緒論 失眠困擾對身心健康有重大的影響，除了藥物取向的治療外，失眠認知行為治療（CBT-I）有足夠的實證研究證據肯定其療效，由於在認知行為治療（CBT）的研究中有證據支持參與者在家中，對治療技術練習與執行的程度與療效有關，因此CBT-I的療效可能也與患者對治療技術的執行程度有關，過去雖然也有少數研究探討CBT-I執行程度與療效的關係，但這些研究缺乏針對CBT-I各個治療技術的執行程度評估，因此本研究欲探討CBT-I中，各項治療技術（睡眠衛生教育、放鬆訓練、刺激控制法、睡眠限制法，及認知重建）的執行程度及執行規律程度，與特定療效指標改善程度的關係。 方法 研究參與者含原發性失眠患者22位，共病其它疾患的失眠患者16位，經篩選階段確認符合收案條件後，在接受為期七週的CBT-I團體治療期間，於第二週起需每日填寫執行程度問卷，同時帶領團體的治療師也於治療第三週起，以治療師執行程度評估量表來評估參與者的執行程度。參與者在治療前後另需分別填寫一週睡眠日誌以及睡眠困擾問卷（Insomnia Severity Inventory；ISI），以睡眠日誌中的SOL、WASO、TST、SE，及ISI得分的前後測改變分數，作為代表療效指標之依變項，預測變項則為參與者自評及治療師所評估的各項治療技術之執行程度分數，治療技術包括：睡眠衛生、放鬆訓練、刺激控制法、睡眠限制法，以及認知重建；並分別以平均數代表執行程度，而以變異數代表執行期間的規律程度。 結果 資料分析以皮爾森相關分析檢驗執行程度與療效間的關聯性，在全部樣本中的結果發現，參與者自評對認知重建的平均數與WASO的改善程度有正相關，以及治療師評估CBT-I的平均數與SOL的改善程度有正相關；而參與者自評放鬆訓練的平均數越低、刺激控制法變異數越高，則ISI的改善程度越好，為不符合預期的結果。在原發性失眠組中發現治療師評估睡眠衛生的平均數與WASO的改善有正相關，治療師評估睡眠限制法的平均數與SOL、TST，以及SE的改善有正相關，而變異數與SOL的改善有負相關，以及治療師評估CBT-I的平均數與SOL的改善有正相關；而不符合預期的結果為，參與者自評執行刺激控制法的變異數與ISI的改善有正相關。最後，在共病組中並沒有發現執行程度與療效之間有顯著相關的結果，而放鬆訓練以及刺激控制法兩項治療技術，也沒有與療效指標有符合預期的顯著相關結果。 結論 對於共病失眠患者而言，治療技術的執行評估與療效間未反映出顯著相關，可能因受限於睡眠生理疾患的干擾，使得療效未如原發性失眠組明顯；而就原發性失眠組而言，睡眠限制法的執行程度是與較多療效指標達到顯著相關的治療技術，顯示睡眠限制法的執行對於改善睡眠症狀有所幫助。本研究較為重大的限制在於，治療技術執行程度評估的評分者間一致性有限，後續研究可進一步發展評估執行程度更適當的方法。 / Introduction Insomnia is a common problem that has a significant impact on patients' physical and mental health. In addition to pharmacological therapy, there are sufficient empirical data to support treatment efficacy of cognitive behavioral therapy for insomnia (CBT-I). A major part of cognitive behavioral therapy is to teach the patients to learn specific cognitive and behavioral techniques that requires to be practiced at home by the patients. Previous studies have reported an association between the degree of adherence to treatment techniques and treatment effects in cognitive behavioral therapy for disorders other than insomnia. Some studies further explored the relationship between treatment adherence and treatment outcome in CBT-I. However, none of the study looked into the adherence to different treatment components on different aspects of treatment outcome. The aim of this study therefore is to explore the relationship between the adherence to different treatment components in CBT-I and the improvement in different sleep parameters. Method Twenty-two patients with primary insomnia and sixteen patients with comorbid insomnia were recruited for this study. During the 6-week period of treatment with CBT-I, they completed a treatment adherence questionnaire daily. The therapists also evaluated the patients’ adherence weekly after treatment sessions. They were required to keep sleep diaries from one week before to one week after the end of the 6-week CBT-I program. They also completed the ISI and sleep diary for one week before and after the treatment. The treatment outcome variables included the ISI score, and sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST) and the sleep efficiency (SE) from sleep diaries. The treatment components evaluated included sleep hygiene, relaxation, stimulus control, sleep restriction and cognitive reconstruction. The predictive variables included the mean for the adherence degrees and the variance for the adherence regularity of the adherence score evaluated by the participants and therapists. Results Pearson correlation was used to examine the associations between the adherence to respective treatment components in CBT-I and the variables of treatment outcome. In the whole sample, the decrease of the WASO correlated significantly with adherence to cognitive reconstruction evaluated by the patients, and the decrease of the SOL correlated significantly with adherence to CBT-I evaluated by the therapists. Nonetheless, the lower adherence to relaxation and the higher variance of adherence to stimulus control, the