Cell Biochem Biophys DOI 10.1007/s12013-014-9828-4
ORIGINAL PAPER
Effects of Cognitive Behavioral Therapy on Insomnia of Maintenance Hemodialysis Patients Yongmei Hou • Peicheng Hu • Yanping Liang Zhanyu Mo
•
Ó Springer Science+Business Media New York 2014
Abstract The objective of the study was to evaluate the effects of cognitive behavioral therapy [sleep-related behavior modification and progressive muscle relaxation on insomnia of maintenance hemodialysis (MHD) patients] on improving insomnia of MHD patients. 103 MHD patients complicated with insomnia were randomly assigned to treatment (n = 52) and control (n = 51) groups. The control group was treated with conventional hemodialysis, and the treatment group was additionally treated with cognitive behavioral therapy for 3 months (sleep-related behavior modification and progressive muscle relaxation). All cases were assessed by Symptom Checklist 90 (SCL-90) and Pittsburgh Sleep Quality Index (PSQI) before and 2, 4, 6, 8, 10, and 12 weeks after treatment. Fifty-one patients in the treatment group and 47 patients in the control group completed the experiments. After treatment, the total mean scores were (1.94 ± 0.50/ 2.29 ± 0.31); scores of somatization, depression, anxiety, hostility, and additional items were (1.87 ± 0.58/2.56 ± 0.26), (2.25 ± 0.80/2.79 ± 0.50), (1.79 ± 0.26/2.37 ± 0.34), (1.71 ± 0.46/2.25 ± 0.43), and (1.91 ± 0.67/ 2.26 ± 0.59) in SCL-90, respectively. The total scores for PSQI were (12.63 ± 2.27/16.40 ± 2.16); scores of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, hypnotics, and daytime dysfunction which were (1.98 ± 0.76/2.57 ± 0.58), (1.75 ± 0.59/2.60 ± 0.50), (2.10 ± 0.50/2.62 ± 0.53), (2.06 ± 0.47/2.57 ± 0.54), (2.04 ± 0.69/2.45 ± 0.72), (1.02 ± 0.79/1.51 ± 0.98), and (1.69 ± 0.55/2.09 ± 0.58), respectively, were significantly lower in the Y. Hou (&) P. Hu Y. Liang Z. Mo Department of Psychology, Guangdong Medical College, Zhanjiang 524023, Guangdong Province, China e-mail: [email protected]
treatment group compared with the control group. However, there were no significant differences in the scores of factors of obsessive–compulsive (2.26 ± 0.62/2.32 ± 0.38), interpersonal sensitivity (2.23 ± 0.64/2.43 ± 0.47), phobic anxiety (1.98 ± 0.62/2.01 ± 0.67), paranoid ideation (1.55 ± 0.43/1.69 ± 0.39), and psychoticism (1.57 ± 0.46/1.66 ± 0.49). The conclusion is that sleeprelated behavior modification in combination with progressive muscle relaxation effectively improved the mental state and sleep quality of MHD patients with insomnia. Keywords Maintenance hemodialysis Cognitive behavioral therapy Progressive muscle relaxation Sleeprelated behavior modification Insomnia Quality of sleep Randomly controlled study
Introduction Insomnia is the common sleep disorder in maintenance hemodialysis (MHD) patients, and about 50 % of MHD patients suffer insomnia [1–5]. Insomnia induces impaired concentration, delayed response, impaired memory and thinking, and decreased work efficiency. Compared with MHD patients with normal sleep, the immunity is worse and complications are more serious in MHD patients suffering insomnia [5, 6], and their self-rated health and quality of life are worse [1]. Insomnia in MHD patients is multifactorial and a result from interaction among biological, psychological, and social factors. In particular, psychological factor has great impact. Previous studies showed that anxiety and depression are influential factors for insomnia in MHD patients [7] and depression degree is an independent factor for the general sleep quality of MHD patients [8].
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Drug treatment, acupuncture and massage and mental intervention are main therapies for the insomnia in MHD patients. Drugs can effectively shorten sleep latency and improve habitual sleep efficiency and sleep quality [9]. Generally, the sleep of patients can be significantly improved in 1 week. However, most hypnotics have tolerance and dependency, which can worsen in vivo toxin accumulation. Therefore, drug treatment is not recommended for MHD patients with chronic insomnia and renal inadequacy for a long period of time. In addition, drugsinduced hangover can reduce work efficiency, increase daytime sleep, and affect night sleep. Thus, MHD patients are not willing to receive drug treatment. Ear acupoint pressing, acupuncture, and massage have shown to effectively improve insomnia of MHD patients. However, this therapy requires professional instrument or training, not convenient for MHD patients. Considering conditions of MHD patients, such as renal inadequacy and impaired cognitive and learning abilities, it is necessary to develop a simple, convenient, effective, and atoxic treatment to improve their sleep quality. As psychological factor can greatly influence insomnia of MHD patients, the quality of sleep may be improved by ameliorating their mental condition. A previous study reported that sleep-related behavior modification in combination with progressive muscle relaxation can effectively improve emotional problems of general populations to better their sleeping [12]. Moreover, this therapy is simple, effective, convenient, and free of toxicity. The present study aimed to verify the effects of sleep-related behavior modification in combination with progressive muscle relaxation on insomnia in MHD patients.
