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Culturally Adapted CBTI for Chinese Insomnia Patients: a One-Arm Pilot Trial

  • Yoann Birling
  • Jian Wang
  • Guixia Li
  • Enlai Wu
  • Zhidan Yu
  • Yunshu Feng
  • Yuting Wu
Article

Abstract

Purpose

Insomnia is a common mental disorder with severe consequences. Cognitive-behavioral therapy for insomnia (CBTI) has been proved effective against insomnia, but most of the research is limited to Western countries. This trial objective is to develop a Chinese culture-adapted CBTI program and assess its efficacy.

Method

An 8-week culturally adapted CBTI program was developed that included mixed group and individual session and culturally adapted relaxation and cognitive restructuring treatment components. A one-arm clinical trial was conducted at a public hospital between March 2016 and January 2017. Seventy-two Chinese adults (15 males, 57 females; mean age, 50 years) with insomnia disorder underwent the culturally adapted CBTI program. Sleep diaries and self-report scales, as well as polysomnography (PSG, for a subgroup only), were used to assess qualitative and quantitative measures of sleep, mental health status, and quality of life at baseline, post-treatment, and 4-month follow-up.

Results

Pre-post analyses showed significant changes in sleep diary sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time of respectively − 37.03 min (CI, − 48.90 to − 25.16), − 28.16 min (CI, − 40.22 to − 16.10), and + 27.49 min (CI, 10.51 to 44.47). Self-reported sleep quality, mental health, and quality of life improved compared to baseline. The self-reported outcomes were mainly stable at follow-up. PSG outcomes globally failed to show improvement.

Conclusion

The design of a CBTI program adapted to Chinese population was achieved. Culturally adapted CBTI showed promising results. More rigorously designed studies are needed to ensure efficacy.

Keywords

Insomnia Clinical trial Treatment Cognitive-behavioral therapy Cultural adaptation 

Notes

Funding

This study was funded by the projects “clinical pathways and comprehensive intervention model of insomnia pharmacological and psychological treatment” supported by the Beijing Municipal Commission of Science and Technology (Grant No. Z121107001012034) and “insomnia clinical research bases on the courage determining judgment and response” (Grant No. 2016S358) supported by the Guang’an Men Hospital.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

This study was approved by Guang’an Men hospital ethical board. All procedures performed involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all the individual participants included in the study.