more improvement of the ISI. In patients with primary insomnia, the decrease of WASO correlated significantly with adherence to sleep hygiene evaluated by the therapists; the decrease of SOL and the increase of TST and SE showed significant correlation with adherence to sleep restriction evaluated by the therapists; the decrease of SOL showed significant negative correlation with the variance of adherence to sleep restriction evaluated by the therapists; the decrease of SOL showed significant positive correlation with the adherence to CBT-I evaluated by the therapists. Opposite to expectation, the decrease of the ISI score correlated significantly with variability of adherence to stimulus control evaluated by the patients. Finally, in patients with comorbid insomnia, the treatment component adherence did not correlate significantly with any outcome variables. The adherence of relaxation and stimulus control did not show significant correlation with outcome variables. Conclusion In patients with comorbid insomnia, treatment effects were not associated with adherence. This may due to the multifactorial nature of comorbid insomnia. Among the treatment components, adherence to sleep restriction seems to be the most predictive factor for good treatment outcome in primary insomnia. One limitation of the present study is its low inter-rater reliability of treatment components adherence evaluation. Therefore, more appropriate methods need to be developed to evaluate the adherence of treatment techniques.

Sleep disturbances are a core and salient feature of PTSD and can maintain or exacerbate associated symptoms. Recent research demonstrates that cognitive-behavioral sleep-focused interventions improve sleep disturbances as well as PTSD symptoms. The present study is a randomized controlled trial comparing Cognitive Behavioral Therapy for Insomnia (CBT-I) to a waitlist control group. Conducted at a Veterans Affairs Medical Center, the study: 1) compared subjective outcome measures of sleep amongst veterans assigned to either a treatment group (CBT-I) or a waitlist control group; (2) examined the influence of the intervention on measures of PTSD, general mood and daytime functioning, comparing veterans in a treatment group to those in a waitlist control group and (3) examined the effect of the CBT-I intervention using objective measures of sleep for veterans included in the treatment arm of the study. Study participants were (n = 40) combat veterans who served in Afghanistan and/or Iraq (OEF/OIF). Participants were randomized to either a CBT-I treatment group or a wait-list control group. Those in the treatment condition participated in four CBT-I sessions over six weeks. CBT-I included sleep restriction, stimulus control, cognitive restructuring, sleep education, sleep hygiene and imagery rehearsal therapy. All participants completed subjective and objective measures at baseline and post-treatment. At six weeks post treatment, veterans who participated in CBT-I reported improved sleep, a reduction in PTSD symptom severity and PTSD-related nightmares, as well as a reduction in depression and distressed mood compared to veterans in the waitlist control group. When controlling for current participation in evidence-based PTSD treatment, veterans in the CBT-I group reported a reduction in PTSD symptom severity while their waitlist counterparts demonstrated an increase in these PTSD symptoms. Veterans in the treatment group also reported improved objectively measured sleep quality between baseline and posttreatment. These data suggest that CBT-I is an effective treatment for insomnia, nightmares and PTSD symptoms in OEF/OIF veterans with combat related PTSD and should be used as an adjunctive therapy to standard PTSD treatment.

