Fiona Yan-Yee Ho

Self-help cognitive-behavioral therapy for insomnia: a meta-analysis of randomized controlled trials.

Self-help cognitive-behavioral therapy (CBT) is an increasingly popular treatment option for insomnia. The objective of this meta-analysis was to compile an up-to-date evaluation on the efficacy, adherence, acceptability and dropout rate of self-help CBT for insomnia. We systematically searched six key electronic databases up until May 2013. Two researchers independently selected relevant publications, extracted data, and evaluated methodological quality according to the Cochrane criteria. Twenty randomized controlled trials were included; 10 of which were published after the last review up until January 2007. Meta-analysis of self-help CBT vs. waiting-list, routine care or no treatment was performed. Results showed that self-help CBT improved sleep, sleep-related cognitions and anxiety and depressive symptoms. Effect sizes for sleep-diary-derived sleep efficiency, sleep onset latency, and wake after sleep onset at immediate posttreatment were 0.80, 0.66, and 0.55, respectively. The average dropout rate of self-help CBT at immediate posttreatment was 14.5%, which was not significantly different from the 16.7% in therapist-administered CBT. Subgroup analyses supported the added benefit of telephone consultation. In conclusion, self-help CBT is efficacious and acceptable as an entry level of a stepped care model for insomnia. In places where face-to-face treatments are unavailable or too costly, self-help CBT can be considered as a compromise.

Sleep-wake disturbance in interepisode bipolar disorder and high-risk individuals: A systematic review and meta-analysis

Over the past decade, researchers have shifted focus from the manic and depressive episodes to the interepisode period in the study of sleep-wake disturbance in bipolar disorder. The objective of this systematic review was to compile and synthesize studies that employed sleep diary, actigraphy, polysomnography, and questionnaires to compare sleep-wake patterns in people with interepisode bipolar disorder or high-risk individuals vs. normal controls and/or people with primary insomnia. We searched key databases until June 2013. Our search identified 21 eligible studies, yielding 24 sleep-wake variables. A total of 531 people with interepisode bipolar disorder, 157 high-risk individuals, 678 normal controls and 67 adults with primary insomnia were evaluated. Using a random-effects model, our analyses suggest that adults with interepisode bipolar disorder appear worse than normal controls in most variables and comparable to adults with primary insomnia in certain aspects. Sleep onset latency, wake after sleep onset, and variability of sleep-wake variables were most consistently impaired in interepisode bipolar disorder. In comparison with controls, high-risk individuals were found to have higher variability in sleep efficiency and lower relative amplitude. The findings provide a foundation for the search for candidate endophenotypes and the development of novel interventions for bipolar disorder.

Acupressure, reflexology, and auricular acupressure for insomnia: a systematic review of randomized controlled trials.

Previous randomized controlled trials (RCTs) have shown that acupuncture may be efficacious for insomnia. Instead of needling, acupressure, reflexology, and auricular acupressure are procedures involving physical pressure on acupoints or reflex areas. These variants of acupuncture are gaining popularity, perhaps due to their non-invasive nature. A systematic review has therefore been conducted to examine their efficacy and safety for insomnia. Two independent researchers searched five English and 10 Chinese databases from inception to May 2010. Forty RCTs were identified for analysis. Only 10 studies used sham controls, four used double-blind design, nine studies scored three or more by the Jadad scale, and all had at least one domain with high risk of bias. Meta-analyses of the moderate-quality RCTs found that acupressure as monotherapy fared marginally better than sham control. Studies that compared auricular acupressure and sham control showed equivocal results. It was also found that acupressure, reflexology, or auricular acupressure as monotherapy or combined with routine care was significantly more efficacious than routine care or no treatment. Owing to the methodological limitations of the studies and equivocal results, the current evidence does not allow a clear conclusion on the benefits of acupressure, reflexology, and auricular acupressure for insomnia.

Chinese herbal medicine for insomnia: A systematic review of randomized controlled trials

Chinese herbal medicine (CHM), either in single herb or in herbal formula, has been used to treat insomnia for more than 2000 years. A systematic review including Chinese and English literature of randomized controlled trials was conducted to examine the efficacy, safety, and composition of CHM for insomnia. Among the 217 studies we have reviewed, only eight had a Jadad score ≥3, and seven out of these eight studies had at least one domain with high risks of bias. Meta-analyses of the studies with Jadad score ≥3 found that CHM was similar to Western medication (three studies) and placebo (three studies) in treating insomnia. Due to the poor methodological quality of the studies and the small number of trials included in meta-analyses, the current evidence is insufficient to support the efficacy of CHM for insomnia. The frequency of adverse events associated with CHM was similar to that of placebo, but lower than with Western medication. Gui Pi Tang was the most commonly used standardized formula, while Suan Zao Ren (Ziziphus jujuba) was the most frequently used single herb. Further studies with a double-blind placebo-controlled design are needed to accurately determine the benefits and risks of CHM for insomnia.

