Sweetman Alexander, Lovato Nicole, Micic Gorica, Scott Hannah, Bickley Kelsey, Haycock Jenny, Harris Jodie, Gradisar Michael, Lack Leon
The Adelaide Institute for Sleep Health, A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia; National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.
The Adelaide Institute for Sleep Health, A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia; National Centre for Sleep Health Services Research, A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.
Sleep Med. 2020 Nov;75:401-410. doi: 10.1016/j.sleep.2020.08.023. Epub 2020 Aug 27.
Co-occurring insomnia and symptoms of depression, anxiety, and stress pose difficult diagnostic and treatment decisions for clinicians. Cognitive Behavioural Therapy for Insomnia (CBTi) is the recommended first-line insomnia treatment, however symptoms of depression, anxiety and stress may reduce the effectiveness of CBTi. We examined the effect of low, moderate, and severe symptoms of depression, anxiety, and stress on insomnia improvements during CBTi.
We undertook a chart-review of 455 patients (67% Female, Age M = 51.7, SD = 15.6) attending an outpatient CBTi program. Sleep diaries and questionnaire measures of insomnia, depression, anxiety, and stress symptoms were completed at pre-treatment, post-treatment and three-month follow up. We examined 1) the effect of low, moderate, and severe symptoms of depression, anxiety, and stress before treatment on changes in sleep diary and questionnaire measures of insomnia during CBTi, and 2) changes in symptoms of depression, anxiety, and stress during CBTi.
Sleep diary and questionnaire measures of insomnia severity showed moderate-to-large improvements during CBTi (d = 0.5-2.7, all p ≤ 0.001), and were not moderated by levels of depression, anxiety or stress before treatment (all interactions p > 0.05). Symptoms of depression, anxiety, and stress improved by three-month follow-up (M improvement = 41-43%; CI = 28-54, Cohen's d = 0.4-0.7).
Symptoms of depression, anxiety, and stress do not impair the effectiveness of CBTi. Instead, CBTi was associated with moderate-to-large improvement of depression, anxiety, and stress symptoms in patients with insomnia disorder. Clinicians should refer patients with insomnia for CBTi even in the presence of comorbid symptoms of depression, anxiety, and stress.
失眠与抑郁、焦虑和压力症状同时出现，给临床医生带来了艰难的诊断和治疗决策。失眠认知行为疗法（CBTi）是推荐的一线失眠治疗方法，然而抑郁、焦虑和压力症状可能会降低CBTi的疗效。我们研究了轻度、中度和重度抑郁、焦虑和压力症状对CBTi期间失眠改善的影响。
我们对参加门诊CBTi项目的455名患者（67%为女性，年龄M = 51.7，标准差 = 15.6）进行了病历审查。在治疗前、治疗后和三个月随访时完成了睡眠日记以及失眠、抑郁、焦虑和压力症状的问卷调查。我们研究了：1）治疗前轻度、中度和重度抑郁、焦虑和压力症状对CBTi期间睡眠日记和失眠问卷调查指标变化的影响；2）CBTi期间抑郁、焦虑和压力症状的变化。
CBTi期间，睡眠日记和失眠严重程度的问卷调查指标显示出中度到大幅改善（d = 0.5 - 2.7，所有p≤0.001），且不受治疗前抑郁、焦虑或压力水平的影响（所有交互作用p > 0.05）。到三个月随访时，抑郁、焦虑和压力症状有所改善（改善幅度M = 41 - 43%；置信区间 = 28 - 54，科恩d值 = 0.4 - 0.7）。
抑郁、焦虑和压力症状不会损害CBTi的疗效。相反，CBTi与失眠症患者的抑郁、焦虑和压力症状的中度到大幅改善相关。即使存在抑郁、焦虑和压力的共病症状，临床医生也应将失眠患者转诊接受CBTi治疗。
