Summary Insomnia is a major public health problem considering its high prevalence, impact on daily life, co-morbidity with other disorders and societal costs. Cognitive behavioral treatment for ...insomnia (CBTI) is currently considered to be the preferred treatment. However, no meta-analysis exists of all studies using at least one component of CBTI for insomnia, which also uses modern techniques to pool data and to analyze subgroups of patients. We included 87 randomized controlled trials, comparing 118 treatments (3724 patients) to non-treated controls (2579 patients). Overall, the interventions had significant effects on: insomnia severity index (ISI; g =0.98), sleep efficiency (SE; g =0.71), Pittsburgh sleep quality index (PSQI; g =0.65), wake after sleep onset (WASO; g=0.63) and sleep onset latency (SOL; g =0.57), number of awakenings (NWAK; g = 0.29) and sleep quality (SQ; g = 0.40). The smallest effect was on total sleep time (TST; g =0.16). Face-to-face treatments of at least 4 sessions seem to be more effective than self-help interventions or face-to-face interventions with fewer sessions. Otherwise the results seem to be quite robust (similar for patients with or without comorbid disease, younger or older patients, using or not using sleep medication). We conclude that CBTI, either its components or the full package, is effective in the treatment of insomnia.
There are not enough trained psychologists available and waiting lists for mental health services are long. ...the trial does not address the issue of primary care physicians not recognising ...insomnia, and therefore implementation of sleep restriction therapy in regular practice might still be disappointing. ...patients in the study were mostly from a White ethnic background, from areas with low deprivation, and nearly half had a university degree.
Abstract Background Standardised effect sizes have been criticized because they are difficult to interpret and offer little clinical information. This meta-analyses examine the extent of actual ...improvement, the absolute numbers of patients no longer meeting criteria for major depression, and absolute rates of response and remission. Methods We conducted a meta-analysis of 92 studies with 181 conditions (134 psychotherapy and 47 control conditions) with 6937 patients meeting criteria for major depressive disorder. Within these conditions, we calculated the absolute number of patients no longer meeting criteria for major depression, rates of response and remission, and the absolute reduction on the BDI, BDI-II, and HAM-D. Results After treatment, 62% of patients no longer met criteria for MDD in the psychotherapy conditions. However, 43% of participants in the control conditions and 48% of people in the care-as-usual conditions no longer met criteria for MDD, suggesting that the additional value of psychotherapy compared to care-as-usual would be 14%. For response and remission, comparable results were found, with less than half of the patients meeting criteria for response and remission after psychotherapy. Additionally, a considerable proportion of response and remission was also found in control conditions. In the psychotherapy conditions, scores on the BDI were reduced by 13.42 points, 15.12 points on the BDI-II, and 10.28 points on the HAM-D. In the control conditions, these reductions were 4.56, 4.68, and 5.29. Discussion Psychotherapy contributes to improvement in depressed patients, but improvement in control conditions is also considerable.
Internet-delivered treatment is effective for insomnia, but little is known about the beneficial effects of support. The aim of the current study was to investigate the additional effects of ...low-intensity support to an internet-delivered treatment for insomnia. Two hundred and sixty-two participants were randomized to an internet-delivered intervention for insomnia with (n = 129) or without support (n = 133). All participants received an internet-delivered cognitive behavioral treatment for insomnia. In addition, the participants in the support condition received weekly emails. Assessments were at baseline, post-treatment, and 6-month follow-up. Both groups effectively ameliorated insomnia complaints. Adding support led to significantly higher effects on most sleep measures (d = 0.3–0.5; p < 0.05), self-reported insomnia severity (d = 0.4; p < 0.001), anxiety, and depressive symptoms (d = 0.4; p < 0.01). At the 6-month follow-up, these effects remained significant for sleep efficiency, sleep onset latency, insomnia symptoms, and depressive symptoms (d = 0.3–0.5; p < 0.05). Providing support significantly enhances the benefits of internet-delivered treatment for insomnia on several variables. It appears that motivational feedback increases the effect of the intervention and encourages more participants to complete the intervention, which in turn improves its effectiveness.
