Behavioural adherence in the treatments of disorders of sleep and wakefulness - a biopsychosocial approach

BF Psychology;R Medicine (General);RA0421 Public health. Hygiene. Preventive Medicine

Crawford, Megan R. ; Espie, Colin

University:University of Glasgow

Department:Institute of Neuroscience and Psychology

关键词: Sleep apnea, insomnia, adherence, continuous positive airway pressure, cognitive behavioural therapy;   

Others  :  http://theses.gla.ac.uk/4191/1/2012CrawfordPhd.pdf

来源: University of Glasgow

【 摘 要 】

Obstructive sleep apnoea (OSA) and insomnia are the two most prevalent sleepdisorders. Their respective treatments Continuous Positive Airway Pressure(CPAP) and Cognitive Behaviour Therapy for insomnia (CBT-I), are effective, butat the same time challenging. It is this challenge that may translate to pooradherence, which ultimately leads to a reduction in treatment effectiveness.The evaluation of these treatments should not fall short of understandingeffectiveness by only considering efficacy; the effort to establish whatinfluences adherence makes up a large part of that goal. The aim of this thesis isto contribute to the literature by adopting a biopsychosocial approach (BPS).That is, the consideration of biomedical, psychological and social factors andhow they interact to influence behaviour. The implications for both CPAP andCBT-I adherence literature were tested in the context of four experimentalstudies.Semi-structured interviews were conducted with 11 CPAP users, with 5individuals completing the three required interviews prior to, at 1 week and 3months after treatment initiation. The core themes emerging from a thematicanalysis were ‘internal conflict around acceptance and adherence’, ‘integrationof CPAP into life’ and ‘motivators and resources for CPAP use’. The interviewswith 11 individuals having completed a CBT-I program revealed three importantissues: ‘Making sense of CBT-I’, ‘Ongoing evaluation of components’ and‘Obstacles to implementation’. Both studies reveal potential psychological andsocial factors contributing to adherence to CPAP and CBT-I, which need to beconsidered in a BPS framework.A patient-level meta-analysis of three randomised placebo-control studiesshowed that the relationship between CPAP adherence and improvements indaytime sleepiness was caused by both physiological (high use of real CPAPreduced sleepiness more than high use of placebo and more than low use of realCPAP) and psychological effects (high use of placebo was superior to low use ofplacebo), possibly as a result of an expectation of benefit. The results supportthe importance of considering both biomedical and psychosocial factors andtheir interactive effects on adherence.The translation of the BPS approach to clinical practice will be facilitatedby the development of brief, reliable and valid measures to assess psychologicaliiiand social variables in addition to the existing biomedical tools. The Stage ofChange Scale for Insomnia (SOCSI) assessing components of the transtheoreticalmodel (stage of change, self-efficacy, decisional balance and processes ofchange), was constructed and cognitively pre-tested in 13 individuals completingCBT-I. The reliability and validity of this comprehensible scale was subsequentlyexamined in the context of a sleep restriction trial. Insomnia-related symptomsat post-treatment and follow-up, which were significantly different frombaseline in the 27 individuals with insomnia, were associated with actigraphdeterminedadherence to the agreed bed window. The SOCSI was deemed a validtool with participants in the self-identified action/maintenance stage revealingsignificantly better adherence, higher motivation and self-efficacy than those inthe contemplation and preparation stage. Test-retest reliability of the SOCSI wasexcellent and the content analysis of open-box responses revealed informationfor further validation of decisional balance and processes of change scales.This thesis provides novel information about the variables that influenceadherence to CPAP and CBT-I. It distinguishes itself from previous efforts byacknowledging the need for the adoption of a BPS framework. This approach isnecessary to successfully advancing not only the CPAP and CBT-I adherenceliterature individually, but potentially the adherence field in general.