References

  1. 1.
    Ohayon MM. Epidemiological overview of sleep disorders in the general population. Sleep Med Res. 2011;2(1):1–9.  https://doi.org/10.17241/smr.2011.2.1.1.CrossRefGoogle Scholar
  2. 2.
    Cao XL, Wang SB, Zhong BL, Zhang L, Ungvari GS, Ng CH, et al. The prevalence of insomnia in the general population in China: a meta-analysis. PLoS One. 2017;12(2):1–11.Google Scholar
  3. 3.
    Léger D, Partinen M, Hirshkowitz M, Chokroverty S, Touchette E, Hedner J. Daytime consequences of insomnia symptoms among outpatients in primary care practice: EQUINOX international survey. Sleep Med. 2010;11(10):999–1009.  https://doi.org/10.1016/j.sleep.2010.04.018.CrossRefPubMedGoogle Scholar
  4. 4.
    Ohayon MM, Smirne S. Prevalence and consequences of insomnia disorders in the general population of Italy. Sleep Med. 2002;3(2):115–20.  https://doi.org/10.1016/S1389-9457(01)00158-7.CrossRefPubMedGoogle Scholar
  5. 5.
    Roberts RE, Roberts CR, Duong HT. Chronic insomnia and its negative consequences for health and functioning of adolescents: a 12-month prospective study. J Adolesc Health. 2008;42(3):294–302.  https://doi.org/10.1016/j.jadohealth.2007.09.016.CrossRefPubMedGoogle Scholar
  6. 6.
    Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behav Sleep Med. 2003;4:227–47.CrossRefGoogle Scholar
  7. 7.
    Scalo J, Desai P, Rascati K. Insomnia, hypnotic use, and health-related quality of life in a nationally representative sample. Qual Life Res. 2015;24(5):1223–33.  https://doi.org/10.1007/s11136-014-0842-1.CrossRefPubMedGoogle Scholar
  8. 8.
    Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J. The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep. 2009;32(1):55–64.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Morin CM. Cognitive-behavioral therapy of insomnia. Sleep Med Clin. 2006;1(3):375–86.  https://doi.org/10.1016/j.jsmc.2006.06.008.CrossRefGoogle Scholar
  10. 10.
    Perlis ML, Jungquist C, Smith MT, Posner D. Cognitive–behavioral treatment of insomnia: a session-by-session guide. New York: Springer; 2005.Google Scholar
  11. 11.
    Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol. 1995;63(1):79–89.  https://doi.org/10.1037/0022-006X.63.1.79.CrossRefPubMedGoogle Scholar
  12. 12.
    Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159(1):5–11.  https://doi.org/10.1176/appi.ajp.159.1.5.CrossRefPubMedGoogle Scholar
  13. 13.
    Okajima I, Komada Y, Inoue Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep Biol Rhythms. 2011;9(1):24–34.  https://doi.org/10.1111/j.1479-8425.2010.00481.x.CrossRefGoogle Scholar
  14. 14.
    Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009;13(3):205–14.  https://doi.org/10.1016/j.smrv.2008.06.001.CrossRefPubMedGoogle Scholar
  15. 15.
    Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;13(1):40.  https://doi.org/10.1186/1471-2296-13-40.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Espie CA. “Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep. 2009;32(12):1549–58.  https://doi.org/10.1093/sleep/32.12.1549.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Lancee J, van den Bout J, Sorbi MJ, van Straten A. Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: a randomized trial. Behaviour Res Ther. 2013;51(12):797–805.  https://doi.org/10.1016/j.brat.2013.09.004.CrossRefGoogle Scholar
  18. 18.
    Ström L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol. 2004;72(1):113–20.  https://doi.org/10.1037/0022-006X.72.1.113.CrossRefPubMedGoogle Scholar
  19. 19.
    Espie CA, MacMahon KM, Kelly H, Broomfield NM, Douglas NJ, Engleman HM, et al. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep. 2007;30(5):574–84.  https://doi.org/10.1093/sleep/30.5.574.CrossRefPubMedGoogle Scholar
  20. 20.
    Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999;281(11):991–9.  https://doi.org/10.1001/jama.281.11.991.CrossRefPubMedGoogle Scholar
  21. 21.
    Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285(14):1856–64.  https://doi.org/10.1001/jama.285.14.1856.CrossRefPubMedGoogle Scholar