•Internet-delivered treatment is effective for insomnia.•Support enhances the benefits of internet-delivered treatment for insomnia.•Motivational feedback encourages more participants to complete the intervention.
Abstract
Objective
We aimed to determine the prevalence of insomnia and insomnia symptoms and its association with metabolic parameters and glycemic control in people with type 2 diabetes (T2D) in a ...systematic review and meta-analysis.
Data Sources
A systematic literature search was conducted in PubMed/Embase until March 2018.
Study Selection
Included studies described prevalence of insomnia or insomnia symptoms and/or its association with metabolic parameters or glycemic control in adults with T2D.
Data Extraction
Data extraction was performed independently by 2 reviewers, on a standardized, prepiloted form. An adaptation of Quality Assessment Tool for Quantitative Studies was used to assess the methodological quality of the included studies.
Data Synthesis
When possible, results were meta-analyzed using random-effects analysis and rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results
A total of 11 329 titles/abstracts were screened and 224 were read full text in duplicate, of which 78 studies were included. The pooled prevalence of insomnia (symptoms) in people with T2D was 39% (95% confidence interval, 34–44) with I2 statistic of 100% (P < 0.00001), with a very low GRADE of evidence. Sensitivity analyses identified no clear sources of heterogeneity. Meta-analyses showed that in people with T2D, insomnia (symptoms) were associated with higher hemoglobin A1c levels (mean difference, 0.23% 0.1–0.4) and higher fasting glucose levels (mean difference, 0.40 mmol/L 0.2–0.7), with a low GRADE of evidence. The relative low methodological quality and high heterogeneity of the studies included in this meta-analysis complicate the interpretation of our results.
Conclusions
The prevalence of insomnia (symptoms) is 39% (95% confidence interval, 34–44) in the T2D population and may be associated with deleterious glycemic control.
Sleep disorders are linked to development of type 2 diabetes and increase the risk of developing diabetes complications. Treating sleep disorders might therefore play an important role in the ...prevention of diabetes progression. However, the detection and treatment of sleep disorders are not part of standardised care for people with type 2 diabetes. To highlight the importance of sleep disorders in people with type 2 diabetes, we provide a review of the literature on the prevalence of sleep disorders in type 2 diabetes and the association between sleep disorders and health outcomes, such as glycaemic control, microvascular and macrovascular complications, depression, mortality and quality of life. Additionally, we examine the extent to which treating sleep disorders in people with type 2 diabetes improves these health outcomes. We performed a literature search in PubMed from inception until January 2021, using search terms for sleep disorders, type 2 diabetes, prevalence, treatment and health outcomes. Both observational and experimental studies were included in the review. We found that insomnia (39% 95% CI 34, 44), obstructive sleep apnoea (55–86%) and restless legs syndrome (8–45%) were more prevalent in people with type 2 diabetes, compared with the general population. No studies reported prevalence rates for circadian rhythm sleep–wake disorders, central disorders of hypersomnolence or parasomnias. Additionally, several cross-sectional and prospective studies showed that sleep disorders negatively affect health outcomes in at least one diabetes domain, especially glycaemic control. For example, insomnia is associated with increased HbA
1c
levels (2.51 mmol/mol 95% CI 1.1, 4.4; 0.23% 95% CI 0.1, 0.4). Finally, randomised controlled trials that investigate the effect of treating sleep disorders in people with type 2 diabetes are scarce, based on a small number of participants and sometimes inconclusive. Conventional therapies such as weight loss, sleep education and cognitive behavioural therapy seem to be effective in improving sleep and health outcomes in people with type 2 diabetes. We conclude that sleep disorders are highly prevalent in people with type 2 diabetes, negatively affecting health outcomes. Since treatment of the sleep disorder could prevent diabetes progression, efforts should be made to diagnose and treat sleep disorders in type 2 diabetes in order to ultimately improve health and therefore quality of life.
