Ka-Fai Chung

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.

Use of the Epworth Sleepiness Scale in Chinese patients with obstructive sleep apnea and normal hospital employees

OBJECTIVE To determine the use of the Epworth Sleepiness Scale (ESS) in Chinese patients with obstructive sleep apnea syndrome (OSA) and normal hospital employees. METHODS Our sample consisted of 61 healthy controls and 100 patients with OSA. The test-retest reliability, internal consistency, and concurrent validity of the Chinese version of the ESS were analyzed. We also compared the ESS scores between controls and patients, studied the association between the ESS score and the apnea-hypopnea index (AHI) and minimum oxygen saturation (mO(2)), and examined to what extent the ESS score was predictive of mean sleep latency of the Multiple Sleep Latency Test (MSLT). RESULTS The Chinese version of the ESS was found to have satisfactory reliability and validity. The mean+/-S.D. of ESS scores in normals was 7.5+/-3.0; in patients, it was 13.2+/-4.7. The ESS score had a negative association with mean sleep latency of the MSLT (rho=-0.42, P=0.0001) but no correlation with the AHI and mO(2). ESS scores of 14 and above significantly predicted a low mean sleep latency of the MSLT. CONCLUSION The ESS should be included as one of the methods for assessing sleepiness in clinic samples of patients with OSA. Our data showed that the ESS was useful to separate patients with and without pathological degree of objective daytime sleepiness as determined by the MSLT.

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.

Assessing insomnia in adolescents: Comparison of Insomnia Severity Index, Athens Insomnia Scale and Sleep Quality Index

OBJECTIVES To compare the psychometric properties of the Chinese versions of Insomnia Severity Index (ISI), Athens Insomnia Scale (AIS) and Sleep Quality Index (SQI) for assessment and screening of insomnia in adolescents. METHODS This is a school-based survey of 1516 adolescents aged 12-19 years. Sleep-wake habit questionnaire, ISI, AIS, SQI, Epworth Sleepiness Scale (ESS) and 12-item General Health Questionnaire (GHQ-12) were administered. Insomnia Interview Schedule was used to assess the severity of insomnia symptoms and DSM-IV-TR diagnosis of insomnia. RESULTS The Cronbachs alpha of ISI, AIS and SQI were 0.83, 0.81 and 0.65, respectively, and the 2-week test-retest reliability were 0.79, 0.80 and 0.72. All three scales had a 2-factor structure, and their scores were significantly correlated with sleep-wake variables, ESS and GHQ-12 scores, smoking and drinking habits, and academic performance. The areas under curve of ISI, AIS and SQI for detecting clinical insomnia were 0.85, 0.80 and 0.85, respectively. The optimal cut-offs for ISI, AIS and SQI were a total score of nine (sensitivity/specificity: 0.87/0.75), seven (sensitivity/specificity: 0.78/0.74) and five (sensitivity/specificity: 0.83/0.79), respectively. CONCLUSION The Chinese versions of ISI, AIS and SQI are reliable and valid instruments. The ISI and AIS appear to have better psychometric properties than the SQI.

Insomnia Subtypes and Their Relationships to Daytime Sleepiness in Patients with Obstructive Sleep Apnea

Background: Insomnia and obstructive sleep apnea syndrome (OSA) are the two most common sleep disorders. Studies showed that insomnia complaints were prevalent in OSA. Relatively little is known about the causes of insomnia in OSA and whether etiological factors differ for insomnia subtypes. We hypothesized that sleep onset problem was mainly due to hyperarousal and sleep maintenance difficulty was primarily related to sleep-disordered breathing. Objectives: To determine the prevalence of insomnia subtypes in OSA, compare subjects with sleep onset insomnia, sleep maintenance insomnia and no insomnia symptom, and study the relationship of insomnia subtypes to daytime sleepiness. Methods: We analyzed intake questionnaires and polysomnography and Multiple Sleep Latency Test results of 157 OSA patients. Results: Forty-two percent of the sample had at least one problematic insomnia symptom. The prevalence of sleep onset insomnia, sleep maintenance insomnia and insomnia with early awakening was 6, 26 and 19%, respectively. Patients with sleep onset insomnia had significantly lower apnea-hypopnea (AHI) and arousal indices. There were significant inverse relationships between sleep onset insomnia and measures of daytime sleepiness. On the contrary, subjects with repeated wakening had more severe subjective sleepiness. Results were similar in patients with AHI ≧5 or ≧15. Conclusions: Insomnia symptoms were common in OSA patients. Insomnia subtypes related differently to measures of daytime sleepiness. Our findings suggest that OSA patients with sleep onset insomnia may be in a state of hyperarousal. It is clinically relevant to examine insomnia subtypes, which may influence the treatment decision in sleep-disordered breathing.