Subjects and Methods Subjects MHD patients admitted to Hemodialysis Center of Affiliated Hospital of Guangdong Medical College from early December 2005 to April 2006 were selected. Prior to grouping, they were assessed using Symptom Checklist 90 (SCL-90) [13], Pittsburgh Sleep Quality Index (PSQI) [14], and adult intelligence disability scale [15] and confirmed by physicians in Department of Psychiatry. Inclusion criteria: patients with end-stage renal disease, who underwent hemodialysis for at least 3 months, with stable condition, free of infection or hemorrhage; undergoing hemodialysis 2–3 times a week, 4–5 h each; confirmed by diagnostic standards of Chinese classification of mental disorders (version three) [16] for insomnia, with insomnia occurring after hemodialysis; with total scores [7 for PSQI; with clear consciousness, free of psychiatric history or
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personality disorder; with normal intelligence (0–2 scores for the adult intelligence disability scale [15]); able to understand content of the questionnaire; voluntary to participate in the study. In addition, those with history of hypnotics were asked to terminate medication until the end of the study. Written informed consent was obtained from all subjects. The study was approved by the Ethics Committee of Affiliated Hospital of Guangdong Medical College and the Ethics Committee of Guangdong Province. Grouping A total of 106 patients were selected, and 3 rejected to participate in the investigation. Therefore, 103 were included. The patients were numbered and randomly assigned to treatment (n = 52) and control (n = 51) groups. The investigation was conducted from mid December 2005 to late March 2006. During the study (investigation), five subjects withdrew, including one in treatment group (transferred to another hospital) and four in control group (hospitalization due to worsened disease). Therefore, 98 subjects completed the study (investigation), including 51 in treatment group and 47 in control group. General condition of two groups was listed in Table 1.
Methods During experimentation for 3 months, the control group underwent conventional hemodialysis. The treatment group was treated with cognitive behavioral therapy in addition to conventional hemodialysis. The intervention methods, theory, effects, and notes were told to the patients and their families. The cognitive behavioral therapy included two aspects: (1) progressive muscle relaxation: according to hemodialysis schedule, the treatment group was divided into six training groups, with 8–9 subjects in each subgroup. During the 20-min interval of training, they did progressive muscle relaxation with a magnetic tape of ‘‘self-relaxation’’ [14]. The physician did the progressive muscle relaxation for the patients and guided the patients. Each subgroup was trained every 2 days for three times in a week. (2) Sleeprelated behavior modification: the subjects were only allowed to sleep when they felt drowsiness; did not do activities unrelated to sleep on the bed; left the bedroom if they could not fall in sleep in 20 min to relax until they felt drowsiness; got up at regular time every morning regardless of sleep duration; did not sleep or slept as little as possible at daytime; recorded times of getting up in night, sleep duration, and daytime drowsiness degree to evaluate quality of sleep.
Cell Biochem Biophys Table 1 Baseline data of two groups Item
Treatment group
Control group
v2/t
P
Sex (male: female)
20/31
22/25
0.576
0.448
Age (x±s)
54.5 ± 13.8
52.4 ± 14.5
0.722
0.472
Serum creatinine/lmol/L (x±s)
1080.1 ± 202.9
1046.9 ± 188.9
0.838
0.404
Number of hypnotic administration (yes: no)
6/45
9/38
Primary disease Chronic glomerulonephritis
19
13
Renal arteriolar sclerosis
10
7
Chronic pyelonephritis
7
8
Diabetic glomerular sclerosis
5
8
Hypertensive nephropathy
9
11
Polycystic kidney
1
0
After the patients were well trained, they began to do the progressive muscle relaxation on the bed every night, twice a day for 30 min. In addition, they did the requirements of sleep-related behavior modification every day. The physician discussed training effects with every patient, once a week, to help them overcome difficulties in training and provide mental support. Tools SCL-90 utilized five scoring grade [10]: high scores represent severe mental disorder. PSQI was used to assess quality of sleep of patients in the latest 1 month [11]. It included 23 items, comprising seven factors: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, hypnotics, and daytime dysfunction. Every factor scored 0–3, and the total score of every factor was regarded as the total score of PSQI. High scores represent poor quality of sleep. Patients with total PSQI scores [7 were regarded as general sleep disturbance.
1.029
0.310
3.456
0.630
Results Comparison of SCL-90 scores between two groups before and after treatment As shown in Table 2, there were no significant differences in total score of SCL-90 or scores of each factor between two groups before treatment (P [ 0.05). However, the total score, scores of somatization, depression, anxiety, hostility, and additional items were lower in treatment group compared with control group following treatment (P \ 0.01). Comparison of PSQI scores between two groups before and after treatment As shown in Table 3, there were no significant differences in total scores of PSQI or scores of each factor between two groups before treatment (P [ 0.05). However, the total scores and scores of each factor were lower in treatment group compared with control group following treatment (P \ 0.01).
Testing methods Two groups were assessed using the questionnaires before and 2, 4, 6, 8, 10, and 12 weeks after treatment. The evaluation was performed by professional physicians. The subjects should ask questions independently. If they did not understand the question, the physicians should explain, but not give a hint. Statistical analysis Measurement data were compared using independent sample t test. Comparison in two or multiple constituent ratio was performed using v2 test.
Comparison of scores reduction in SCL-90 and PSQI between two groups in various stages After treatment for 2 weeks, the total scores of SCL-90 and PSQI were increased in both groups (score reduction rate was negative), and the increased scores in treatment were significantly more than the control group. In the following stages, the total scores of SCL-90 and PSQI were decreased significantly in both groups (score reduction rates were positive); the total scores of two questionnaires slightly increased or decreased sometimes in control group, but significantly less than the treatment group (Table 4).
