Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions A Meta-analysis
Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions A Meta-analysis
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DOI：
10.1001/jamainternmed.2015.3006
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发表时间：
2015-09-01
影响因子：
39
通讯作者：
Ong, Jason C.
中科院分区：
文献类型：
--
作者：
Wu, Jade Q.;Appleman, Erica R.;Ong, Jason C.
认知行为疗法治疗失眠症（CBT-I）是最突出的非药物治疗失眠症。虽然荟萃分析研究了原发性失眠症，但对CBT-I对共病性失眠症的比较疗效知之甚少。目的：研究CBT-I对失眠症合并精神和/或医学疾病的疗效，包括：（1）失眠缓解;（2）自我报告的睡眠效率、入睡潜伏期、入睡后觉醒、总睡眠时间和主观睡眠质量;资料来源：2014年6月2日，通过PubMed、PsycINFO、科克伦图书馆和人工检索进行系统检索。检索词包括（1）CBT-I或CBT或认知行为[及其变体]或行为治疗[及其变体]或行为睡眠药物或刺激控制或睡眠限制或放松治疗或放松训练或渐进性肌肉放松或矛盾意图;资料选择研究包括随机临床试验，其中至少有一个CBT-我的手臂，并有一个成年人口符合诊断标准的失眠以及伴随疾病。数据提取和综合数据由2位作者独立提取，并使用随机效应模型合并。研究质量由两位作者使用科克伦偏倚风险评估工具进行独立评估。（即临床睡眠和共病结果）来自睡眠日记和其他自我报告措施。接受CBT-I治疗的患者中有36.0%的患者失眠缓解，而对照或比较条件下的患者为16.9%（合并比值比，3.28; 95% CI，2.30 - 4.68; P <0.001）。对于大多数睡眠参数，治疗前和治疗后的控制效应量为中等到大（睡眠效率：Hedges g = 0.91 [95% CI，0.74 - 1.08];睡眠开始潜伏期：Hedges g = 0.80 [95% CI，0.60 - 1.00];睡眠开始后清醒：Hedges g = 0.68;睡眠质量：Hedges g = 0.84;所有P <.001），除了总睡眠时间。共病结局产生的效应量较小（模糊限制语g = 0.39 [95%CI，0.60 - 0.98]; P <.001）;精神科人群的改善程度大于医学人群（对冲g = 0.20 [95% CI，0.09 - 0.30];交互作用的卡方检验= 12.30;结论和相关性失眠的认知行为疗法对改善失眠共病患者的失眠症状和睡眠参数是有效的。在共病结局中发现了小到中等的积极影响，与医疗条件相比，对精神疾病的影响更大。为了提高证据的质量，需要进行更严格设计的大规模研究，以减少检测和性能偏倚。
IMPORTANCE Cognitive behavioral therapy for insomnia (CBT-I) is the most prominent nonpharmacologic treatment for insomnia disorders. Although meta-analyses have examined primary insomnia, less is known about the comparative efficacy of CBT-I on comorbid insomnia.OBJECTIVE To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions for (1) remission from insomnia; (2) self-reported sleep efficiency, sleep onset latency, wake after sleep onset, total sleep time, and subjective sleep quality; and (3) comorbid symptoms.DATA SOURCES A systematic search was conducted on June 2, 2014, through PubMed, PsycINFO, the Cochrane Library, and manual searches. Search terms included (1) CBT-I or CBT or cognitive behavioral [and its variations] or behavioral therapy [and its variations] or behavioral sleep medicine or stimulus control or sleep restriction or relaxation therapy or relaxation training or progressive muscle relaxation or paradoxical intention; and (2) insomnia or sleep disturbance.STUDY SELECTION Studies were included if they were randomized clinical trials with at least one CBT-I arm and had an adult population meeting diagnostic criteria for insomnia as well as a concomitant condition. Inclusion in final analyses (37 studies) was based on consensus between 3 authors' independent screenings.DATA EXTRACTION AND SYNTHESIS Data were independently extracted by 2 authors and pooled using a random-effects model. Study quality was independently evaluated by 2 authors using the Cochrane risk of bias assessment tool.MAIN OUTCOMES AND MEASURES A priori main outcomes (ie, clinical sleep and comorbid outcomes) were derived from sleep diary and other self-report measures.RESULTS At posttreatment evaluation, 36.0% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio, 3.28; 95% CI, 2.30-4.68; P < .001). Pretreatment and posttreatment controlled effect sizes were medium to large for most sleep parameters (sleep efficiency: Hedges g = 0.91 [95% CI, 0.74 to 1.08]; sleep onset latency: Hedges g = 0.80 [95% CI, 0.60 to 1.00]; wake after sleep onset: Hedges g = 0.68; sleep quality: Hedges g = 0.84; all P < .001), except total sleep time. Comorbid outcomes yielded a small effect size (Hedges g = 0.39 [95% CI, 0.60-0.98]; P < .001); improvements were greater in psychiatric than in medical populations (Hedges g = 0.20 [95% CI, 0.09-0.30];chi(2) test for interaction = 12.30; P < .001).CONCLUSIONS AND RELEVANCE Cognitive behavioral therapy for insomnia is efficacious for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia. A small to medium positive effect was found across comorbid outcomes, with larger effects on psychiatric conditions compared with medical conditions. Large-scale studies with more rigorous designs to reduce detection and performance bias are needed to improve the quality of the evidence.