Cross-cultural and comparative epidemiology of insomnia: the Diagnostic and Statistical Manual (DSM), International Classification of Diseases (ICD) and International Classification of Sleep Disorders (ICSD)

OBJECTIVE To compare the prevalence of insomnia according to symptoms, quantitative criteria, and Diagnostic and Statistical Manual of Mental Disorders, 4th and 5th Edition (DSM-IV and DSM-5), International Classification of Diseases, 10th Revision (ICD-10), and International Classification of Sleep Disorders, 2nd Edition (ICSD-2), and to compare the prevalence of insomnia disorder between Hong Kong and the United States by adopting a similar methodology used by the America Insomnia Survey (AIS). METHODS Population-based epidemiological survey respondents (n = 2011) completed the Brief Insomnia Questionnaire (BIQ), a validated scale generating DSM-IV, DSM-5, ICD-10, and ICSD-2 insomnia disorder. RESULTS The weighted prevalence of difficulty falling asleep, difficulty staying asleep, waking up too early, and non-restorative sleep that occurred ≥3 days per week was 14.0%, 28.3%, 32.1%, and 39.9%, respectively. When quantitative criteria were included, the prevalence dropped the most from 39.9% to 8.4% for non-restorative sleep, and the least from 14.0% to 12.9% for difficulty falling asleep. The weighted prevalence of DSM-IV, ICD-10, ICSD-2, and any of the three insomnia disorders was 22.1%, 4.7%, 15.1%, and 22.1%, respectively; for DSM-5 insomnia disorder, it was 10.8%. CONCLUSION Compared with 22.1%, 3.9%, and 14.7% for DSM-IV, ICD-10, and ICSD-2 in the AIS, cross-cultural difference in the prevalence of insomnia disorder is less than what is expected. The prevalence is reduced by half from DSM-IV to DSM-5. ICD-10 insomnia disorder has the lowest prevalence, perhaps because excessive concern and preoccupation, one of its diagnostic criteria, is not always present in people with insomnia.

The use of conventional and complementary therapies for insomnia among Hong Kong Chinese: a telephone survey.

OBJECTIVE To examine the prevalence and utilization pattern of complementary and alternative medicine (CAM) for insomnia in Hong Kong. METHODS Respondents were selected from the general population and interviewed by telephone Their sleep was assessed by a Chinese version of the Brief Insomnia Questionnaire (BIQ) and CAM use by a checklist. Prevalence findings were weighted by the BIQ insomnia diagnosis, age, and sex. RESULTS 402 respondents completed the survey. The population-weighted prevalence of any treatment in the past 12 months was 21.3%, any CAM use at 12.3%, any conventional treatment at 6.5%, and alcohol use at 1.6%; however, 46.6% of the BIQ insomnia cases did not seek treatment. The most commonly used CAM modalities was Chinese herbal medicine (7.9%), followed by acupuncture (1.7%) and Western herbal products (1.7%). Most CAM therapies were used infrequently and without consultation of healthcare professionals. Only BIQ insomnia diagnosis and being female were found predictive of CAM use. CONCLUSIONS Apart from Chinese herbal medicine and acupuncture, the use of conventional treatments, CAM, and alcohol for trouble sleeping was all less common in Hong Kong. Public education on the consequences of insomnia and various treatment modalities is needed.

Eveningness and Its Associated Impairments in Remitted Bipolar Disorder

Sleep-wake and circadian rhythm disturbances are common in remitted bipolar disorder. These disturbances include difficulty initiating and maintaining sleep, daytime sleepiness, sleep irregularity, and a circadian tendency toward eveningness. To date, few studies have examined the impact of eveningness on impairments in remitted bipolar disorder. Ninety-eight adults diagnosed with bipolar disorder I, II, or not otherwise specified were evaluated. Hierarchical linear regression analyses showed that eveningness was associated with greater sleep-wake disturbances, more unhealthy dietary habits, worse quality of life, more impaired interpersonal relationships, and more dysfunctional sleep-related cognitions and behaviors, controlling for age, gender, and years of education. Targeted intervention on dysfunctional sleep-related cognitions and behaviors may reverse eveningness and improve functioning in bipolar disorder.