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Cell Biochem Biophys Table 2 Comparison of scores for Symptom Checklist 90 between two groups before and after treatment (x ± SD) Item
Before treatment Treatment group (n = 51)
After treatment Control group (n = 47)
t
P
Treatment group (n = 51)
Control group (n = 47)
t
P
Total scores
2.4 ± 0.4
2.3 ± 0.4
0.68
0.497
1.9 ± 0.5
2.3 ± 0.3
-4.14
0.000
Somatization
2.7 ± 0.3
2.5 ± 0.3
1.93
0.057
1.9 ± 0.6
2.6 ± 0.3
-7.65
0.000
Obsessive– compulsive
2.4 ± 0.5
2.3 ± 0.4
1.12
0.266
2.3 ± 0.6
2.3 ± 0.4
-0.55
0.585
Interpersonal sensitivity
2.6 ± 0.5
2.5 ± 0.5
-1.05
0.295
2.2 ± 0.6
2.4 ± 0.5
-1.82
0.072
Depression
2.8 ± 0.7
2.9 ± 0.6
-0.24
0.809
2.3 ± 0.8
2.8 ± 0.5
-4.08
0.000
Anxiety
2.4 ± 0.4
2.4 ± 0.4
-0.63
0.529
1.8 ± 0.3
2.4 ± 0.3
-9.46
0.000
Hostility
2.3 ± 0.5
2.3 ± 0.5
0.59
0.555
1.7 ± 0.5
2.3 ± 0.4
-5.98
0.000
Phobic anxiety
2.1 ± 0.6
2.0 ± 0.6
0.87
0.388
2.0 ± 0.6
2.0 ± 0.7
-0.21
0.838
Paranoid ideation
1.7 ± 0.5
1.7 ± 0.5
-0.55
0.582
1.6 ± 0.4
1.7 ± 0.4
-1.71
0.09
Psychoticism Additional items
1.7 ± 0.4 2.4 ± 0.6
1.6 ± 0.4 2.3 ± 0.6
0.36 1.33
0.722 0.188
1.6 ± 0.5 1.9 ± 0.7
1.7 ± 0.5 2.3 ± 0.6
-0.88 -2.75
0.381 0.007
t
P
Table 3 Comparison of scores for PSQI between two groups before and after treatment (x ± SD) Item
Before treatment
After treatment
Treatment group (n = 51)
Control group (n = 47)
t
P
Treatment group (n = 51)
Control group (n = 47)
Total scores
15.7 ± 2.1
16.2 ± 2.2
-0.98
0.328
12.6 ± 2.3
16.4 ± 2.2
8.41
0.000
Sleep quality
2.6 ± 0.5
2.7 ± 0.5
-1.14
0.256
2.0 ± 0.8
2.6 ± 0.6
-4.32
0.000
Sleep latency Sleep duration
2.7 ± 0.5 2.7 ± 0.5
2.6 ± 0.5 2.5 ± 0.7
0.71 1.14
0.481 0.255
1.8 ± 0.6 2.1 ± 0.5
2.6 ± 0.5 2.6 ± 0.5
-7.65 -4.96
0.000 0.000
Habitual sleep efficiency
2.6 ± 0.6
2.5 ± 0.6
0.99
0.327
2.1 ± 0.5
2.6 ± 0.5
-5.04
0.000 0.005
Sleep disturbance
2.3 ± 0.8
2.4 ± 0.9
-0.53
0.596
2.0 ± 0.7
2.5 ± 0.7
-2.87
Hypnotics
1.1 ± 1.0
1.5 ± 1.0
-1.66
0.101
1.0 ± 0.8
1.5 ± 1.0
-2.73
0.008
Daytime dysfunction
1.8 ± 0.6
2.0 ± 0.6
-1.73
0.087
1.7 ± 0.6
2.1 ± 0.6
-3.49
0.001
P
Table 4 Score reduction rate (%) in Symptom Checklist 90 (SCL-90) and PSQI between two groups (x ± SD) Time (week)
SCL-90
PSQI
Treatment group (n = 51)
Control group (n = 47)
t
2
-2.1 ± 1.7
-0.1 ± 1.0
4
1.1 ± 1.7
0.1 ± 1.2
6 8
6.8 ± 3.6 8.2 ± 2.9
10 After treatment
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P
Treatment group (n = 51)
Control group (n = 47)
t
-7.19
0.000
-6.4 ± 7.5
-1.1 ± 6.0
-3.81
0.000
3.36
0.001
4.4 ± 8.0
1.2 ± 4.9
2.38
0.020
-1.2 ± 0.9 0.9 ± 2.6
14.87 16.22
0.000 0.000
8.9 ± 8.3 12.6 ± 9.1
1.4 ± 4.4 0.5 ± 1.8
5.64 9.26
0.000 0.000
11.0 ± 4.4
-1.5 ± 2.3
17.30
0.000
15.6 ± 9.1
-0.8 ± 3.6
11.92
0.000
18.1 ± 11.8
0.0 ± 4.8
9.77
0.000
19.5 ± 11.7
-2.0 ± 8.7
10.33
0.000
\0.001 4.9 ± 0.5 5.9 ± 0.6
9.31
\0.1001
\0.1001 6.25
6.18
4.8 ± 0.16
4.9 ± 0.6
5.1 ± 0.5 5.3 ± 0.6
5.5 ± 0.5
5.0 ± 0.6 4.8 ± 0.16
4.6 ± 0.6
5.6 ± 0.6
0.006 0.671
4.9 ± 0.6
0.43
\0.001 -4.45 2.7 ± 0.5 48.3 ± 17.9 After treatment
70.3 ± 21.1
-5.60
\0.001
4.1 ± 2.1
\0.001
\0.001 -5.35
-5.21 4.2 ± 2.0
3.9 ± 2.0
2.4 ± 1.5
2.2 ± 1.2
0.002
\0.1001 -4.40
-3.19 71.1 ± 21.1 57.3 ± 21.8
52.8 ± 18.9
8 weeks after treatment
10 weeks after treatment
70.1 ± 19.9
0.004 \0.001 -2.99 -3.81 4.2 ± 2.1 4.2 ± 2.1 3.0 ± 2.0 2.7 ± 1.7 0.322 0.013 72.8 ± 22.4 73.2 ± 22.2 67.9 ± 25.7 61.2 ± 24.6 4 week after treatment 6 weeks after treatment
-1.00 -2.53
4.9 ± 0.16
0.275 -1.10
4.9 ± 0.5 0.352
4.0 ± 2.2 3.5 ± 2.4
-0.194 4.1 ± 2.1
0.004 2.99
3.7 ± 2.3 72.0 ± 21.8 73.8 ± 22.3
86.2 ± 23.4
Before treatment
2 weeks after treatment
Control (n = 109) Treatment (n = 104)
Comparison in sleep latency, times of wakefulness in night, and sleep duration between groups There were no significant differences in sleep latency between groups before treatment. After treatment for 2 weeks, the sleep latency was significantly prolonged in treatment group, but remained unchanged in control group, and the sleep latency was higher than that of the control group. In the following stages, the sleep latency was decreased in treatment group, but remained unchanged in control group. Since 6 weeks, the sleep latency was significantly less in treatment group compared with the control group (Table 5).