Insomnia is defined as difficulty initiating or maintaining sleep, or nonrestorative sleep that lasts for at least one month and is accompanied by significant impairment in daytime functioning including fatigue, irritability, and/or difficulty concentrating. It is one of the most common complaints reported by individuals with cancer, especially around the time of cancer diagnosis and treatment. Yet it is often unrecognized and untreated, leading to adverse health consequences and increased healthcare costs. Cognitive Behavioral Therapy for Insomnia (CBT-I) has been recommended as the gold standard for treating insomnia among individuals with cancer. Multiple studies have tested and proven the efficacy and effectiveness of CBT-I among individuals with cancer. However, only one study has investigated the efficacy of CBT-I in individuals newly diagnosed with cancer who are undergoing cancer treatment. Moreover, previous studies have been limited by their focus on largely homogenous samples of White, well-educated women with breast cancer. The dissemination of CBT-I among individuals with cancer is greatly limited by the lack of available providers and resources needed to implement the standard face-to-face treatment. One strategy to address this shortage has been to abbreviate standard CBT-I into low-intensity modalities that require fewer resources and can be self-administered on the Internet. The current study sought to examine the feasibility and acceptability, as well as the efficacy of one such program, an online low-intensity CBT-I intervention, Sleeping Healthy Using the Internet (SHUTi), supplemented with clinician support, in a sample of individuals newly diagnosed with heterogeneous malignancies who were undergoing chemotherapy and/or radiation. Results yielded support for the feasibility and acceptability of addressing individuals’ insomnia with a low-intensity CBT-I intervention while they are undergoing cancer treatment. With regard to sleep, there were significant treatment effects observed on a global measure of insomnia severity and on subjective sleep consolidation. There were also significant treatment effects for depressive symptoms. Findings are discussed in the context of study limitations and for the purpose of expanding the literature on disseminating CBT-I early in the cancer care trajectory.

SammanfattningSömnproblem är vanligt förekommande hälsoproblem i befolkningen. Kognitiv beteendeterapi (KBT) har visats vara en effektiv behandling för personer med insomni men mindre forskning har bedrivits på effekten av KBT i grupp för personer med insomni (KBT-I) och samtidiga depressiva symtom. Studien syftade till att undersöka effekten av KBT-I i grupp med avseende på graden av insomni, depressiva symtom, och samvariationen med transdiagnostiska processer. En single-subject design användes med dagliga skattningar och för-, mellan- och eftermätningar. Resultatet visade att graden av insomni minskade för samtliga deltagare och graden av depressiva symtom minskade för majoriteten. En samvariation mellan sömnrelaterad oro, selektiv uppmärksamhet, och insomni fanns. Det återstår för framtida forskning att undersöka de transdiagnostiska processernas samband med insomni och depressiva symtom närmare. / AbstractSleep disorders are a common health problem in the population. Cognitive behavior therapy for insomnia (CBT-I) have proved to be an effective treatment for people with insomnia, but less research has been conducted on the efficacy of CBT-I in a group of people with insomnia (CBT-I) and comorbid depressive symptoms. The purpose of this study was to investigate the effect of CBT-I in group with respect to insomnia, depressive symptoms, and transdiagnostic processes. A single-subject design was used with daily estimates and pre- between-and posttest measures. The study concluded that the degree of insomnia symtoms decreased for all participants and the degree of depressive symptoms decreased for the majority. A correlation was found between sleep-related worry, selective attention, and insomnia. It remains for future research to investigate transdiagnostic processes associated with insomnia and depressive symptoms further.

Depression och insomni är två vanliga former av psykisk ohälsa. I den här studien undersöktes om en bevisat effektiv behandling för insomni, (KBT-I), påverkade grad av depressiva symtom hos personer med konstaterade symtom på såväl depression som insomni. I studien kontrollerades för en minskning av nedstämdhet kunde tillskrivas en ökad fysisk aktivitetsnivå. En single case experimental design användes för ändamålet, med dagliga skattningar av sömn, nedstämdhet och fysisk aktivitetsnivå. Symtom på såväl insomi som nedstämdhet minskade signifikant hos tre av sex deltagare. Minskad nedstämdhet kunde inte förklaras av ökad fysisk aktivitetsnivå. Samvariation observerades mellan depression och insomni. Resultaten visar att insomni och depression kan påverkas av samma behandling, vilket antyder förekomst av gemensamma vidmakthållande mekanismer. / Insomnia and depression are two common mental health problems. This study investigated whether a proven effective treatment for insomnia CBT-I, would change the severity of depressive symptoms, for participants with comorbid insomnia and depression. It was controlled for, whether a reduction in depressive symptoms could be the result of increased physical activity. A single case experimental design, including daily measurements of sleep, depression and physical activity, was used as a means to answer the research questions. Symptoms of both depression and insomnia were significantly reduced for three out of six participants. Increased physical activity was not able to explain the decrease in depression scores. A correlation was observed, between depression and insomnia. The results shows that insomnia and depression can be affected by the same treatment, which implies existence of common perpetual mechanisms.

