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      Digital cognitive behavioral therapy for insomnia – The first Georgian version. Can we use it in practice?

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          Abstract

          Insomnia is a common sleep disorder which has a 5–6% prevalence rate and shows high social impact. At least 10% of patients with insomnia will see a medical specialist. Hence, 20,000–40,000 people in Georgia require medical help for insomnia. Treatment of insomnia is very effective. Pharmacotherapy is common, but it is recognized that cognitive behavioral therapy (CBT) is a better choice, since it is safe for patients and shows sustainable improvement. CBT of insomnia is not currently available in Georgia.

          The aim of our study was to evaluate a Georgian version of an innovative, internet-delivered digital CBT (dCBT) for insomnia in terms of therapeutic efficacy, adherence, and ease of handling.

          The Georgian digital cognitive behavioral therapy for insomnia was developed as an analogue of Dutch dCBT “i-Sleep.” All online materials were made applicable for the Georgian population through translation, validation by translation back to the original language, and adaptation to the Georgian reality, in order to avoid linguistic, cultural, and social pitfalls.

          Fifty-two adult patients with insomnia were recruited for the study: 34 women and 18 men, aged 18–64 years (mean: 33.5 years). Inclusion criteria included: age over 18, access to internet, and sufficient skills to use electronic devices. The patients who were treated pharmacologically continued their usual medication and received dCBT in addition to this treatment. DCBT was guided by a therapist. Clinical efficacy was evaluated on the basis of Insomnia Severity Index (ISI), measured before the dCBT and one month after its completion.

          25 out of 52 patients (48%) completed a full dCBT course. Mean ISI in this group dropped from 22.88 to 8.24 (P < 0.01), showing significant therapeutic effect one month after CBT completion. 27 patients (52%) stopped treatment for various reasons at different stages of dCBT. Sixteen patients dropped out from the first module (31%). 7 patients older than 50 years encountered problems with handling electronic devices and the platform itself. 9 patients stopped therapy, showing bad adherence for different reasons, mostly related to finding the sessions time-consuming and being disappointed by the absence of immediate therapeutic effect. Eleven more patients (21%) stopped at sleep restriction, finding it difficult to accomplish sleep restriction-related tasks. In general, patients found dCBT quite comprehensive and easy to handle.

          This data suggests that the Georgian version of dCBT for insomnia is a promising therapeutic tool, comparable with international analogues in terms of efficacy and adherence. Further studies, involving a greater number of patients and long-term follow-up are required for the final assessment of therapeutic efficacy and sustainability of results.

          Highlights

          • Georgian dCBT for insomnia showed significant therapeutic effect within one month after the CBT.

          • Drop our rate was 52%, being comparable with other dCBT versions.

          • Insomnia severity at the baseline did not affect patient adherence to the dCBT.

          • Patients above 50 years, regardless of adherence, would prefer face-to face sessions to dCBT.

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          Most cited references5

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          European guideline for the diagnosis and treatment of insomnia

          This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).
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            Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis

            Insomnia is a major public health problem considering its high prevalence, impact on daily life, co-morbidity with other disorders and societal costs. Cognitive behavioral treatment for insomnia (CBTI) is currently considered to be the preferred treatment. However, no meta-analysis exists of all studies using at least one component of CBTI for insomnia, which also uses modern techniques to pool data and to analyze subgroups of patients. We included 87 randomized controlled trials, comparing 118 treatments (3724 patients) to non-treated controls (2579 patients). Overall, the interventions had significant effects on: insomnia severity index (g = 0.98), sleep efficiency (g = 0.71), Pittsburgh sleep quality index (g = 0.65), wake after sleep onset (g = 0.63) and sleep onset latency (SOL; g = 0.57), number of awakenings (g = 0.29) and sleep quality (g = 0.40). The smallest effect was on total sleep time (g = 0.16). Face-to-face treatments of at least four sessions seem to be more effective than self-help interventions or face-to-face interventions with fewer sessions. Otherwise the results seem to be quite robust (similar for patients with or without comorbid disease, younger or older patients, using or not using sleep medication). We conclude that CBTI, either its components or the full package, is effective in the treatment of insomnia.
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              Insomnia as a Precipitating Factor in New Onset Mental Illness: a Systematic Review of Recent Findings

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                Author and article information

                Contributors
                Journal
                Internet Interv
                Internet Interv
                Internet Interventions
                Elsevier
                2214-7829
                09 March 2019
                September 2019
                09 March 2019
                : 17
                : 100244
                Affiliations
                [a ]Tbilisi State Medical University, Georgia
                [b ]SEIN-SKUH Epilepsy and Sleep Centre, Georgia
                [c ]Vrije Universiteit Amsterdam, Netherlands
                [d ]Stichting Epilepsy Institute in the Netherlands, Netherlands
                Author notes
                [* ]Corresponding author at: Tbilisi State Medical University, 0179 Tbilisi, Chavchavadze Ave. 33, SEIN-SKUH Epilepsy and Sleep Centre, Georgia. natelaokujava@ 123456yahoo.com
                Article
                S2214-7829(18)30090-3 100244
                10.1016/j.invent.2019.100244
                6434187
                424ede1d-a4bf-4734-b3f5-2285df221e99
                © 2019 Published by Elsevier B.V.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 17 December 2018
                : 5 March 2019
                : 5 March 2019
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