Discussion
72.6 ± 21.5
Control (n = 109) Treatment (n = 104) Control (n = 109) Treatment (n = 104)
1.40 4.18
-2.83
P t Times of wakefulness in night p t Sleep duration (h) p t Sleep latency (min) Stage
Table 5 Comparison in sleep latency (minute) between two groups (x ± SD) stage
0.164 \0.001
Cell Biochem Biophys
Results from the present study demonstrated that the mental health was poor in MHD patients complicated with insomnia, manifested by positive trend in SCL-90 total score and scores in multiple factors (more than two scores), consistent with previous study results [7, 8]. After treatment, the total score of SCL-90 and scores of somatization, depression, anxiety, hostility, and additional items, as well as PSQI total and factor scores, were decreased compared with control group. This indicates that sleep-related behavior modification in combination with progressive muscle relaxation can improve mental health state and quality of sleep in MHD patients. Mental and behavioral factors play an important role in insomnia of MHD patients [7, 8, 16]. The progressive muscle relaxation reduces activities of adrenergic nerve by continuously increasing and decreasing muscular tension of the whole body [17] to maintain balance between adrenergic nerve and parasympathetic nerve tension [18]. In addition, this method distracted patient focus on insomnia, reduced anxiety and induce sleep. A previous study demonstrated that progressive muscle relaxation can reduce anxiety of patients lying on the bed, induce accurate estimate for sleep latency and sleep duration, and significantly improve subjective sleep quality and efficiency [19]. Insomnia is caused by bad-conditioned reflex between sleep-related time (time on the bed) and environment clues (bed and bedroom) [15]. First, many MHD patients experience hypersomnia in daytime [3, 20], resulting in inadequate hypnesthesia in night; dialysis alters body temperature and eases sleep [18]. In hemodialysis, the patients easily sleep under nursing and monitor because they are free of mental burden; some patients could not sleep well in the night before hemodialysis, and so, they fall asleep during hemodialysis. Moreover, the majority of patients stays at home and often sleeps in daytime or they worry about insomnia and go to sleep early but cannot fall
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asleep. Sometimes, insomnia results from thinking on bed or varied sleep time in the night. All the above-mentioned events can lead to abnormal correlation among sleep, time, and environment, resulting in abnormality in conditioned reflex between sleep time and environment, and worsening insomnia. Therefore, the present study also utilized sleep-related behavior modification to construct normal connection among sleep, time, and environment by reducing activities not related with sleep and strictly fulfilling the sleep–wake schedule. The patients were asked not to sleep in daytime or do activities not related to sleep on the bed, but to go bed when they felt fatigue at night, and get up on time. This helps construct good relationship between sleep time and bedroom, eliminating anxiety to sleep and improving quality of sleep. Drugs are not well accepted by MHD patients. Noda et al. [3] reported that only 25.8 % of MHD patients with insomnia regularly took hypnotics. In the present study, 15.3 % of patients (n = 15) took hypnotics occasionally, and many patients were willing to receive treatment free of drugs. However, early effects of mental treatment were not significant. After treatment for 2 weeks, the sleep latency was significantly prolonged, sleep duration was significantly reduced, and total scores of SCL-90 and PSQI were increased, though times of wake in night were reduced slightly. However, patients adjusted their living habits, such as sleep environment and habit, relaxation training before sleep, which sometimes made them inadapted and increased their anxiety. The sleep of some patients was also affected because of termination of drugs. Therefore, the doctors should encourage the patients during the treatment (especially at the first 2 weeks), increase communication with them, help them overcome problems, and provide mental courage and support to construct better treatment environment and improve their rehabilitation. Results from the present study showed that after treatment for 3 months, the quality of patient sleep was improved. However, they were not recovered as normal people [total scores for PSQI: (12,163 ± 2,127) vs. norm [7]. The results were not consistent with previous study on primary insomnia [9]. It is likely that the insomnia in MHD patients is secondary, and the treatment requires more time. Acknowledgment We thank the staff from Department of Medical Affairs, Hemodialysis Center, and Department of Nursing, Affiliated Hospital of Guangdong Medical College. Yongmei Hou was Supported through THE Science and Technology Development Program of Zhanjiang in 2006, No. 2006C07002.
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2. Merlino, G., Piani, A., Dolso, P., et al. (2006). Sleep disorders in patients with end-stage renal disease undergoing dialysis therapy. Nephrology, Dialysis, Transplantation, 21(1), 184–190. 3. Noda, A., Nakai, S., Soga, T., et al. (2006). Factors contributing to sleep disturbance and hypnotic drug use in hemodialysis patients. Journal of Internal Medicine., 45(22), 1273–1278. 4. Chen, W. C., Lim, P. S., Wu, W. C., et al. (2006). Sleep behavior disorders in a large cohort of chinese (Taiwanese) patients maintained by long-term hemodialysis. American Journal of Kidney Diseases, 48(2), 277–284. 5. Chen, T. W., Chen, G., Funkhouser, L. J., & Nam, S. C. (2009). Membrane domain modulation by Spectrins in Drosophila photoreceptor morphogenesis. Genesis, 47(11), 744–750. 6. De Santo, R. M., Lucidi, F., Violani, C., et al. (2001). Insomnia is associated with systolic hypertension in uremic patients on hemodialysis. International Journal of Artificial Organs, 24(12), 853–862. 7. Yang, J. Y., Huang, J. W., Chiang, C. K., et al. (2007). Higher plasma interleukin-18 levels associated with poor quality of sleep in peritoneal dialysis patients. Nephrology, Dialysis, Transplantation, 22(12), 3606–3609. 