  22. 22.
    Roberts RE, Roberts CR, Chan W. Ethnic differences in symptoms of insomnia among adolescents. Sleep. 2006;29(3):359–65.  https://doi.org/10.1093/sleep/29.3.359.CrossRefPubMedGoogle Scholar
  23. 23.
    Ohayon MM, Partinen M. Insomnia and global sleep dissatisfaction in Finland. J Sleep Res. 2002;11(4):339–46.  https://doi.org/10.1046/j.1365-2869.2002.00317.x.CrossRefPubMedGoogle Scholar
  24. 24.
    Gureje O, Makanjuola VA, Kola L. Insomnia and role impairment in the community: results from the Nigerian survey of mental health and wellbeing. Soc Psychiatry Psychiatr Epidemiol. 2007;42(6):495–501.  https://doi.org/10.1007/s00127-007-0183-2.CrossRefPubMedGoogle Scholar
  25. 25.
    Lee YJ. Sleep disorders in Chinese culture: experiences from a study of insomnia in Taiwan. Psychiatry Clin Neurosci. 1995;49(2):103–6.  https://doi.org/10.1111/j.1440-1819.1995.tb01870.x.CrossRefPubMedGoogle Scholar
  26. 26.
    Xiang YT, Ma X, Cai ZJ, Li SR, Xiang YQ, Guo HL, et al. The prevalence of insomnia, its sociodemographic and clinical correlates, and treatment in rural and urban regions of Beijing, China: a general population-based survey. Sleep. 2008;31(12):1655–62.  https://doi.org/10.1093/sleep/31.12.1655.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Yung KP, Chung KF, Ho FY, Yeung WF, Ng TH. The experience of chronic insomnia in Chinese adults: a study using focus groups and insomnia experience diaries. Behav Sleep Med. 2016;14(4):406–28.  https://doi.org/10.1080/15402002.2015.1017097.CrossRefPubMedGoogle Scholar
  28. 28.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association; 2013.Google Scholar
  29. 29.
    Killen JD, George J, Marchini E, Silverman S, Thoresen C. Estimating sleep parameters: a multitrait-multimethod analysis. J Consult Clin Psychol. 1982;50:345–52.CrossRefPubMedGoogle Scholar
  30. 30.
    Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.  https://doi.org/10.1016/0165-1781(89)90047-4.CrossRefPubMedGoogle Scholar
  31. 31.
    Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307.  https://doi.org/10.1016/S1389-9457(00)00065-4.CrossRefPubMedGoogle Scholar
  32. 32.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–71.  https://doi.org/10.1001/archpsyc.1961.01710120031004.CrossRefPubMedGoogle Scholar
  33. 33.
    Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893–7.  https://doi.org/10.1037/0022-006X.56.6.893.CrossRefPubMedGoogle Scholar
  34. 34.
    Morin CM, Vallières A, Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): validation of a brief version (DBAS-16). Sleep. 2007;30(11):1547–54.  https://doi.org/10.1093/sleep/30.11.1547.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;1:473–83.CrossRefGoogle Scholar
  36. 36.
    Fu S, Ou H, Lu S. Reliability and validity of the brief version of dysfunctional beliefs and attitudes about sleep. Chin J Behav Med Brain Sci. 2014:369–71.Google Scholar
  37. 37.
    Tsai PS, Wang SY, Wang MY, Su CT, Yang TT, Huang CJ, et al. Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res. 2005;14(8):1943–52.  https://doi.org/10.1007/s11136-005-4346-x.CrossRefPubMedGoogle Scholar
  38. 38.
    Yu DS. Insomnia Severity Index: psychometric properties with Chinese community-dwelling older people. J Adv Nurs. 2010;66(10):2350–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Shek DT. Reliability and factorial structure of the Chinese version of the Beck Depression Inventory. J Clin Psychol. 1990;46(1):35–43.  https://doi.org/10.1002/1097-4679(199001)46:1<35::AID-JCLP2270460106>3.0.CO;2-W.CrossRefPubMedGoogle Scholar
  40. 40.
    Kin-wing SC. A study of psychometric properties, normative scores and factor structure of Beck Anxiety Inventory—the Chinese version. Chin J Clin Psychol. 2002;10(1):4–6.Google Scholar
  41. 41.