Graphical abstract
Guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as the first line of treatment for insomnia in general practice, but CBT-I is rarely available. Nurse-guided Internet-delivered ...CBT-I might be a solution to improve access to care.
We aimed to determine the effectiveness of nurse-guided Internet-delivered CBT-I (I-CBT-I) on insomnia severity experienced by patients in general practice.
Nurse-guided I-CBT-I ("i-Sleep") was compared to care-as-usual (and I-CBT-I after 6 months) in 15 participating general practices among 134 patients (≥18 years old) with clinical insomnia symptoms. Assessments took place at 8, 26 and 52 weeks. Primary outcome was self-reported insomnia severity (Insomnia Severity Index) at 8 weeks. Secondary outcomes were sleep diary indices, depression and anxiety symptoms (Hospital Anxiety and Depression Scale), fatigue, daytime consequences of insomnia, sleep medication and adverse events.
Two thirds of the 69 intervention patients (n = 47; 68%) completed the whole intervention. At the posttest examination, there were large significant effects for insomnia severity (Cohen's d =1.66), several sleep diary variables (wake after sleep onset, number of awakenings, terminal wakefulness, sleep efficiency, sleep quality) and depression. At 26 weeks there were still significant effects on insomnia severity (d = 1.02) and on total sleep time and sleep efficiency. No significant effects were observed for anxiety, fatigue, daily functioning or sleep medication. No adverse events were reported.
Nurse-guided I-CBT-I effectively reduces insomnia severity among general practice patients. I-CBT-I enables general practitioners to offer effective insomnia care in accordance with the clinical guidelines.
The advent of Internet-based self-help systems for common mental disorders has generated a need for quick ways to triage would-be users to systems appropriate for their disorders. This need can be ...met by using brief online screening questionnaires, which can also be quickly used to screen patients prior to consultation with a GP.
To test and enhance the validity of the Web Screening Questionnaire (WSQ) to screen for: depressive disorder, alcohol abuse/dependence, GAD, PTSD, social phobia, panic disorder, agoraphobia, specific phobia, and OCD.
A total of 502 subjects (aged 18 - 80) answered the WSQ and 9 other questionnaires on the Internet. Of these 502, 157 were assessed for DSM-IV-disorders by phone in a WHO Composite International Diagnostic Interview with a CIDI-trained interviewer.
Positive WSQ "diagnosis" had significantly (P < .001) higher means on the corresponding validating questionnaire than negative WSQ "diagnosis". WSQ sensitivity was 0.72 - 1.00 and specificity was 0.44 - 0.77 after replacing three items (GAD, OCD, and panic) and adding one question for specific phobia. The Areas Under the Curve (AUCs) of the WSQ's items with scaled responses were comparable to AUCs of longer questionnaires.
The WSQ screens appropriately for common mental disorders. While the WSQ screens out negatives well, it also yields a high number of false positives.
Depression is a common, disabling condition for which psychological treatments are recommended. Behavioural activation has attracted increased interest in recent years. It has been over 5 years since ...our meta-analyses summarised the evidence supporting and this systematic review updates those findings and examines moderators of treatment effect.
Randomised trials of behavioural activation for depression versus controls or anti-depressant medication were identified using electronic database searches, previous reviews and reference lists. Data on symptom level and study level moderators were extracted and analysed using meta-analysis, sub-group analysis and meta-regression respectively.
Twenty six randomised controlled trials including 1524 subjects were included in this meta-analysis. A random effects meta-analysis of symptom level post treatment showed behavioural activation to be superior to controls (SMD -0.74 CI -0.91 to -0.56, k = 25, N = 1088) and medication (SMD -0.42 CI -0.83 to-0.00, k = 4, N = 283). Study quality was low in the majority of studies and follow- up time periods short. There was no indication of publication bias and subgroup analysis showed limited association between moderators and effect size.
The results in this meta-analysis support and strengthen the evidence base indicating Behavioural Activation is an effective treatment for depression. Further high quality research with longer term follow-up is needed to strengthen the evidence base.
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