Sleep Medicine 15 (2014) 161–162
Contents lists available at ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Editorial
One size does not fit all: matching patients with insomnia treatment modality
The article by Holmqvist et al. [1] in 2014 of Sleep Medicine provides provocative data to suggest that tailoring treatment modality based on patient characteristics may improve treatment outcomes in insomnia. In this randomized-controlled trial, the authors compared two versions of cognitive behavioral therapy for insomnia (CBT-I) that were essentially identical in content but considerably varied in format (e.g., telehealth-based vs webbased delivery). Contrary to the study hypotheses, participants in both interventions demonstrated significant improvements in insomnia symptoms and significant reductions in sedative and hypnotic use. In addition, participants in both groups reported satisfaction with treatment and satisfaction did not differ between groups. However, adherence to treatment components differed between groups, with patients in the web-based delivery group demonstrating greater adherence to sleep restriction, stimulus control, and cognitive therapy, compared to patients in the telehealthbased delivery group. The authors concluded that both treatment approaches were effective and that ‘‘an optimal approach would allow consumers to choose the format that is most appropriate for them.’’ This conclusion raises an important question: what treatment is most appropriate for a particular patient? In other words, is it possible to assign patients to treatment approaches based on specific characteristics to maximize adherence and treatment outcomes? A patient-by-treatment interactive model or treatment-matching approach [2] has been used to predict adherence and treatment outcomes in other areas of behavioral medicine. This approach posits that a match between patient characteristics and treatment modality is a robust predictor of patient outcomes. In particular, the importance of a match between patient and treatment characteristics in the domain of control over treatment has been repeatedly demonstrated. Early work in this area compared patients receiving hemodialysis at a center with patients receiving hemodialysis at home (common among patients in rural communities for whom travel to a dialysis center is prohibitive). Although these treatments are physiologically identical, the level of patient selfmanagement and control over care is considerably higher for hemodialysis at home; patients generally have little to no control in hemodialysis at a center. Those patients who endorsed a high preference for shared decision making and involvement in healthcare demonstrated significantly better adherence in the home condition compared to center condition [3,4]. Similar results have been shown in patients with diabetes mellitus; adherence and satisfaction with treatment are higher when patients and their physicians report similar beliefs about patient-centered care [5]. Notably, the objective degree of match or similarity may be less 1389-9457/$ - see front matter Ó 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.sleep.2013.12.002
important than the subjective degree of match. Among a sample of patients who were all receiving hemodialysis at a center, those who preferred a high level of control and had a perception of high control despite low level of objective control over treatment demonstrated better adherence to treatment compared to those who preferred a high level of control but perceived a low level of control. Similarly, hemoglobin A1c values were lower among patients who preferred patient-centered care and felt that their physicians engaged in information sharing (e.g., recommending Web sites, providing pamphlets) compared to patients who that felt their providers did not share information [6]. Patient perception of control is similarly important in insomnia. Previous work by Vincent et al. [7] demonstrated that beliefs about control and treatment preferences impact satisfaction with treatment, adherence with treatment, and treatment outcomes. Internal locus of control for sleep mediates the relationship between treatment and improvement in insomnia symptoms, such that patients who developed more internal locus of control during treatment reported less severe symptoms of insomnia at follow-up [7]. Greater perceived control over sleep is predictive of better next-day sleep quality [8]. More positive beliefs about treatment usefulness are associated with increased treatment satisfaction and improvements in insomnia symptoms [9]. Beliefs about sleep, especially control over sleep, also are associated with poorer adherence to CBT-I [10]. One explanation for these findings may be that patients may perceive limited control over specific treatment components (e.g., need for strict maintenance of wake time even on weekends). It has been hypothesized [11] that patients may respond to perceived loss of control with nonadherence in accordance to reactance theory [12]. Reactance theory posits that when an individual perceives that behavioral freedom is lost, the individual engages in that behavior more strongly to reassert behavioral control. Furthermore, individuals with certain characteristics such as Type A personality may be more sensitive to this loss of control and more likely to engage in reactance [13]. In other words, a mismatch between patient characteristics such as personality type or health beliefs and treatment characteristics leads to poorer adherence. Although Holmqvist et al. [1] did not find significant differences in insomnia outcomes between patients participating in webbased vs telehealth-based CBT-I, the compelling nature of the results lies in the significant differences in adherence between the two groups, and these differences may be explained by a patientby-treatment matching model. While the authors note that these differences were not due to differences between groups in demographic variables, such as gender, educational background, and
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Editorial / Sleep Medicine 15 (2014) 161–162
medical comorbidities, it is possible that groups differed in unmeasured characteristics such as beliefs about control over health and preferences for patient involvement in healthcare. Perhaps for some patients, the self-directed nature of the web-based delivery was a better match with their desire to self-manage their health. Alternatively, perhaps the more structured nature of the telehealth-based delivery was inconsistent with a desire to have individual control over one’s treatment. This article lays important groundwork for future research in the application of a patientby-treatment matching model in the treatment of insomnia. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.12.002. References [1] Holmqvist M, Vincent N, Walsh K. Web-based vs telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Med 2014;15:187–95. [2] Christensen AJ. Patient-by-treatment context interaction in chronic disease: a conceptual framework for the study of patient adherence. Psychosom Med 2000;62:435–43. [3] Christensen AJ, Smith TW, Turner CW, Cundick KE. Patient adherence and adjustment in renal dialysis: a person treatment interactive approach. J Behav Med 1994;17:549–66. [4] Christensen AJ, Smith TW, Turner CW, et al. Type of hemodialysis and preference for behavioral involvement: interactive effects on adherence in end-stage renal disease. Health Psychol 1990;9:225–36.
