RESUMEN
OBJECTIVE/BACKGROUND: Digital cognitive behavioral therapy for insomnia (dCBT-I) improves several sleep and health outcomes in individuals with insomnia. This study investigates whether changes in Dysfunctional Beliefs and Attitudes about Sleep (DBAS) during dCBT-I mediate changes in psychological distress, fatigue, and insomnia severity. PATIENTS/METHODS: The study presents a secondary planned analysis of data from 1073 participants in a randomized control trial (Total sample = 1721) of dCBT-I compared with patient education (PE). Self-ratings with the Dysfunctional Beliefs and Attitudes about Sleep (DBAS), the Hospital Anxiety Depression Scale (HADS), the Chalder Fatigue Scale (CFQ), and the Insomnia Severity Index (ISI) were obtained at baseline and 9-week follow-up. Hayes PROCESS mediation analyses were conducted to test for mediation. RESULTS AND CONCLUSION: sDBAS scores were significantly reduced at 9-week follow-up for those randomized to dCBT-I (n = 566) compared with PE (n = 507). The estimated mean difference was -1.49 (95% CI -1.66 to -1.31, p < .001, Cohen's d. = 0.93). DBAS mediated all the effect of dCBT-I on the HADS and the CFQ, and 64% of the change on the ISI (Estimated indirect effect -3.14, 95% CI -3.60 to -2.68) at 9-week follow-up compared with PE. Changes in the DBAS fully mediated the effects of dCBT-I on psychological distress and fatigue, and the DBAS partially mediated the effects on insomnia severity. These findings may have implications for understanding how dCBT-I works and highlights the role of changing cognitions in dCBT-I.
Asunto(s)
Terapia Cognitivo-Conductual , Distrés Psicológico , Trastornos del Inicio y del Mantenimiento del Sueño , Humanos , Trastornos del Inicio y del Mantenimiento del Sueño/terapia , Sueño , Actitud , Terapia Cognitivo-Conductual/métodos , Resultado del TratamientoRESUMEN
STUDY OBJECTIVES: Numerous studies worldwide have reported the beneficial effects of digital cognitive behavioral therapy for insomnia (dCBT-I). However, few focus on real-world study samples that reflect people in regular care. To test whether dCBT-I is suitable within German regular care, we designed a randomized controlled trial recruiting a heterogenous insomnia population. METHODS: Participants aged ≥18 who met the criteria for insomnia disorder were randomized to 8-weeks dCBT-Iâ +â care-as-usual (CAU) or they were set on a waitlistâ +â CAU. The intervention group was followed-up at 6- and 12-months. The primary outcome was self-reported insomnia severity, assessed with the Insomnia Severity Index (ISI) at 8-weeks post-randomization. A one-way ANCOVA with baseline score as a covariate was fitted to determine group differences. Secondary outcomes included measures of daytime functioning, quality of life, depression, anxiety, dreams, and nightmares. RESULTS: Of the Nâ =â 238 participants (67.6% female), age range 19-81 years, nâ =â 118 were randomized to dCBT-I and nâ =â 120 to the control group. At posttreatment, the use of dCBT-I was associated with a large reduction in the ISI (Diffadjâ =â -7.60) in comparison to WLC (dâ =â -2.08). This clinical improvement was also reflected in responder and remission rates. Treatment effects were also observed for daytime functioning, quality of life, symptoms of depression and anxiety (dsâ =â 0.26-1.02) and at long-term follow-up (intervention group only; dsâ =â 0.18-1.65). No effects were found for dream and nightmare frequency. CONCLUSIONS: This study showed that dCBT-I reduces insomnia symptoms and improves daytime functioning in a heterogenous insomnia population in Germany with sustained long-term treatment effects in the intervention group. Our results underscore the potential of digital health applications, their suitability within regular care, and their role in facilitating widespread implementation of CBT-I as a first-line treatment for insomnia.