diagnoses. Computer-based delivery of CBT-I (cb-CBT-I) has the potential to be a cost-effective tool that could greatly improve accessibility for this at-risk demographic.Thirty-four participants with insomnia who were currently engaged in mental health care treatment were randomized to an active control group (sleep diary group; n = 16) or cb-CBT-I (n = 18) during weekly outpatient sessions over the course of 6 w. All participants completed sleep and activity logs at each appointment, whereas those in the cb-CBT-I group also completed one session of the cb-CBT-I program each week.cb-CBT-I treatment was associated with lower scores (improved sleep) on the Pittsburgh Sleep Quality Index (PSQI). Post hoc tests demonstrated a between groups difference at week 6 (p = 0.02), with a statistically significant decrease in PSQI scores in the cb-CBT-I group (p = 0.0006) but not in the sleep diary group (p = 0.35).cb-CBT-I improves sleep in individuals with insomnia and co-occurring mental illness. The significant improvements on the PSQI suggest that implementing a cb-CBT-I treatment in a community mental health center would be a simple and effective treatment for improving sleep over a short period of time.A commentary on this article appears in this issue on page 161.

SUBMITTER: Feuerstein S

PROVIDER: S-EPMC5263082 | biostudies-other | 2017 Feb

REPOSITORIES: biostudies-other

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Computerized Cognitive Behavioral Therapy for Insomnia in a Community Health Setting.

Feuerstein Seth S Hodges Sarah E SE Keenaghan Brian B Bessette Andrew A Forselius Erica E Morgan Peter T PT

Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 20170215 2

<h4>Study objectives</h4>Insomnia, though quite common in the general population, is especially prevalent among individuals with co-occurring mental illnesses, patients whose condition can be further exacerbated by insomnia and <i>vice versa</i>. For individuals taking one or more psychotropic medications, cognitive behavioral therapy for insomnia (CBT-I), the gold standard in insomnia treatment, is a particularly favorable option (vis-à-vis pharmacotherapy). However, CBT-I can be inaccessible f ...[more]

PMID: 27784409

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Project description:BackgroundMental ill-health presents a major public health problem. A potential part solution that is receiving increasing attention is computer-delivered psychological therapy, particularly during the COVID-19 pandemic as health care systems moved to remote service delivery. However, computerized cognitive behavioral therapy (cCBT) requires active engagement by service users, and low adherence may minimize treatment effectiveness. Therefore, it is important to investigate the acceptability of cCBT to understand implementation issues and maximize potential benefits.ObjectiveThis study aimed to produce a critical appraisal of published reviews about the acceptability of cCBT for adults.MethodsAn umbrella review informed by the Joanna Briggs Institute (JBI) methodology identified systematic reviews about the acceptability of cCBT for common adult mental disorders. Acceptability was operationalized in terms of uptake of, dropping out from, or completion of cCBT treatment; factors that facilitated or impeded adherence; and reports about user, carer, and health care professional experience and satisfaction with cCBT. Databases were searched using search terms informed by relevant published research. Review selection and quality appraisal were guided by the JBI methodology and the AMSTAR tool and undertaken independently by 2 reviewers.ResultsThe systematic searches of databases identified 234 titles, and 9 reviews (covering 151 unique studies) met the criteria. Most studies were comprised of service users with depression, anxiety, or specifically, panic disorder or phobia. Operationalization of acceptability varied across reviews, thereby making it difficult to synthesize results. There was a similar number of guided and unguided cCBT programs; 34% of guided and 36% of unguided users dropped out; and guidance included email, telephone, face-to-face, and discussion forum support. Guided cCBT was completed in full by 8%-74% of the participants, while 94% completed one module and 67%-84% completed some modules. Unguided cCBT was completed in full by 16%-66% of participants, while 95% completed one module and 54%-93% completed some modules. Guided cCBT appeared to be associated with adherence (sustained via telephone). A preference for face-to-face CBT compared to cCBT (particularly for users who reported feeling isolated), internet or computerized delivery problems, negative perceptions about cCBT, low motivation, too busy or not having enough time, and personal circumstances were stated as reasons for dropping out. Yet, some users favored the anonymous nature of cCBT, and the capacity to undertake cCBT in one's own time was deemed beneficial but also led to avoidance of cCBT. There was inconclusive evidence for an association between sociodemographic variables, mental health status, and cCBT adherence or dropping out. Users tended to be satisfied with cCBT, reported improvements in mental health, and recommended cCBT. Overall, the results indicated that service users' preferences were important considerations regarding the use of cCBT.ConclusionsThe review indicated that "one size did not fit all" regarding the acceptability of cCBT and that individual tailoring of cCBT is required in order to increase population reach, uptake, and adherence and therefore, deliver treatment benefits and improve mental health.

Project description:BackgroundIn reality, pharmacotherapy still remains the most common treatment for insomnia.ObjectiveThis study aimed to examine the effectiveness of our internet-delivered computerized cognitive behavioral therapy (ICBT) program as an adjunct to usual care (UC) compared with UC alone in patients with insomnia who remain symptomatic following hypnotics.MethodsWe recruited 23 patients with insomnia who remained symptomatic following pharmacologic treatment including benzodiazepines, and we conducted an exploratory randomized controlled trial. The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) at week 6 of the treatment. Secondary outcomes were sleep onset latency, total sleep time, sleep efficiency, number of awakenings, refreshment and soundness of sleep, anxiety by Hospital Anxiety and Depression Scale, depression measured by the Center for Epidemiologic Studies Depression Scale, and quality of life (QOL) measured by the EuroQol-5D. All parameters were measured at weeks 0 (baseline), 6 (postintervention), and 12 (follow-up).ResultsThe adjusted mean reduction (-6.11) in PSQI at week 6 from baseline in the ICBT plus UC group was significantly (P<.001) larger than the adjusted mean reduction (0.40) in the UC alone group. Significant differences were also found in favor of ICBT plus UC for PSQI, sleep onset latency, sleep efficiency, number of awakenings, and depression at all assessment points. Refreshment, soundness of sleep, anxiety, and QOL improved by week 6 in ICBT plus UC compared with UC alone. There were no reports of adverse events in either group during the study.ConclusionsThese results indicated that our 6-week ICBT program is an effective treatment adjunct to UC for improving insomnia and related symptoms even after unsuccessful pharmacotherapy.Trial registrationUniversity Hospital Medical Information Network Clinical Trials Registry: UMIN000021509; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023545 (Archived by WebCite at http://www.webcitation. org/75tCmwnYt).