    Li L, Wang HM, Shen Y. Chinese SF-36 HHealth SSurvey: translation, cultural adaptation, validation, and normalization. J Epidemiol Community Health. 2003;57(4):259–63.  https://doi.org/10.1136/jech.57.4.259.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Marino M, Li Y, Rueschman MN, Winkelman JW, Ellenbogen JM, Solet JM, et al. Measuring sleep: accuracy, sensitivity, and specificity of wrist actigraphy compared to polysomnography. Sleep. 2013;36(11):1747–55.  https://doi.org/10.5665/sleep.3142.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Riedel BW, Lichstein KL. Strategies for evaluating adherence to sleep restriction treatment for insomnia. Behav Res Ther. 2001;39(2):201–12.  https://doi.org/10.1016/S0005-7967(00)00002-4.CrossRefPubMedGoogle Scholar
  44. 44.
    Oyserman D, Coon HM, Kemmelmeier M. Rethinking individualism and collectivism: evaluation of theoretical assumptions and meta-analyses. Psychol Bull. 2002;128(1):3–72.  https://doi.org/10.1037/0033-2909.128.1.3.CrossRefPubMedGoogle Scholar
  45. 45.
    Oetzel J, Ting-Toomey S, Masumoto T, Yokochi Y, Pan X, Takai J, et al. Face and facework in conflict: a cross-cultural comparison of China, Germany, Japan, and the United States. Commun Monog. 2001;68(3):235–58.  https://doi.org/10.1080/03637750128061.CrossRefGoogle Scholar
  46. 46.
    Tang CR, Dong XB, Birling Y, Feng F, Tian CC, Wang WD. The interpretation of clinical application to Wang integrated insomnia questionnaire. World J Sleep Med. 2016;3(5):310–5.Google Scholar
  47. 47.
    Little RJ, D'agostino R, Cohen ML, Dickersin K, Emerson SS, Farrar JT, et al. The prevention and treatment of missing data in clinical trials. N Engl J Med. 2012;367(14):1355–60.  https://doi.org/10.1056/NEJMsr1203730.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Birling Y, Tang CR, Wang WD. A questionnaire survey on the sleep characteristics of sleep department insomnia patients. World J Sleep Med. 2015;2(6):328–9.Google Scholar
  49. 49.
    Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–8.  https://doi.org/10.1093/sleep/34.5.601.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Lichstein KL, Durrence HH, Taylor DJ, Bush AJ, Riedel BW. Quantitative criteria for insomnia. Behaviour Res Ther. 2003;41(4):427–45.  https://doi.org/10.1016/S0005-7967(02)00023-2.CrossRefGoogle Scholar
  51. 51.
    Newell J, Mairesse O, Verbanck P, Neu D. Is a one-night stay in the lab really enough to conclude? First-night effect and night-to-night variability in polysomnographic recordings among different clinical population samples. Psychiatry Res. 2012;200(2):795–801.  https://doi.org/10.1016/j.psychres.2012.07.045.CrossRefPubMedGoogle Scholar
  52. 52.
    Morin CM. Measuring outcomes in randomized clinical trials of insomnia treatments. Sleep Med Rev. 2003;7(3):263–79.  https://doi.org/10.1053/smrv.2002.0274.CrossRefPubMedGoogle Scholar
  53. 53.
    Anderson NB. Evidence-based practice in psychology. Am Psychol. 2006;61(4):271–85.CrossRefGoogle Scholar
  54. 54.
    Benish SG, Quintana S, Wampold BE. Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta-analysis. J Couns Psychol. 2011;58(3):279–89.  https://doi.org/10.1037/a0023626.CrossRefPubMedGoogle Scholar
  55. 55.
    Kim U, Park YS, Park D. The challenge of cross-cultural psychology: the role of the indigenous psychologies. J Cross-Cult Psychol. 2000;31(1):63–75.  https://doi.org/10.1177/0022022100031001006.CrossRefGoogle Scholar
  56. 56.
    Wang W. Low resistance thought induction psychotherapy: a guide to theory and practice. Beijing: People’s Medical Publishing House; 2012.Google Scholar
  57. 57.
    Wang WD, Li GX, Hong L, Liu YJ, Zhao Y, Lin YN, et al. Low resistance thought induction sleep-regulating technique (tip3-2) combined with medication for primary insomnia: a randomized controlled trial. Int J Behav Med. 2014;21(4):618–28.  https://doi.org/10.1007/s12529-014-9415-5.CrossRefPubMedGoogle Scholar

Copyright information

© International Society of Behavioral Medicine 2018

Authors and Affiliations

  1. 1.Guang’an Men HospitalBeijingChina
  2. 2.Institute of PsychologyChinese Academy of SciencesBeijingChina

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