8. Pai, M. F., Hsu, S. P., Yang, S. Y., et al. (2007). Sleep disturbance in chronic hemodialysis patients: The impact of depression and anemia. Renal Failure, 29(6), 673–677. 9. Sabbatini, M., Crispo, A., Pisani, A., et al. (2003). Zaleplon improves sleep quality in maintenance hemodialysis patients. Nephron Clin Pract, 94(4), c99–c103. 10. Chen, H., Khan, A. A., Liu, F., Gilligan, D. M., Peters, L. L., Messick, J., et al. (2007). Combined deletion of mouse dematinheadpiece and beta-adducin exerts a novel effect on the spectrin– actin junctions leading to erythrocyte fragility and hemolytic anemia. Journal of Biological Chemistry, 282(6), 4124–4135. 11. Dai, X., Xing, X., Shi, Y., et al. (2007). Lower extremity point massage for improving quality of sleep in patients with end-stage renal disease: A ciinical study of 42 cases. Journal of Traditional Chinese Medicin., 48(1), 44–46. 12. Lan, S., Deng, Q., Zhu, X., et al. (2002). Relaxation training and sleep related behavior modification in patients with insomnia. Chinese Mental Health Journal, 16(9), 625–627. 13. Luo, X.-R., Wang, Z.-Z., Zhang, H-M., Wang, C., Yang, X., Yang, J. (1999). Comparative study on mental health status of 10.113 military personnel and the norms of China. Chinese Mental Health Journal, 31–35. 14. Buysse, D. J., Reynolds, C. F., Monk, T. H., et al. (1989). The Pittsburgh sleep quality index: A new Yinst-unment for psychiatric practice and research. Psychiatry Research, 28, 1. 15. Pang, Y.-X., Zhang, J., Yang, C.-L., Cang, F., & Wang, X. (2011). Application of W AIS-RC short forms and adult intelligence disability scale in mental impairment assessment. Journal of Forensic Medicine, 27(3), 189–192. 16. YU, Z.-G., Liu, J.-P., LIU, J., & MA, J.-L. (2007). Investigation of clinical use for classification and diagnostic criteria of mental disorders in china-third edition. Journal of Clinical Psychiatry, 17(5), 312–313. 17. Lichstein, K. L., Wilson, N. M., & Johnson, C. T. (2000). Psychological treatment of secondary insomnia. Psychology & Aging, 15, 232–240. 18. Welch, J. L., & Austin, J. K. (1999). Factors associated with treatment-related stressors in hemodialysis patients. ANNA J, 26(3), 318–325. 19. Janet, L., Welch, D. N. S. R. N., Joan, K., et al. (2001). Stressors, coping and depression in haemodialysis patients. Journal of Advanced Nursing, 33(2), 200–202. 20. Waters, W. F., Adams, S. G., Brinks, J. R., et al. (1993). Attention, stress and negative emotion in persistent sleep-onset and sleep-maintenance insomnia. Sleep, 16(2), 128.
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ORIGINAL PAPER
Effects of Cognitive Behavioral Therapy on Insomnia of Maintenance Hemodialysis Patients Yongmei Hou • Peicheng Hu • Yanping Liang Zhanyu Mo
•
Ó Springer Science+Business Media New York 2014
Abstract The objective of the study was to evaluate the effects of cognitive behavioral therapy [sleep-related behavior modification and progressive muscle relaxation on insomnia of maintenance hemodialysis (MHD) patients] on improving insomnia of MHD patients. 103 MHD patients complicated with insomnia were randomly assigned to treatment (n = 52) and control (n = 51) groups. The control group was treated with conventional hemodialysis, and the treatment group was additionally treated with cognitive behavioral therapy for 3 months (sleep-related behavior modification and progressive muscle relaxation). All cases were assessed by Symptom Checklist 90 (SCL-90) and Pittsburgh Sleep Quality Index (PSQI) before and 2, 4, 6, 8, 10, and 12 weeks after treatment. Fifty-one patients in the treatment group and 47 patients in the control group completed the experiments. After treatment, the total mean scores were (1.94 ± 0.50/ 2.29 ± 0.31); scores of somatization, depression, anxiety, hostility, and additional items were (1.87 ± 0.58/2.56 ± 0.26), (2.25 ± 0.80/2.79 ± 0.50), (1.79 ± 0.26/2.37 ± 0.34), (1.71 ± 0.46/2.25 ± 0.43), and (1.91 ± 0.67/ 2.26 ± 0.59) in SCL-90, respectively. The total scores for PSQI were (12.63 ± 2.27/16.40 ± 2.16); scores of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, hypnotics, and daytime dysfunction which were (1.98 ± 0.76/2.57 ± 0.58), (1.75 ± 0.59/2.60 ± 0.50), (2.10 ± 0.50/2.62 ± 0.53), (2.06 ± 0.47/2.57 ± 0.54), (2.04 ± 0.69/2.45 ± 0.72), (1.02 ± 0.79/1.51 ± 0.98), and (1.69 ± 0.55/2.09 ± 0.58), respectively, were significantly lower in the Y. Hou (&) P. Hu Y. Liang Z. Mo Department of Psychology, Guangdong Medical College, Zhanjiang 524023, Guangdong Province, China e-mail: [email protected]
treatment group compared with the control group. However, there were no significant differences in the scores of factors of obsessive–compulsive (2.26 ± 0.62/2.32 ± 0.38), interpersonal sensitivity (2.23 ± 0.64/2.43 ± 0.47), phobic anxiety (1.98 ± 0.62/2.01 ± 0.67), paranoid ideation (1.55 ± 0.43/1.69 ± 0.39), and psychoticism (1.57 ± 0.46/1.66 ± 0.49). The conclusion is that sleeprelated behavior modification in combination with progressive muscle relaxation effectively improved the mental state and sleep quality of MHD patients with insomnia. Keywords Maintenance hemodialysis Cognitive behavioral therapy Progressive muscle relaxation Sleeprelated behavior modification Insomnia Quality of sleep Randomly controlled study
Introduction Insomnia is the common sleep disorder in maintenance hemodialysis (MHD) patients, and about 50 % of MHD patients suffer insomnia [1–5]. Insomnia induces impaired concentration, delayed response, impaired memory and thinking, and decreased work efficiency. Compared with MHD patients with normal sleep, the immunity is worse and complications are more serious in MHD patients suffering insomnia [5, 6], and their self-rated health and quality of life are worse [1]. Insomnia in MHD patients is multifactorial and a result from interaction among biological, psychological, and social factors. In particular, psychological factor has great impact. Previous studies showed that anxiety and depression are influential factors for insomnia in MHD patients [7] and depression degree is an independent factor for the general sleep quality of MHD patients [8].