Contexte : Les benzodiazépines (BZD) et substances apparentées sont consommées de façon chronique par une large proportion de la population de personnes âgées souffrant d’insomnie chronique. Cet usage dans cette population est cependant critiqué, pour le risque d’effets indésirables associés. La thérapie cognitivo-comportementale pour insomnie (TCC-I) constitue le traitement de première ligne pour lutter contre l’insomnie, en raison de son efficacité et de son innocuité. Objectif : L’objectif de ce projet de recherche est d’évaluer les changements de la qualité du sommeil, de la macroarchitecture et de la microarchitecture du sommeil après un sevrage de BZD chez la personne âgée souffrant d’insomnie chronique. Nous étudierons par la suite l’effet de la TCC-I couplé au sevrage sur les mêmes variables d’intérêts. Nous faisons l’hypothèse que le sevrage s’accompagnera d’une amélioration de la qualité subjective du sommeil (diminution de l’Index de Sévérité de l’Insomnie (ISI) et augmentation de l’efficacité de sommeil (SE)) et d’une modification de certaines variables distinctes : fuseau de sommeil et stade N3 (augmentation du pourcentage au stade N3 et diminution de la densité des fuseaux de sommeil). De plus, nous faisons l’hypothèse que ces changements seront plus prononcés avec la TCC-I couplée au sevrage. Méthodes : 41 participants (âge moyen : 69.39±6.88 ans) ont été randomisés en 2 groupes, stratifiés pour l’âge, la durée et la dose de BZD et apparentés consommés : le groupe sevrage+TCC-I (N=23) et le groupe sevrage (N=18). L’ensemble des participants complètent un plan de sevrage avec suivi de 16 semaines, et dans le même temps, uniquement le groupe sevrage+TCC-I reçoit la TCC-I. L’acquisition des données est réalisée avant et après sevrage à partir de questionnaire (ISI), agenda de sommeil (SE) sur une période de 14 jours, et par enregistrements polysomnographiques (stade N3 et densité des fuseaux de sommeil). Résultats : 60.98% des participants (groupe sevrage+TCC-I: 60.87% ; groupe sevrage: 61.11%) ont réussi une cessation complète de leurs médications après sevrage. Il a été constaté une diminution de l’ISI (F(1,40)=4.36, p=0.01) et de la densité des fuseaux de sommeil (F(1,36)=7.18, p=0.01) après sevrage. Enfin, la TCC-I couplée au sevrage a montré une augmentation plus importante de la SE (F(1,35)=6.75, p=0.01) par rapport au groupe sevrage. Conclusion : Le plan de sevrage avec suivi permet d’obtenir un sevrage complet chez une majorité de participants, sans qu’il ne soit observé d’aggravations significatives de leur qualité de sommeil. L’ajout d’une TCC-I lors d’un sevrage de BZD et apparentés a permis une amélioration plus importante de la qualité du sommeil auto-rapportée (Agenda de sommeil : SE). / Background: Benzodiazepines (BZD) and related drugs are consumed chronically by a large part of the elderly population with chronic insomnia. However, this use in this population is criticized for the risk of associated side effects. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia because of its efficacy and safety. Objective: The objective of this project is to assess changes in sleep quality, macroarchitecture and sleep microarchitecture after withdrawal from BZD in the elderly with chronic insomnia. Then, we study the effect of CBT-I coupled with withdrawal on the same variables of interest. We hypothesize that weaning will be accompanied by an improvement in the subjective sleep quality (decrease in Insomnia Severity Index (ISI) and increase in sleep efficiency (SE)) and a modification of certain distinct variables: sleep spindle and stage N3 (increase in the percentage at stage N3 and decrease in the density of sleep spindles). In addition, we hypothesize that these changes will be more pronounced with CBT-I coupled with weaning. Methods: 41 participants (mean age: 69.39 ± 6.88 years) were randomized into 2 groups; stratified for age, duration and dose of BZD and relatives consumed: the weaning+CBT-I group (N = 23) and the weaning group (N = 18). All participants complete a 16-week weaning plan with follow-up, and at the same time, only the therapy group receives CBT-I. Data acquisition is carried out before and after weaning from questionnaire (ISI), sleep diary (SE) over a period of 14 days, and by polysomnographic recordings (stage N3 and density of sleep spindles). Results: 60.98% of participants (weaning+CBT-I group: 60.87%; weaning group: 61.11%) succeeded in completely stopping their medication after withdrawal. A decrease in ISI (F(1.40) = 4.36, p = 0.04) and in sleep spindle density (F(1.36) = 7.18, p = 0.01) was observed after weaning. Finally, CBT-I coupled with weaning showed a greater increase in SE (Sleep Diary; F(1.35) = 6.75, p = 0.01) compared to the control group. Conclusion: The weaning plan with follow-up makes it possible to obtain complete weaning in a majority of participants, without any significant worsening of their quality of sleep being observed. The addition of CBT-I during withdrawal from BZD and related products resulted in a greater improvement in self-reported sleep quality (Sleep Diary: SE).