Project description:BACKGROUND:Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown. OBJECTIVE:This open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS). METHODS:A total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi. RESULTS:Average baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005). CONCLUSIONS:Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):RR2-10.2196/11324.

Project description:STUDY OBJECTIVES:The current archival analyses examine the direct and indirect effects of cognitive behavioral therapy for insomnia (CBT-I) on depression in cancer survivors. METHODS:We report on 67 cancer survivors from a 2 × 2 randomized controlled trial of CBT-I and armodafinil for insomnia, after collapsing across the noneffective study medication conditions (armodafinil/placebo) to create CBT-I (yes/no). Depression and insomnia were assessed before, during the 7-week CBT-I intervention, at postintervention, and 3 months later by the Patient Health Questionnaire and the Insomnia Severity Index, respectively. RESULTS:Mean depression at baseline for all participants was 6.44 (standard error = 0.41, range 0-15). Paired t tests showed that depression improved from baseline to postintervention by 48% (P < .001) in the CBT-I group versus 15% (P = .016) in the non-CBT-I group. Analysis of covariance controlling for baseline found that participants receiving CBT-I had significantly less depression at postintervention (effect size = -0.62; P = .001), compared to those who did not receive CBT-I. These benefits were maintained at the 3-month follow-up. Spearman rank correlations showed that changes in insomnia severity from baseline to postintervention were significantly correlated with concurrent changes in depression (r = .73; P < .001). Path analysis revealed that improvement in depression was mediated by improvement in insomnia severity (P < .001). CONCLUSIONS:Our findings provide preliminary support that in cancer survivors, CBT-I reduces depression via improvement in insomnia. Further, this reduction in depression remained stable 3 months after completing CBT-I. This suggests that a CBT-I intervention has a meaningful effect on depression. CLINICAL TRIAL REGISTRATION:Registry: ClinicalTrials.gov; Title: Cognitive Behavioral Therapy +/- Armodafinil for Insomnia and Fatigue Following Chemotherapy; Identifier: NCT01091974; URL: https://clinicaltrials.gov/ct2/show/record/NCT01091974.

Project description:ObjectiveTo evaluate the effectiveness of cognitive behavioral therapy for insomnia during pregnancy.MethodsRandomized, unmasked, 3-site controlled trial. Participants were randomly allocated to cognitive behavioral therapy for insomnia (a first-line, empirically supported psychosocial intervention that addresses sleep-related behaviors and cognitions) or a control intervention consisting of imagery exercises that paired patient-identified distressing nighttime experiences with patient-identified neutral images. Participants were eligible if they met diagnostic criteria for insomnia disorder and were between 18 and 32 weeks of gestation. Patients were ineligible if they met diagnostic criteria for major psychiatric disorders, including depression, or were receiving nonstudy treatments that could affect sleep (or both). The primary outcome was the Insomnia Severity Index score, a validated brief questionnaire, with scores between 14 and 21 representing clinically meaningful insomnia of moderate severity, scores higher than 21 representing severe insomnia, and scores less than 8 representing no insomnia. Secondary outcomes included remission of insomnia (Insomnia Severity Index score less than 8), objectively measured and self-reported time awake (ie, total wake time), and the Edinburgh Postnatal Depression Scale score. All outcomes were measured weekly. Analysis included 48 participants who did not complete treatment. We estimated that 184 women would be required to have 80% power, with a two-tailed test, to detect a moderate Cohen's d effect size (.5) with α=.05.ResultsBetween May 2013 and April 2017, 194 pregnant women were randomized and 149 completed treatment; 179 with available baseline data (92%) were ultimately analyzed, 89 in the cognitive therapy group and 90 in the control group. Women assigned to cognitive behavioral therapy for insomnia experienced significantly greater reductions in insomnia severity (scores decreased from 15.4±4.3 to 8.0±5.2 in the cognitive behavioral therapy group vs from 15.9±4.4 to 11.2±4.9 in the control therapy group [P<.001, d=0.5]). Remission of insomnia (to an Insomnia Severity Index score less than 8) disorder was attained by 64% of women in the cognitive behavioral therapy for insomnia group vs 52% in the control group. Women receiving cognitive behavioral therapy for insomnia experienced faster remission of insomnia disorder, with a median of 31 days vs 48 days in the control therapy (P<.001). Cognitive behavioral therapy for insomnia led to significantly greater reduction in self-reported but not objective total wake time and a small but significantly greater decline in Edinburgh Postnatal Depression Scale scores vs the control group.ConclusionCognitive behavioral therapy for insomnia is an effective nonpharmacologic treatment for insomnia during pregnancy.Clinical trial registrationClinicalTrials.gov, NCT01846585.

Dataset Information

Computerized Cognitive Behavioral Therapy for Insomnia in a Community Health Setting.

Publications

Computerized Cognitive Behavioral Therapy for Insomnia in a Community Health Setting.

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