Kam-Ping Yung

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.

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.

Acupuncture for Residual Insomnia Associated With Major Depressive Disorder: A Placebo- and Sham-Controlled, Subject- and Assessor-Blind, Randomized Trial

OBJECTIVE To evaluate the efficacy and safety of acupuncture for residual insomnia and other residual symptoms associated with major depressive disorder (MDD). METHOD 150 participants having significant insomnia for more than 3 months and a history of MDD (both based on DSM-IV-TR criteria) were recruited from 4 psychiatric outpatient clinics in Hong Kong from May 2011 to August 2013 to receive 9 sessions of treatment over 3 weeks. They were randomized to receive acupuncture, minimal acupuncture, or placebo acupuncture. Primary outcome was sleep diary-derived sleep efficiency. Secondary outcomes included other sleep diary parameters, actigraphy, anxiety and depressive symptoms, daytime functioning, and adverse events. RESULTS The mean difference in sleep diary-derived sleep efficiency at 1-week posttreatment was -1.40 (95% CI, -7.08 to 4.28) between the acupuncture and minimal acupuncture groups and was 3.10 (95% CI, -3.64 to 9.84) between the acupuncture and placebo acupuncture groups. A χ(2) test showed that acupuncture produced a significantly higher proportion of participants achieving sleep-onset latency ≤ 30 minutes than did minimal acupuncture at 1-week posttreatment (P = .04). However, there was no significant between-group difference in most of the other outcomes. Treatment blinding was successful, as a majority of participants did not know which treatment they had received. CONCLUSIONS Acupuncture was well tolerated, but the efficacy was only mild and similar to that of minimal acupuncture and placebo acupuncture. A high proportion of patients remained clinically significantly affected by insomnia after treatment. The finding raises certain doubts about the value of acupuncture and underscores the difficulties in the treatment of residual insomnia in MDD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01707706.

Randomized non-invasive sham-controlled pilot trial of electroacupuncture for postpartum depression

BACKGROUND Postpartum depression affects 10-15% of mothers. Although acupuncture was efficacious for major depressive disorder in pregnancy and in women outside the perinatal period, there has been no randomized controlled study on the feasibility, tolerability, and efficacy of acupuncture for postpartum depression. METHODS This was a randomized, subject- and assessor-blind, parallel-group, sham-controlled trial. Twenty women within six months postpartum with DSM-IV-diagnosed major depressive disorder of mild severity, defined as a 17-item Hamilton Depression Rating Scale (HDRS(17)) score of 12 to 19, were randomly assigned to either electroacupuncture or non-invasive sham acupuncture two sessions weekly for four weeks. RESULTS There was significant reduction in HDRS(17) score from baseline to 4-week posttreatment in both groups, with an effect size 1.4 and 1.8 for electroacupuncture and sham acupuncture, respectively. Improvement was observed as early as two weeks after commencing acupuncture. The response and remission rate in the electroacupuncture group at 4-week posttreatment was 33% and 44%, respectively; for the sham acupuncture group, it was 60% and 50%, respectively. There was no significant between-group difference in all outcome measures, including the HDRS(17), Edinburgh Postnatal Depression Scale, Hospital Anxiety and Depression Scale, Clinical Global Impression, and Sheehan Disability Scale. Treatment credibility, success of blinding, and adverse events were similar between groups. LIMITATION Small sample size and high attrition rate. No waiting list observation group. CONCLUSION Both electroacupuncture and non-invasive sham acupuncture were effective for postpartum depression. Further studies utilizing larger sample size, better recruitment strategies, and home-based acupuncture treatment are warranted. CLINICAL TRIAL INFORMATION Pilot Study on the Use of Acupuncture for Postpartum Depression; ClinicalTrials.gov Registration #NCT01178008; URL - http://clinicaltrials.gov/ct2/show/NCT01178008?term=postpartum+acupuncture&rank=1.

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.

Sleep in schizophrenia: A systematic review and meta-analysis of polysomnographic findings in case-control studies.

Polysomnographic studies have been performed to examine the sleep abnormalities in schizophrenia, but the results are inconsistent. An updated systematic review, meta-analysis, and moderator analysis was conducted. Major databases were searched without language restriction from 1968 to January 2014. Data were analyzed using the random-effects model and summarized using the Hedgess g. Thirty-one studies with 574 patients and 515 healthy controls were evaluated. Limited by the number of studies and a lack of patient-level data, moderator analysis was restricted to medication status, duration of medication withdrawal, and illness duration. We showed that patients with schizophrenia have significantly shorter total sleep time, longer sleep onset latency, more wake time after sleep onset, lower sleep efficiency, and decreased stage 4 sleep, slow wave sleep, and duration and latency of rapid eye movement sleep compared to healthy controls. The findings on delta waves and sleep spindles were inconsistent. Moderator analysis could not find any abnormalities in sleep architecture in medication-naïve patients. Patients with antipsychotic withdrawal for longer than eight weeks were shown to have less sleep architectural abnormalities, compared to shorter duration of withdrawal, but the abnormalities in sleep continuity were similar. Slow wave sleep deficit was found in patients with schizophrenia for more than three years, while sleep onset latency was increased in medication-naïve, medication-withdrawn, and medicated patients. Our study showed that polysomnographic abnormalities are present in schizophrenia. Illness duration, medication status, and duration of medication withdrawal are several of the clinical factors that contribute to the heterogeneity between studies.

Hypnotherapy for insomnia: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE To examine the efficacy and safety of hypnotherapy for insomnia as compared to placebo, pharmacological or non-pharmacological intervention, or no treatment. METHODS A systematic search on major electronic databases was conducted up until March 2014. Inclusion criteria are: (1) randomized controlled trials (RCTs) or quasi-RCTs; (2) intervention targeted at improving sleep; (3) hypnosis as an intervention; and (4) English language articles. Sleep diary variable is the primary outcome measure. RESULTS Six RCTs of hypnotherapy and seven on autogenic training or guided imagery, comprising 502 subjects, were included. Eleven of the 13 studies had low methodological quality, as indicated by a modified Jadad score below 3, and high risks of bias in blinding and design of the control interventions. No adverse events related to hypnosis were reported, though seldom investigated. Meta-analyses found hypnotherapy significantly shortened sleep latency compared to waitlist (standardized mean difference, SMD=-0.88, 95% confidence interval (CI): -1.56, -0.19, P=0.01, I(2)=15%), but no difference compared to sham intervention (SMD: -1.08, 95% CI: -3.15, 0.09, P=0.31, I(2)=90%). Similar results were found for autogenic training or guided imagery (SMD with waitlist=-1.16, 95% CI: -1.92, -0.40, P=0.003, I(2)=0%; SMD with sham intervention=-0.50, 95% CI: -1.19, 0.19, P=0.15, I(2)=0%). CONCLUSIONS Generalizability of the positive results is doubtful due to the relatively small sample size and methodological limitations. Future studies with larger sample size and better study design and methodology are called for.

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.