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Drug treatment, acupuncture and massage and mental intervention are main therapies for the insomnia in MHD patients. Drugs can effectively shorten sleep latency and improve habitual sleep efficiency and sleep quality [9]. Generally, the sleep of patients can be significantly improved in 1 week. However, most hypnotics have tolerance and dependency, which can worsen in vivo toxin accumulation. Therefore, drug treatment is not recommended for MHD patients with chronic insomnia and renal inadequacy for a long period of time. In addition, drugsinduced hangover can reduce work efficiency, increase daytime sleep, and affect night sleep. Thus, MHD patients are not willing to receive drug treatment. Ear acupoint pressing, acupuncture, and massage have shown to effectively improve insomnia of MHD patients. However, this therapy requires professional instrument or training, not convenient for MHD patients. Considering conditions of MHD patients, such as renal inadequacy and impaired cognitive and learning abilities, it is necessary to develop a simple, convenient, effective, and atoxic treatment to improve their sleep quality. As psychological factor can greatly influence insomnia of MHD patients, the quality of sleep may be improved by ameliorating their mental condition. A previous study reported that sleep-related behavior modification in combination with progressive muscle relaxation can effectively improve emotional problems of general populations to better their sleeping [12]. Moreover, this therapy is simple, effective, convenient, and free of toxicity. The present study aimed to verify the effects of sleep-related behavior modification in combination with progressive muscle relaxation on insomnia in MHD patients.
Subjects and Methods Subjects MHD patients admitted to Hemodialysis Center of Affiliated Hospital of Guangdong Medical College from early December 2005 to April 2006 were selected. Prior to grouping, they were assessed using Symptom Checklist 90 (SCL-90) [13], Pittsburgh Sleep Quality Index (PSQI) [14], and adult intelligence disability scale [15] and confirmed by physicians in Department of Psychiatry. Inclusion criteria: patients with end-stage renal disease, who underwent hemodialysis for at least 3 months, with stable condition, free of infection or hemorrhage; undergoing hemodialysis 2–3 times a week, 4–5 h each; confirmed by diagnostic standards of Chinese classification of mental disorders (version three) [16] for insomnia, with insomnia occurring after hemodialysis; with total scores [7 for PSQI; with clear consciousness, free of psychiatric history or
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personality disorder; with normal intelligence (0–2 scores for the adult intelligence disability scale [15]); able to understand content of the questionnaire; voluntary to participate in the study. In addition, those with history of hypnotics were asked to terminate medication until the end of the study. Written informed consent was obtained from all subjects. The study was approved by the Ethics Committee of Affiliated Hospital of Guangdong Medical College and the Ethics Committee of Guangdong Province. Grouping A total of 106 patients were selected, and 3 rejected to participate in the investigation. Therefore, 103 were included. The patients were numbered and randomly assigned to treatment (n = 52) and control (n = 51) groups. The investigation was conducted from mid December 2005 to late March 2006. During the study (investigation), five subjects withdrew, including one in treatment group (transferred to another hospital) and four in control group (hospitalization due to worsened disease). Therefore, 98 subjects completed the study (investigation), including 51 in treatment group and 47 in control group. General condition of two groups was listed in Table 1.
Methods During experimentation for 3 months, the control group underwent conventional hemodialysis. The treatment group was treated with cognitive behavioral therapy in addition to conventional hemodialysis. The intervention methods, theory, effects, and notes were told to the patients and their families. The cognitive behavioral therapy included two aspects: (1) progressive muscle relaxation: according to hemodialysis schedule, the treatment group was divided into six training groups, with 8–9 subjects in each subgroup. During the 20-min interval of training, they did progressive muscle relaxation with a magnetic tape of ‘‘self-relaxation’’ [14]. The physician did the progressive muscle relaxation for the patients and guided the patients. Each subgroup was trained every 2 days for three times in a week. (2) Sleeprelated behavior modification: the subjects were only allowed to sleep when they felt drowsiness; did not do activities unrelated to sleep on the bed; left the bedroom if they could not fall in sleep in 20 min to relax until they felt drowsiness; got up at regular time every morning regardless of sleep duration; did not sleep or slept as little as possible at daytime; recorded times of getting up in night, sleep duration, and daytime drowsiness degree to evaluate quality of sleep.
Cell Biochem Biophys Table 1 Baseline data of two groups Item
Treatment group
Control group
v2/t
P
Sex (male: female)
20/31
22/25
0.576
0.448
Age (x±s)
54.5 ± 13.8
52.4 ± 14.5
0.722
0.472
Serum creatinine/lmol/L (x±s)
1080.1 ± 202.9
1046.9 ± 188.9
0.838
0.404
Number of hypnotic administration (yes: no)
6/45
9/38
Primary disease Chronic glomerulonephritis
19
13
Renal arteriolar sclerosis
10
7
Chronic pyelonephritis
7
8
Diabetic glomerular sclerosis
5
8
Hypertensive nephropathy
9
11
Polycystic kidney
1
0
After the patients were well trained, they began to do the progressive muscle relaxation on the bed every night, twice a day for 30 min. In addition, they did the requirements of sleep-related behavior modification every day. The physician discussed training effects with every patient, once a week, to help them overcome difficulties in training and provide mental support. Tools SCL-90 utilized five scoring grade [10]: high scores represent severe mental disorder. PSQI was used to assess quality of sleep of patients in the latest 1 month [11]. It included 23 items, comprising seven factors: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, hypnotics, and daytime dysfunction. Every factor scored 0–3, and the total score of every factor was regarded as the total score of PSQI. High scores represent poor quality of sleep. Patients with total PSQI scores [7 were regarded as general sleep disturbance.
1.029
0.310
3.456
0.630
Results Comparison of SCL-90 scores between two groups before and after treatment As shown in Table 2, there were no significant differences in total score of SCL-90 or scores of each factor between two groups before treatment (P [ 0.05). However, the total score, scores of somatization, depression, anxiety, hostility, and additional items were lower in treatment group compared with control group following treatment (P \ 0.01). Comparison of PSQI scores between two groups before and after treatment As shown in Table 3, there were no significant differences in total scores of PSQI or scores of each factor between two groups before treatment (P [ 0.05). However, the total scores and scores of each factor were lower in treatment group compared with control group following treatment (P \ 0.01).
