vkoiuy 2010-3-17 11:34
團體CBT對於慢性失眠有效
作者：Jill Stein
出處：WebMD醫學新聞
March 2, 2010 (德國慕尼黑) — 根據一項發表於歐洲精神科協會第18屆歐洲精神疾病研討會的研究指出，團體認知行為治療(Cognitive behavioral therapy，CBT)可以有效治療慢性失眠。
英國Bristol聯商精神科醫師Jane Hicks博士向Medscape Psychiatry表示，我們發現，在短期的團體CBT之後，睡眠測量和生活品質方面都有顯著改善，這項結果相當令人鼓舞，意味著病患可以恢復工作或上學。
Hicks博士等人在Bristol的Frenchay醫院疾病負擔研究中心進行這項研究。
研究者檢視了最近10年由Bristol失眠小組提供團體CBT治療之102名病患的結果；Bristol失眠小組是英國少數提供團體CBT的機構之一。
Hicks博士表示，現在，清楚確定CBT對於慢性失眠可以和鎮靜安眠藥物一樣有效，甚至在維持改善睡眠上更有效，迄今，多數有關CBT用於慢性失眠的研究著重在個人的CBT而非團體CBT。
疾病負擔研究中心的團體CBT課程，是由包括睡眠異常專科醫師、職能治療師以及睡眠研究科學家等組成的團隊所領導，每週舉辦一次、每次90分鐘，總共進行7週。
介入方式包括睡眠科學、睡眠衛生學教育資訊、刺激控制技術、放鬆與認知治療。
【顯著的臨床結果】
研究對象年紀為21-77歲，約四分之三為女性，整體而言，12%的失眠病史在2年內、30% 為3-5年、15%為6-10年、22%為11-20年、21%超過20年。
如同其他的慢性失眠團體計畫，該研究並未排除輕微到中度憂鬱患者，研究者發現，平均整體睡眠時間(TST)平均增加20分鐘(P = .0025)；平均入睡所需時間(SOL)平均減少17分鐘(P = .0011)。
整體而言，三分之二病患TST增加30分鐘或以上，三分之一的SOL 減少30分鐘或以上，Hicks博士表示，這些在臨床上都是顯著的結果。
36項的簡短版健康調查(SF36)問卷結果顯示，9個範圍全部都有顯著的改善，SF-36是一種由病患完成的生活品質問卷，可測量整體的功能性健康與生活情況。
研究者也指出，睡眠失能信念與態度量表的分數顯著降低，這是一種經過驗證、共有32項的自我報告量表，可評估多種睡眠相關認知(如過失信念與評估，以及不切實際的期待)。
【根深蒂固的態度】
她表示，我們對於慢性失眠患者通常有著相當根深蒂固的態度，例如，因為他們前一天睡眠不佳，他們一定無法有效率的工作，或者，認為他們需要實際的8小時睡眠才能在隔天發揮功能。
Hicks博士指出，雖然研究者並未進行次組分析來確認哪些人對團體CBT的反應最好，但有某些模式已經開始成形。
她表示，有些人的態度和信念相當固執而難以變動，這種人在思想上相當頑固，無法在心理上思考，這些人一般是年長的男性。
Hicks博士指出，除了臨床效果之外，團體CBT對於長期而言，是具有成本效益的選項，一開始或許比較貴，因為你得給付運作團體CBT的員工薪資，但是長久看來，病患可以停止服用原本的失眠處方藥物。
她表示，至於結果是否可持續，病患可以參與追蹤會議來修改在團體中所學的技術，藉此獲得幫助，然後獲得後續的結果資料。
最後，Hicks博士承認，雖然她的團隊發現使用團體CBT對於慢性失眠有好的結果，她仍希望有更好的結果。
她表示，我們對於TST和SOL的資料有點失望，因為我們的數據略遜於之前一般開業團體發表的資料。
不過，Bristol的研究者迅即指出，她們的研究對象來自一個三級轉診中心，病患的失眠情況可能比一般開業醫師所見的病患更嚴重。
【有效的非藥物治療】
紐約市NYU 醫學院醫學副教授Joyce Walsleben博士表示，此研究強調，非藥物治療可有效幫助病患改善睡眠的觀念。
她指出，這個療法的兩個缺點是，需花時間教導認知療法，而有此種訓練者不多。
Walsleben博士表示，該研究證明團體治療可以更有時效性，且有成本效益，這些資料為數百萬失眠患者帶來希望。
Hicks博士與 Walsleben博士皆宣告沒有相關財務關係。
歐洲精神科協會第18屆歐洲精神疾病研討會：摘要S27-02，發表於2010年3月1日。
Group CBT Effective for Chronic Insomnia
By Jill Stein
Medscape Medical News
March 2, 2010 (Munich, Germany) — Cognitive behavioral therapy (CBT) in a group setting is an effective treatment for chronic insomnia, new research presented here at the European Psychiatric Association 18th European Congress of Psychiatry, shows.