Assessment of fatigue using the Multidimensional Fatigue Inventory in patients with major depressive disorder

OBJECTIVES There are problems with the fatigue measures currently used in depressed patients. The Multidimensional Fatigue Inventory (MFI-20) covering general fatigue, physical fatigue, mental fatigue, reduced activity and reduced motivation has been widely used in patients with cancer and chronic fatigue syndrome. To address the multidimensional nature of fatigue, we examined the validity and reliability of a Chinese version of the MFI-20 in major depressive disorder (MDD). METHODS Data were derived from a randomized controlled trial of acupuncture in 137 patients with partially remitted MDD. The test-retest reliability, internal consistency, construct and concurrent validity and sensitivity to change of the MFI-20 were analyzed. RESULTS The MFI-20 was found to have good internal consistency (Cronbachs alpha=0.89) and 1-week test-retest reliability (Pearson correlation of the total score=0.73). Factor analysis showed 5 factors, but the factor structure was different from that in medical conditions. The 2 most prominent factors, explaining 46% of the total variance, were both associated with physical and mental energy but different in directions. There were adequate concurrent validity and sensitivity to change as evidenced by the significant correlations between the MFI-20 scores and depressive and anxiety symptoms, general health and quality of life. CONCLUSION The Chinese MFI-20 is a valid and reliable instrument for the assessment of fatigue in MDD patients with residual symptoms. The construct of fatigue in MDD seems to be different from that in medical conditions. Further studies are needed to examine the MFI-20 in MDD patients from other cultures.

The Experience of Chronic Insomnia in Chinese Adults: A Study Using Focus Groups and Insomnia Experience Diaries

The subjective experience in 43 Chinese adults with chronic primary insomnia was assessed using focus groups and insomnia experience diaries. Participants recruited from the community and a sleep clinic were diagnosed with DSM-IV-TR insomnia disorder and had sleep difficulties on 3 or more nights per week for at least 6 months. Six focus groups, of 6–8 participants each, were conducted; it was stopped as thematic saturation emerged in the last 2 groups. Using grounded theory approach, we identified 4 themes and 16 subthemes, covering beliefs about the nature and treatment of insomnia, behavioral responses to insomnia, cognitive-emotional and physiological arousal, and emotional experiences associated with insomnia. The findings are in general compatible with qualitative studies in the West, but some subthemes are influenced by Chinese cultural beliefs and values, in particular, use of the traditional Chinese medicine concept, being modest in sleep expectation, and a letting go attitude. Strategies for cultural adaptation of cognitive-behavioral therapy for insomnia in a Chinese society using patients’ subjective experience are discussed.

Validity and reliability of the Brief Insomnia Questionnaire in the general population in Hong Kong

OBJECTIVES The Brief Insomnia Questionnaire (BIQ) was first validated in the U.S. for insomnia disorders according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR), International Classification of Diseases, Tenth Edition (ICD-10) and research diagnostic criteria/International Classification of Sleep Disorders, Second Edition (RDC/ICSD-2). We aimed to determine the validity and reliability of a Hong Kong Chinese version of the BIQ to derive the DSM-5 in addition to other insomnia diagnoses in a general population sample. METHODS Probability subsamples of population-based epidemiological survey respondents (n=2011) completed test-retest (n=120) and clinical reappraisal (n=176) interviews. RESULTS Short-term test-retest reliability was moderate for most BIQ items (Pearson r>0.40), except for the number of nights with problems staying asleep, amount of time awake, duration of sleep problems and sleep onset latency. The areas under the receiver operating characteristic curve for the DSM-IV-TR, DSM-5, ICD-10 and RDC/ICSD-2 insomnia disorder ranged from 0.76 to 0.86, indicating high individual-level concordance between BIQ and clinical-interview diagnoses. The use of super-normal control and BIQ symptom-level data further improves the diagnostic concordance. Prevalence estimates based on the BIQ dichotomous classification were comparable with estimates based on clinical interviews for the DSM-5, RDC/ICSD-2 and any of the DSM-IV-TR, ICD-10 and RDC/ICSD-2 insomnia disorders. CONCLUSION The Hong Kong Chinese version of the BIQ generates accurate prevalence estimates for insomnia disorders in the general population. Modification of the BIQ scoring algorithms and use of trained interviewers may further improve its diagnostic performance.