Testing methods Two groups were assessed using the questionnaires before and 2, 4, 6, 8, 10, and 12 weeks after treatment. The evaluation was performed by professional physicians. The subjects should ask questions independently. If they did not understand the question, the physicians should explain, but not give a hint. Statistical analysis Measurement data were compared using independent sample t test. Comparison in two or multiple constituent ratio was performed using v2 test.
Comparison of scores reduction in SCL-90 and PSQI between two groups in various stages After treatment for 2 weeks, the total scores of SCL-90 and PSQI were increased in both groups (score reduction rate was negative), and the increased scores in treatment were significantly more than the control group. In the following stages, the total scores of SCL-90 and PSQI were decreased significantly in both groups (score reduction rates were positive); the total scores of two questionnaires slightly increased or decreased sometimes in control group, but significantly less than the treatment group (Table 4).
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Cell Biochem Biophys Table 2 Comparison of scores for Symptom Checklist 90 between two groups before and after treatment (x ± SD) Item
Before treatment Treatment group (n = 51)
After treatment Control group (n = 47)
t
P
Treatment group (n = 51)
Control group (n = 47)
t
P
Total scores
2.4 ± 0.4
2.3 ± 0.4
0.68
0.497
1.9 ± 0.5
2.3 ± 0.3
-4.14
0.000
Somatization
2.7 ± 0.3
2.5 ± 0.3
1.93
0.057
1.9 ± 0.6
2.6 ± 0.3
-7.65
0.000
Obsessive– compulsive
2.4 ± 0.5
2.3 ± 0.4
1.12
0.266
2.3 ± 0.6
2.3 ± 0.4
-0.55
0.585
Interpersonal sensitivity
2.6 ± 0.5
2.5 ± 0.5
-1.05
0.295
2.2 ± 0.6
2.4 ± 0.5
-1.82
0.072
Depression
2.8 ± 0.7
2.9 ± 0.6
-0.24
0.809
2.3 ± 0.8
2.8 ± 0.5
-4.08
0.000
Anxiety
2.4 ± 0.4
2.4 ± 0.4
-0.63
0.529
1.8 ± 0.3
2.4 ± 0.3
-9.46
0.000
Hostility
2.3 ± 0.5
2.3 ± 0.5
0.59
0.555
1.7 ± 0.5
2.3 ± 0.4
-5.98
0.000
Phobic anxiety
2.1 ± 0.6
2.0 ± 0.6
0.87
0.388
2.0 ± 0.6
2.0 ± 0.7
-0.21
0.838
Paranoid ideation
1.7 ± 0.5
1.7 ± 0.5
-0.55
0.582
1.6 ± 0.4
1.7 ± 0.4
-1.71
0.09
Psychoticism Additional items
1.7 ± 0.4 2.4 ± 0.6
1.6 ± 0.4 2.3 ± 0.6
0.36 1.33
0.722 0.188
1.6 ± 0.5 1.9 ± 0.7
1.7 ± 0.5 2.3 ± 0.6
-0.88 -2.75
0.381 0.007
t
P
Table 3 Comparison of scores for PSQI between two groups before and after treatment (x ± SD) Item
Before treatment
After treatment
Treatment group (n = 51)
Control group (n = 47)
t
P
Treatment group (n = 51)
Control group (n = 47)
Total scores
15.7 ± 2.1
16.2 ± 2.2
-0.98
0.328
12.6 ± 2.3
16.4 ± 2.2
8.41
0.000
Sleep quality
2.6 ± 0.5
2.7 ± 0.5
-1.14
0.256
2.0 ± 0.8
2.6 ± 0.6
-4.32
0.000
Sleep latency Sleep duration
2.7 ± 0.5 2.7 ± 0.5
2.6 ± 0.5 2.5 ± 0.7
0.71 1.14
0.481 0.255
1.8 ± 0.6 2.1 ± 0.5
2.6 ± 0.5 2.6 ± 0.5
-7.65 -4.96
0.000 0.000
Habitual sleep efficiency
2.6 ± 0.6
2.5 ± 0.6
0.99
0.327
2.1 ± 0.5
2.6 ± 0.5
-5.04
0.000 0.005
Sleep disturbance
2.3 ± 0.8
2.4 ± 0.9
-0.53
0.596
2.0 ± 0.7
2.5 ± 0.7
-2.87
Hypnotics
1.1 ± 1.0
1.5 ± 1.0
-1.66
0.101
1.0 ± 0.8
1.5 ± 1.0
-2.73
0.008
Daytime dysfunction
1.8 ± 0.6
2.0 ± 0.6
-1.73
0.087
1.7 ± 0.6
2.1 ± 0.6
-3.49
0.001
P
Table 4 Score reduction rate (%) in Symptom Checklist 90 (SCL-90) and PSQI between two groups (x ± SD) Time (week)
SCL-90
PSQI
Treatment group (n = 51)
Control group (n = 47)
t
2
-2.1 ± 1.7
-0.1 ± 1.0
4
1.1 ± 1.7
0.1 ± 1.2
6 8
6.8 ± 3.6 8.2 ± 2.9
10 After treatment
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P
Treatment group (n = 51)
Control group (n = 47)
t
-7.19
0.000
-6.4 ± 7.5
-1.1 ± 6.0
-3.81
0.000
3.36
0.001
4.4 ± 8.0
1.2 ± 4.9
2.38
0.020
-1.2 ± 0.9 0.9 ± 2.6
14.87 16.22
0.000 0.000
8.9 ± 8.3 12.6 ± 9.1
1.4 ± 4.4 0.5 ± 1.8
5.64 9.26
0.000 0.000
11.0 ± 4.4
-1.5 ± 2.3
17.30
0.000
15.6 ± 9.1
-0.8 ± 3.6
11.92
0.000
18.1 ± 11.8
0.0 ± 4.8
9.77
0.000
19.5 ± 11.7
-2.0 ± 8.7
10.33
0.000
\0.001 4.9 ± 0.5 5.9 ± 0.6
9.31
\0.1001
\0.1001 6.25
6.18
4.8 ± 0.16
4.9 ± 0.6
5.1 ± 0.5 5.3 ± 0.6
5.5 ± 0.5
5.0 ± 0.6 4.8 ± 0.16
4.6 ± 0.6
5.6 ± 0.6
0.006 0.671
4.9 ± 0.6
0.43
\0.001 -4.45 2.7 ± 0.5 48.3 ± 17.9 After treatment
70.3 ± 21.1
-5.60
\0.001
4.1 ± 2.1
\0.001
\0.001 -5.35
-5.21 4.2 ± 2.0
3.9 ± 2.0
2.4 ± 1.5
2.2 ± 1.2
0.002
\0.1001 -4.40
-3.19 71.1 ± 21.1 57.3 ± 21.8
52.8 ± 18.9
8 weeks after treatment
10 weeks after treatment
70.1 ± 19.9
0.004 \0.001 -2.99 -3.81 4.2 ± 2.1 4.2 ± 2.1 3.0 ± 2.0 2.7 ± 1.7 0.322 0.013 72.8 ± 22.4 73.2 ± 22.2 67.9 ± 25.7 61.2 ± 24.6 4 week after treatment 6 weeks after treatment
-1.00 -2.53
4.9 ± 0.16
0.275 -1.10
4.9 ± 0.5 0.352
4.0 ± 2.2 3.5 ± 2.4
-0.194 4.1 ± 2.1
0.004 2.99
3.7 ± 2.3 72.0 ± 21.8 73.8 ± 22.3
86.2 ± 23.4
Before treatment
2 weeks after treatment
Control (n = 109) Treatment (n = 104)
Comparison in sleep latency, times of wakefulness in night, and sleep duration between groups There were no significant differences in sleep latency between groups before treatment. After treatment for 2 weeks, the sleep latency was significantly prolonged in treatment group, but remained unchanged in control group, and the sleep latency was higher than that of the control group. In the following stages, the sleep latency was decreased in treatment group, but remained unchanged in control group. Since 6 weeks, the sleep latency was significantly less in treatment group compared with the control group (Table 5).