[5] Cvengros JA, Christensen AJ, Hillis SL, et al. Patient and physician attitudes in the health care context: attitudinal symmetry predicts patient satisfaction and adherence. Ann Behav Med 2007;33:262–8. [6] Cvengros JA, Christensen AJ, Cunningham C, et al. Patient preference for and reports of provider behavior: impact of symmetry on patient outcomes. Health Psychol 2009;28:660–7. [7] Vincent N, Walsh K, Lewycky S. Sleep locus of control and computerized cognitive-behavioral therapy (cCBT). Behav Res Ther 2010;48:779–83. [8] Vincent N, Walsh K, Chiang D. Control and coping in chronic insomnia: a daily diary study. Behav Res Ther 2013;51:240–6. [9] Vincent N, Lionberg C. Treatment preference and patient satisfaction in chronic insomnia. Sleep 2001;24:411–7. [10] Cvengros JA, Crawford M, Manber R. The relationship between beliefs about sleep and adherence to behavioral treatment combined with meditation for insomnia. Behav Sleep Med 2014. in press. [11] Cvengros JA, Christensen AJ, Lawton WJ. The role of perceived control and preference for control in adherence to a chronic medical regimen. Ann Behav Med 2004;27:155–61. [12] Brehm JW. A theory of psychological reactance. New York, NY: Academic Press; 1966. [13] Rhodewalt F, Fairfield M. An alternative approach to type A behavior and health: Psychological reactance and medical noncompliance. J Soc Behav Person 1990;5:323–42.
⇑
Jamie A. Cvengros Rush Sleep Disorders Service & Research Center, 1653 West Congress Parkway, Chicago, IL 60612, United States ⇑ Tel.: +1 3129425440. E-mail address: [email protected] Available online 30 December 2013
Contents lists available at ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Editorial
One size does not fit all: matching patients with insomnia treatment modality
The article by Holmqvist et al. [1] in 2014 of Sleep Medicine provides provocative data to suggest that tailoring treatment modality based on patient characteristics may improve treatment outcomes in insomnia. In this randomized-controlled trial, the authors compared two versions of cognitive behavioral therapy for insomnia (CBT-I) that were essentially identical in content but considerably varied in format (e.g., telehealth-based vs webbased delivery). Contrary to the study hypotheses, participants in both interventions demonstrated significant improvements in insomnia symptoms and significant reductions in sedative and hypnotic use. In addition, participants in both groups reported satisfaction with treatment and satisfaction did not differ between groups. However, adherence to treatment components differed between groups, with patients in the web-based delivery group demonstrating greater adherence to sleep restriction, stimulus control, and cognitive therapy, compared to patients in the telehealthbased delivery group. The authors concluded that both treatment approaches were effective and that ‘‘an optimal approach would allow consumers to choose the format that is most appropriate for them.’’ This conclusion raises an important question: what treatment is most appropriate for a particular patient? In other words, is it possible to assign patients to treatment approaches based on specific characteristics to maximize adherence and treatment outcomes? A patient-by-treatment interactive model or treatment-matching approach [2] has been used to predict adherence and treatment outcomes in other areas of behavioral medicine. This approach posits that a match between patient characteristics and treatment modality is a robust predictor of patient outcomes. In particular, the importance of a match between patient and treatment characteristics in the domain of control over treatment has been repeatedly demonstrated. Early work in this area compared patients receiving hemodialysis at a center with patients receiving hemodialysis at home (common among patients in rural communities for whom travel to a dialysis center is prohibitive). Although these treatments are physiologically identical, the level of patient selfmanagement and control over care is considerably higher for hemodialysis at home; patients generally have little to no control in hemodialysis at a center. Those patients who endorsed a high preference for shared decision making and involvement in healthcare demonstrated significantly better adherence in the home condition compared to center condition [3,4]. Similar results have been shown in patients with diabetes mellitus; adherence and satisfaction with treatment are higher when patients and their physicians report similar beliefs about patient-centered care [5]. Notably, the objective degree of match or similarity may be less 1389-9457/$ - see front matter Ó 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.sleep.2013.12.002