The impact of family experience on the duration of untreated psychosis (DUP) in Hong Kong

BackgroundPrevious family experience of psychotic illness may play an important role in whether and when a patient seeks help in first-episode psychosis. This study investigated the relationship between family experience of psychosis and the duration of untreated psychosis in a prospective sample of first-episode psychosis patients in Hong Kong. We also studied the effects of pre-morbid adjustment, educational level, living alone, and mode of onset as potential determinants of the duration of untreated psychosis (DUP).MethodsA total of 131 first-episode psychosis patients in Hong Kong were recruited in a study of the DUP and related factors. The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) was used to measure the DUP and to provide a structured assessment of family history, educational level, household arrangement, and mode of onset.ResultsPrevious family experience of psychiatric illness (the presence of another family member who has been receiving psychiatric treatment) and an acute mode of onset were significant predictors of a shorter DUP. Educational level had a modest effect on its own, but was not significant in the binary logistic regression model. Living alone had a moderate effect size, but was non-significant, possibly because of the small proportion of single-person households in the sample. The symptom profile, pre-morbid adjustment, and other demographic factors were not significantly related to the DUP.ConclusionIn addition to the mode of onset, previous family experience plays an important role in the presentation of early psychosis. Educational efforts that target the family should be an important part of any strategy for the early detection of psychosis.

Traditional needle acupuncture treatment for insomnia: a systematic review of randomized controlled trials.

OBJECTIVES Previous reviews regarding traditional needle acupuncture (TNA) treatment for insomnia were limited to English scientific literature. A comprehensive review including Chinese and English literature has therefore been conducted to examine the efficacy of TNA for insomnia. METHODS We performed systematic review of randomized controlled trials (RCTs) of TNA as intervention for insomnia against placebo, Western medication, and non-treated controls. The methodological quality of the studies was assessed by the modified Jadad score and the acupuncture procedure was appraised by the STRICTA criteria. RESULTS Twenty RCTs were identified for detailed analysis. Majority of the RCTs concluded that TNA was significantly more effective than benzodiazepines for treating insomnia, with mean effective rates for acupuncture and benzodiazepines being 91% and 75%, respectively. In two more appropriately conducted trials, TNA appeared to be more efficacious in improving sleep than sleep hygiene counseling and sham acupuncture. Standardized and individualized acupuncture had similar effective rates. Despite these positive outcomes, there were methodological shortcomings in the studies reviewed, including imprecise diagnostic procedure, problems with randomization, blinding issues, and insufficient safety data. Hence, the superior efficacy of TNA over other treatments could not be ascertained. CONCLUSION Since the majority of evidence regarding TNA for insomnia is based on studies with poor-quality research designs, the data, while somewhat promising, do not allow a clear conclusion on the benefits of TNA for insomnia. Moreover, the results support the need for large scale placebo-controlled double-blinded trials.

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.

Electroacupuncture for residual insomnia associated with major depressive disorder: a randomized controlled trial.

STUDY OBJECTIVES To evaluate the efficacy and safety of electroacupuncture as an additional treatment for residual insomnia associated with major depressive disorder (MDD). DESIGN Randomized, placebo-controlled. SETTING A psychiatric outpatient clinic. PARTICIPANTS 78 Chinese patients with DSM-IV-diagnosed MDD, insomnia complaint, a Hamilton Rating Scale for Depression (HDRS(17)) score ≤ 18, and fixed antidepressant dosage. INTERVENTION Electroacupuncture, minimal acupuncture (superficial needling at non-acupuncture points), or noninvasive placebo acupuncture 3 sessions weekly for 3 weeks. MEASUREMENTS AND RESULTS Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), HDRS(17), 1 week sleep diaries, and 3 day actigraphy were administered at baseline, 1 week post-treatment, and 4 week post-treatment. There was significant group by time interaction in ISI, PSQI, and sleep diary-derived sleep efficiency (mixed-effects models, P = 0.04, P = 0.03, and P = 0.01, respectively). Post hoc pairwise comparisons revealed that electroacupuncture and minimal acupuncture were more efficacious than placebo acupuncture in ISI and PSQI at 1 week and 4 week post-treatment. Minimal acupuncture resulted in greater improvement in sleep diary-derived sleep efficiency than placebo acupuncture at 1 week post-treatment. There was no significant between-group difference in actigraphy measures, depressive symptoms, daily functioning, and hypnotic consumption, and no difference in any measures between electroacupuncture and minimal acupuncture. CONCLUSION Compared with placebo acupuncture, electroacupuncture and minimal acupuncture resulted in greater improvement in subjective sleep measures at 1 week and 4 week post-treatment. No significant difference was found between electroacupuncture and minimal acupuncture, suggesting that the observed differences could be due to nonspecific effects of needling, regardless of whether it is done according to traditional Chinese medicine theory.