Discussion
72.6 ± 21.5
Control (n = 109) Treatment (n = 104) Control (n = 109) Treatment (n = 104)
1.40 4.18
-2.83
P t Times of wakefulness in night p t Sleep duration (h) p t Sleep latency (min) Stage
Table 5 Comparison in sleep latency (minute) between two groups (x ± SD) stage
0.164 \0.001
Cell Biochem Biophys
Results from the present study demonstrated that the mental health was poor in MHD patients complicated with insomnia, manifested by positive trend in SCL-90 total score and scores in multiple factors (more than two scores), consistent with previous study results [7, 8]. After treatment, the total score of SCL-90 and scores of somatization, depression, anxiety, hostility, and additional items, as well as PSQI total and factor scores, were decreased compared with control group. This indicates that sleep-related behavior modification in combination with progressive muscle relaxation can improve mental health state and quality of sleep in MHD patients. Mental and behavioral factors play an important role in insomnia of MHD patients [7, 8, 16]. The progressive muscle relaxation reduces activities of adrenergic nerve by continuously increasing and decreasing muscular tension of the whole body [17] to maintain balance between adrenergic nerve and parasympathetic nerve tension [18]. In addition, this method distracted patient focus on insomnia, reduced anxiety and induce sleep. A previous study demonstrated that progressive muscle relaxation can reduce anxiety of patients lying on the bed, induce accurate estimate for sleep latency and sleep duration, and significantly improve subjective sleep quality and efficiency [19]. Insomnia is caused by bad-conditioned reflex between sleep-related time (time on the bed) and environment clues (bed and bedroom) [15]. First, many MHD patients experience hypersomnia in daytime [3, 20], resulting in inadequate hypnesthesia in night; dialysis alters body temperature and eases sleep [18]. In hemodialysis, the patients easily sleep under nursing and monitor because they are free of mental burden; some patients could not sleep well in the night before hemodialysis, and so, they fall asleep during hemodialysis. Moreover, the majority of patients stays at home and often sleeps in daytime or they worry about insomnia and go to sleep early but cannot fall
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asleep. Sometimes, insomnia results from thinking on bed or varied sleep time in the night. All the above-mentioned events can lead to abnormal correlation among sleep, time, and environment, resulting in abnormality in conditioned reflex between sleep time and environment, and worsening insomnia. Therefore, the present study also utilized sleep-related behavior modification to construct normal connection among sleep, time, and environment by reducing activities not related with sleep and strictly fulfilling the sleep–wake schedule. The patients were asked not to sleep in daytime or do activities not related to sleep on the bed, but to go bed when they felt fatigue at night, and get up on time. This helps construct good relationship between sleep time and bedroom, eliminating anxiety to sleep and improving quality of sleep. Drugs are not well accepted by MHD patients. Noda et al. [3] reported that only 25.8 % of MHD patients with insomnia regularly took hypnotics. In the present study, 15.3 % of patients (n = 15) took hypnotics occasionally, and many patients were willing to receive treatment free of drugs. However, early effects of mental treatment were not significant. After treatment for 2 weeks, the sleep latency was significantly prolonged, sleep duration was significantly reduced, and total scores of SCL-90 and PSQI were increased, though times of wake in night were reduced slightly. However, patients adjusted their living habits, such as sleep environment and habit, relaxation training before sleep, which sometimes made them inadapted and increased their anxiety. The sleep of some patients was also affected because of termination of drugs. Therefore, the doctors should encourage the patients during the treatment (especially at the first 2 weeks), increase communication with them, help them overcome problems, and provide mental courage and support to construct better treatment environment and improve their rehabilitation. Results from the present study showed that after treatment for 3 months, the quality of patient sleep was improved. However, they were not recovered as normal people [total scores for PSQI: (12,163 ± 2,127) vs. norm [7]. The results were not consistent with previous study on primary insomnia [9]. It is likely that the insomnia in MHD patients is secondary, and the treatment requires more time. Acknowledgment We thank the staff from Department of Medical Affairs, Hemodialysis Center, and Department of Nursing, Affiliated Hospital of Guangdong Medical College. Yongmei Hou was Supported through THE Science and Technology Development Program of Zhanjiang in 2006, No. 2006C07002.
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