important than the subjective degree of match. Among a sample of patients who were all receiving hemodialysis at a center, those who preferred a high level of control and had a perception of high control despite low level of objective control over treatment demonstrated better adherence to treatment compared to those who preferred a high level of control but perceived a low level of control. Similarly, hemoglobin A1c values were lower among patients who preferred patient-centered care and felt that their physicians engaged in information sharing (e.g., recommending Web sites, providing pamphlets) compared to patients who that felt their providers did not share information [6]. Patient perception of control is similarly important in insomnia. Previous work by Vincent et al. [7] demonstrated that beliefs about control and treatment preferences impact satisfaction with treatment, adherence with treatment, and treatment outcomes. Internal locus of control for sleep mediates the relationship between treatment and improvement in insomnia symptoms, such that patients who developed more internal locus of control during treatment reported less severe symptoms of insomnia at follow-up [7]. Greater perceived control over sleep is predictive of better next-day sleep quality [8]. More positive beliefs about treatment usefulness are associated with increased treatment satisfaction and improvements in insomnia symptoms [9]. Beliefs about sleep, especially control over sleep, also are associated with poorer adherence to CBT-I [10]. One explanation for these findings may be that patients may perceive limited control over specific treatment components (e.g., need for strict maintenance of wake time even on weekends). It has been hypothesized [11] that patients may respond to perceived loss of control with nonadherence in accordance to reactance theory [12]. Reactance theory posits that when an individual perceives that behavioral freedom is lost, the individual engages in that behavior more strongly to reassert behavioral control. Furthermore, individuals with certain characteristics such as Type A personality may be more sensitive to this loss of control and more likely to engage in reactance [13]. In other words, a mismatch between patient characteristics such as personality type or health beliefs and treatment characteristics leads to poorer adherence. Although Holmqvist et al. [1] did not find significant differences in insomnia outcomes between patients participating in webbased vs telehealth-based CBT-I, the compelling nature of the results lies in the significant differences in adherence between the two groups, and these differences may be explained by a patientby-treatment matching model. While the authors note that these differences were not due to differences between groups in demographic variables, such as gender, educational background, and
162
Editorial / Sleep Medicine 15 (2014) 161–162
medical comorbidities, it is possible that groups differed in unmeasured characteristics such as beliefs about control over health and preferences for patient involvement in healthcare. Perhaps for some patients, the self-directed nature of the web-based delivery was a better match with their desire to self-manage their health. Alternatively, perhaps the more structured nature of the telehealth-based delivery was inconsistent with a desire to have individual control over one’s treatment. This article lays important groundwork for future research in the application of a patientby-treatment matching model in the treatment of insomnia. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.12.002. References [1] Holmqvist M, Vincent N, Walsh K. Web-based vs telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Med 2014;15:187–95. [2] Christensen AJ. Patient-by-treatment context interaction in chronic disease: a conceptual framework for the study of patient adherence. Psychosom Med 2000;62:435–43. [3] Christensen AJ, Smith TW, Turner CW, Cundick KE. Patient adherence and adjustment in renal dialysis: a person treatment interactive approach. J Behav Med 1994;17:549–66. [4] Christensen AJ, Smith TW, Turner CW, et al. Type of hemodialysis and preference for behavioral involvement: interactive effects on adherence in end-stage renal disease. Health Psychol 1990;9:225–36.
[5] Cvengros JA, Christensen AJ, Hillis SL, et al. Patient and physician attitudes in the health care context: attitudinal symmetry predicts patient satisfaction and adherence. Ann Behav Med 2007;33:262–8. [6] Cvengros JA, Christensen AJ, Cunningham C, et al. Patient preference for and reports of provider behavior: impact of symmetry on patient outcomes. Health Psychol 2009;28:660–7. [7] Vincent N, Walsh K, Lewycky S. Sleep locus of control and computerized cognitive-behavioral therapy (cCBT). Behav Res Ther 2010;48:779–83. [8] Vincent N, Walsh K, Chiang D. Control and coping in chronic insomnia: a daily diary study. Behav Res Ther 2013;51:240–6. [9] Vincent N, Lionberg C. Treatment preference and patient satisfaction in chronic insomnia. Sleep 2001;24:411–7. [10] Cvengros JA, Crawford M, Manber R. The relationship between beliefs about sleep and adherence to behavioral treatment combined with meditation for insomnia. Behav Sleep Med 2014. in press. [11] Cvengros JA, Christensen AJ, Lawton WJ. The role of perceived control and preference for control in adherence to a chronic medical regimen. Ann Behav Med 2004;27:155–61. [12] Brehm JW. A theory of psychological reactance. New York, NY: Academic Press; 1966. [13] Rhodewalt F, Fairfield M. An alternative approach to type A behavior and health: Psychological reactance and medical noncompliance. J Soc Behav Person 1990;5:323–42.
⇑
Jamie A. Cvengros Rush Sleep Disorders Service & Research Center, 1653 West Congress Parkway, Chicago, IL 60612, United States ⇑ Tel.: +1 3129425440. E-mail address: [email protected] Available online 30 December 2013
