دانلود رایگان مقاله درمان شناختی - رفتاری برای بی خوابی مداوم

Abstract

While impairment of daytime functioning due to poor sleep is often the main determinant for seeking treatment, few studies have examined the clinical impact of insomnia therapies on daytime outcomes. The main objective of this study was to evaluate the impact of cognitive-behavior therapy (CBT), alone and combined with medication, on various indices of daytime and psychological functioning. Participants were 160 individuals with chronic insomnia who received CBT alone or CBT plus medication (zolpidem) for an initial six-week therapy, followed by an extended six-month therapy. Participants treated with CBT initially received maintenance CBT or no additional treatment and those treated with combined therapy initially continued with CBT plus intermittent medication (prn) or CBT without medication (taper). Measures of anxiety and depressive symptoms, fatigue, quality of life, and perceived impact of sleep difficulties on various indices of daytime functioning were completed at baseline, after each treatment stage, and at six-month follow-up. Following acute treatment, significant improvements of fatigue, quality of life (mental component), anxiety, and depression were obtained in the CBT alone condition but not in the combined CBT plus medication condition. Following extended treatment, further improvements were noted for the subgroup receiving extended CBT relative to that with no additional treatment, and for the subgroup receiving CBT and intermittent medication relative to that with CBT but no medication. Improvements were well maintained at the 6-month follow-up. These findings indicate that insomnia-specific therapy is effective at improving daytime and psychological functioning in the short term, and that maintenance therapy produces an added value to optimize long-term outcomes. Trial registration: www.clinicaltrials.gov (#NCT 00042146).

4. Discussion

This study evaluated changes in psychological and daytime functioning following insomnia treatment. The main findings indicate that insomnia-specific therapy is effective at improving several indices of psychological and daytime functioning in the short term, and that maintenance therapy produced an added value to optimize long-term outcomes. The first study objective was to examine if there were differential effects of CBT with and without concurrent sleep medication on daytime outcomes. During acute treatment, improvements of mood, anxiety, fatigue, and quality of life (mental health) were obtained with CBT used singly but not when it was combined with medication. Conversely, both acute therapies were associated with improvements of all daytime functioning indices (e.g., mood, energy, concentration, relationships) measured by additional ISI items. A second objective was to evaluate whether an extended treatment adding maintenance CBT sessions or intermittent hypnotic medications would enhance daytime outcomes relative to acute interventions alone. Among participants who received CBT alone in the acute phase, those receiving individualized CBT during the extended treatment showed greater changes in daytime outcomes relative to those receiving no additional treatment, on measures of fatigue, quality of life (mental health), and on most daytime functioning indices evaluated by the ISI. In the combined treatment arm, the group receiving individualized CBT and intermittent medication (prn) showed improvements on the majority of daytime variables, while the extended CBT with no additional medication (i.e., medication taper) showed improvements only for the impact of sleep diffi- culties on general daytime functioning, fatigue, concentration and memory, and quality of life. Taken together, these results suggest that CBT alone has a greater impact on improving daytime functioning than when it is combined with medication during the initial 6-week treatment, while maintenance CBT and intermittent medication are more effective than no additional treatment or medication tapering during the extended 6-month treatment.