Insomnia : treatment needs, effectiveness, and experiences

Background and aim: The sleep-wake disorder insomnia reduces daytime functioning and quality of life and increases the risk for mental and physical illness. Most people with insomnia who seek treatment do so in primary health care (PHC). Although the recommended first-line treatment is cognitive behavioral therapy for insomnia (CBT-I), the most common treatment remains hypnotics. The aims of this thesis were to investigate the need for treatment for sleep difficulties in the general population (study I), evaluate whether a nurse-led group treatment for insomnia is more effective than treatment as usual in improving insomnia in PHC (studies II and III), and to explore patients' experiences of the group treatment (study IV). Material and methods: Study I was a telephone survey investigating factors associated with self-reported need for treatment for sleep difficulties. Participants were 1115 people randomly selected from the general population of Sweden. Studies II and III were based on a randomized controlled trial (n = 165) that investigated the effects of a group treatment program for insomnia. The 10-week program (seven sessions) was based on the techniques of CBT-I and led by district nurses in routine PHC. The control condition was treatment as usual. Patient-reported outcome measures were used to assess outcomes at baseline and post- treatment. Additionally, patients who received group treatment were assessed 1 year after group treatment. In study IV, patients’ experiences of the group treatment were explored via five focus group interviews that were transcribed and analyzed with qualitative content analysis. Results: Study I showed that 12.5% of the general population reported a need for treatment for sleep difficulties. Difficulty initiating sleep was the factor most strongly related to need for treatment. Other important factors were nonrestorative sleep, mental disorders, and fatigue. Study II showed that the nurse-led group treatment for insomnia was more effective than treatment as usual in reducing insomnia severity, improving sleep, and reducing patients' use of hypnotics. Study III showed that the group treatment was more effective than treatment as usual in improving the daytime symptomatology of insomnia (fatigue, depressive symptoms, psychological distress, health-related quality of life, general daytime functioning, specific daytime symptoms, and dysfunctional beliefs). All improvements found after group treatment in studies II and III were sustained 1 year later. In study IV, the qualitative analysis revealed four themes that described patients' experiences: involvement and trust open the door for change, competence arising from deeper understanding, struggling with vulnerability and failure, and tailoring treatment to individual needs. Conclusions: Many people in the general population feel that they need treatment for sleep difficulties. An important factor behind this need is difficulty initiating sleep, followed by nonrestorative sleep, mental health problems, and fatigue. Nurse-led group treatment can effectively improve insomnia, is feasible to implement in routine PHC, and has the potential to increase patients’ access to recommended first-line treatment (CBT-I). Patients' experiences of group treatment illuminate what motivated them to change, what helped them improve, and the challenges they faced

Gender perspective on older people’s exercise preferences and motivators in the context of falls prevention: a qualitative study

Background: Several factors have previously been identified to positively influence the uptake and adherence for fall prevention exercise programmes. There is, however, a lack of studies investigating if men and women differ in their views and preferences for fall prevention exercises. Aim: To explore exercise preferences and motivators of older community-dwelling women and men in the context of falls prevention from a gender perspective. Methods: Workshops including multistage focus group discussions were conducted with 18 older community-dwelling people with and without history of falls. Participants were purposively selected and divided into two groups. Each group met on six occasions over a period of five months. Participatory and Appreciative Action and Reflection methodology was used to guide the discussions. A qualitative content analysis approach was used in the analysis. Results: Older participants had many diverse preferences and confirmed that individually tailored exercise, in terms of mode, intensity, challenge, and social context, is important. Moreover, important factors for exercise adherence and maintenance included the experience of individual confirmation; different spirit lifters to increase enjoyment; and personal tricks to maintain exercise routines. The individual differences within genders were more diverse than the differences between women and men. Conclusion: Exercise interventions to prevent falls should be individually tailored, based on the specific needs and preferences of the older participant, and do not appear to require gender specific approaches. To increase adherence, intrinsic motivation for exercise may be encouraged by competence enhancing confirmations, energizing spirit lifters, and practical tips for exercise maintenance. The study provides an awareness about women's and men's preferences for fall prevention exercises, and this information could be used as guidance in designing inclusive exercise interventions

The Performance Appraisal Interview – An Arena for the Reinforcement of Norms for Employeeship

In the present paper, we report findings from a study of performance appraisal interviews between middle managers and employees. The study is based on analysis of video uptake of authentic performance appraisal interviews, and through detailed examination of participant conduct and orientation, we point to structural mechanisms and institutional norms which limit the possibilities for employees to raise topics connected to negative experiences of stress in performance ap- praisal talk. It is argued that norms concerning ideal employeeship are shaped by a partly hidden curriculum in the organization which in turn is talked into being in the performance appraisal interviews.The study concludes that empirical attention to the social interplay in performance ap- praisal interactions reveal how participant conduct aligns or disaligns with institutional and social underpinnings of workplace ideals

Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review

Background: To offer fall prevention exercise programs that attract older people of both sexes there is a need to understand both womens and mens views and preferences regarding these programs. This paper aims to systematically review the literature to explore any underlying gender perspectives or gender interpretations on older peoples views or preferences regarding uptake and adherence to exercise to prevent falls. Methods: A review of the literature was carried out using a convergent qualitative design based on systematic searches of seven electronic databases (PubMed, CINAHL, Amed, PsycINFO, Scopus, PEDro, and OTseeker). Two investigators identified eligible studies. Each included article was read by at least two authors independently to extract data into tables. Views and preferences reported were coded and summarized in themes of facilitators and barriers using a thematic analysis approach. Results: Nine hundred and nine unique studies were identified. Twenty five studies met the criteria for inclusion. Only five of these contained a gender analysis of mens and womens views on fall prevention exercises. The results suggests that both women and men see women as more receptive to and in more need of fall prevention messages. The synthesis from all 25 studies identified six themes illustrating facilitators and six themes describing barriers for older people either starting or adhering to fall prevention exercise. The facilitators were: support from professionals or family; social interaction; perceived benefits; a supportive exercise context; feelings of commitment; and having fun. Barriers were: practical issues; concerns about exercise; unawareness; reduced health status; lack of support; and lack of interest. Considerably more women than men were included in the studies. Conclusion: Although there is plenty of information on the facilitators and barriers to falls prevention exercise in older people, there is a distinct lack of studies investigating differences or similarities in older womens and mens views regarding fall prevention exercise. In order to ensure that fall prevention exercise is appealing to both sexes and that the inclusion of both men and women are encouraged, more research is needed to find out whether gender differences exists and whether practitioners need to offer a range of opportunities and support strategies to attract both women and men to falls prevention exercise.Funding Agencies|Swedish Research Council [2015-03481]; Strategic Research Programme in Care Sciences, Umea University; Karolinska Institute, Sweden; Umea University</p

A European research agenda for somatic symptom disorders, bodily distress disorders, and functional disorders: Results of an estimate-talk-estimate delphi expert study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe

Characteristics of Patients with Subjective Sleep Problems after Cognitive Behavioral Therapy for Insomnia : Secondary Analyses of a Randomized Controlled Trial

Objective: Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia, but half of the patients do not reach remission. This study aimed to explore subjective remission by investigating the characteristics of patients who reported lingering sleep problems after CBT-I. Methods: Secondary analyses of a randomized controlled trial of group CBT-I in 72 primary care patients with insomnia disorder. Sociodemographic characteristics and outcomes (insomnia severity, sleep variables, hypnotics use, fatigue, depressive symptoms, and dysfunctional beliefs/attitudes), including baseline data and symptom change, were investigated in relation to patients' posttreatment response to the yes-or-no question “Would you say that you have sleep problems?” Results: A total of 56.9% of patients reported sleep problems after CBT-I. At baseline, they had worse depressive symptoms (14.9 (SD 7.5) vs. 10.2 (SD 5.9), p = 0.006) and more awakenings (2.6 (SD 1.5) vs. 1.8 (SD 1.3), p = 0.034) than those in subjective remission from sleep problems. Patients in the non-remission and remission groups showed similar improvements in sleep, fatigue, and depressive symptoms, but patients in the non-remission group had improved less in insomnia severity, dysfunctional beliefs/attitudes about sleep, and hypnotic use. In patients with more pronounced depressive symptoms before CBT-I, change in depressive symptoms during treatment partially explained subjective remission from sleep problems. Discussion: More severe depressive symptoms prior to CBT-I and less improvements in depressive symptoms during treatment predicted remaining subjective sleep problems after treatment. These findings highlight the importance of assessing depressive symptoms in primary care patients with insomnia, as patients with pronounced depressive symptoms may need tailored treatment

Patients’ experiences of motivation, change, and challenges in group treatment for insomnia in primary care: a focus group study

Abstract Background The majority of patients who seek help for insomnia do so in primary health care. Nurse-led group treatment in primary care based on cognitive behavioral therapy for insomnia (CBT-I) can lead to improvements in both day- and nighttime symptoms. This study aimed to explore patients’ experiences of nurse-led group treatment for insomnia in primary health care. Methods Seventeen patients who had participated in the group treatment program were interviewed in five focus groups. Interview transcriptions were analyzed with qualitative content analysis. Results Four themes emerged that described patients’ experiences of the group treatment program. Involvement and trust open the door for change: Motivation to engage in treatment arose from patients’ own desire for change, from being together with others who shared or understood their struggles, and from feeling emotionally affirmed and trustful. Competence arising from deeper understanding: Patients obtained knowledge and made it their own, which enabled them to develop functional sleep habits and let go of sleep performance and worry. The ability to impact their insomnia increased patients’ trust in their own efficacy and helped them persist in behavioral change. Struggling with vulnerability and failure: Treatment was tough, and patients could feel challenged by external circumstances. Moreover, they could distrust their own efficacy. Tailoring treatment to individual needs: Patients experienced different life circumstances and adapted the techniques to their needs and abilities by focusing on what felt right for them. Conclusions Patients went through a process of motivation, change, and challenges. They experienced certain aspects of treatment as essential to changing behavior and achieving improvements. Examples included being in a group with others who shared similar experiences, gaining knowledge about sleep, keeping a sleep diary, and practicing the sleep restriction technique. The study provides insights into patients’ struggles during treatment, both those related to external circumstances and those related to feelings of vulnerability and failure. It also highlights the importance of adapting treatment to patients’ differing needs, underscoring the value of person-centered care

Diskursiv och könad normering kring stress i ett föränderligt arbetsliv

Artikeln problematiserar diskursiva konstruktioner av stress i dagens arbetsliv ur ett genusperspektiv. Genom analys av intervjuer och inspelade medarbetarsamtal i tre organisationer argumenterar författarna för att normalisering av stress villkoras av nyliberala principer om valfrihet och individuella lösningar. I den nyliberala stressdiskursen frånskrivs arbetsgivare ansvar för stressproblematik, och en normalisering av stress riskerar därmed att dölja strukturer som blir diskriminerande och långsiktigt ohållbara för hälsa i arbetslivet