"The significant improvements in sleep measures and quality of life we observed in our patients following a short course of group CBT are very encouraging and may mean that patients can return to employment or education despite their insomnia," Jane Hicks, MD, PhD, a liaison psychiatrist in Bristol, United Kingdom, told Medscape Psychiatry.
Dr. Hicks and colleagues conducted their research at the Frenchay Hospital’s Burden Centre in Bristol.
The investigators examined results in 102 patients who underwent group CBT during a recent 10-year period offered by the Bristol Insomnia Group. The Bristol Insomnia Group is one of the few teams to provide group CBT in the United Kingdom.
"It is now well established that CBT for chronic insomnia is as effective as hypnotic medications and is also likely to be better at maintaining improved sleep," said Dr. Hicks. "To date, most studies on CBT for chronic insomnia have examined the use of individual rather than group-based CBT."
Group CBT sessions at the Burden Centre are led by a team that includes a physician specializing in sleep disorders, an occupational therapist, and a research sleep scientist. Sessions are held once a week for 90 minutes for a total of 7 weeks.
The intervention includes education about sleep science, information on sleep hygiene and stimulus control techniques, relaxation, and cognitive therapy.
Clinically Significant Results
Patients ranged from 21 to 77 years of age, and about three-quarters of them were female. Of the total cohort, 12% had insomnia for 2 years or less, 30% for 3 to 5 years, 15% for 6 to 10 years, 22% for 11 to 20 years, and 21% for more than 20 years.
Patients with mild to moderate depression were not excluded as in some other group programs for chronic insomnia. The investigators found that the mean total sleep time (TST) increased by a mean of 20 minutes (P = .0025).
The mean sleep onset latency (SOL) decreased by a mean of 17 minutes (P = .0011).
Overall, two-thirds of patients increased their TST by 30 minutes or more, and one-third decreased their SOL by 30 minutes or more. "These are clinically significant results," said Dr. Hicks.
Results on the 36-item Short Form Health Survey (SF36) questionnaire showed significant improvements in all 9 domains. The SF-36 is a patient-completed quality-of-life questionnaire that measures overall functional health and well-being.
The researchers also documented a significant decrease in scores on the Dysfunctional Beliefs and Attitudes about Sleep, a validated, 32-item, self-report measure that evaluates multiple sleep-related cognitions (eg, faulty beliefs and appraisals and unrealistic expectations).
Ingrained Attitudes
"Chronic insomniacs often have very ingrained attitudes whereby they think, for example, that they always won’t be able to perform as efficiently at work because they didn’t sleep well the night before," she said. "Or they may think that they need exactly 8 hours of sleep to function the next day."
Although the investigators did not conduct a subgroup analysis to determine who might respond best to group CBT, some patterns emerged, Dr. Hicks noted.
"It appears that individuals with very entrenched attitudes and beliefs were very difficult to move or change," she said. "Such people are very concrete in their thinking and can’t think psychologically," she added. "These individuals were usually older and male."
Besides clinical efficacy, group CBT is a cost-effective option for the long term, Dr. Hicks pointed out. "It may be expensive initially because you have to pay staff to run group CBT, but in the long term patients are often able to stop taking the medications they have been prescribed for their insomnia," she said.
"As for whether her results will be maintained over time, patients may benefit from contact at follow-up meetings to revise techniques learnt in the group and further outcome data can be obtained," she said.
Finally, Dr. Hicks acknowledged that although her team found good results using group CBT to manage chronic insomnia, she had expected even better results.
"We were slightly disappointed with our TST and SOL data because our figures fall short of those reported earlier by a general practice group," she said.
The Bristol investigator was quick to add, however, that the patient population in her series were from a tertiary referral center and may have had more severe insomnia than those patients usually seen in general practice.
Nonpharmacological Treatment Effective
"The study reinforces the idea that nonpharmacological therapies do work to help people improve their sleep," Joyce Walsleben, RN, PhD, associate professor of medicine at NYU School of Medicine in New York City, said.
"Two drawbacks to this therapy have been the time needed to teach the cognitive therapies and the few number of people trained to do so," she added.
Dr. Walsleben also said the study offers proof that "more time-effective, and presumably cost-effective, group therapy also works. These are hopeful data for the millions of people who suffer from insomnia."
Dr. Hicks and Dr. Walsleben have disclosed no relevant financial relationships.
European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract S27-02. Presented March 1, 2010.