Cognitive Behavioral Therapy With Acupressure Shows Promise for Insomnia

Fiona Yan-Yee Ho, PhD, MPhil

Data from a study of integrated cognitive behavioral therapy (CBT) and acupressure for the treatment of insomnia suggest that the combination approach is comparably efficacious to CBT alone in addressing symptoms of the sleep disorder.¹

Additionally, advantages appeared apparent in improving fatigue associated with insomnia and acceptability of use in this patient population. The study population (n = 40) consisted of those randomized to CBT and acupressure (CBTA; n = 14), CBT alone (n = 13), and a waitlist control group (n = 13). All told, at week 7, patients randomized to CBTA and CBT alone had significantly lower insomnia severity (d = −1.74 and d = −2.61, respectively; P <.05), dysfunctional beliefs related to sleep (d = −2.17 and d = −2.76, respectively; P <.001), and mental fatigue (d = −1.43 and d = −1.60, respectively; P <.05) compared with the WL group at Week 7.

The CBTA group provided additional benefits in reducing total fatigue (d = −1.41; P <.05) and physical fatigue (d = −1.45; P <.05). Treatment credibility was also observed to be improved in the CBTA group from baseline to week 7, based on Credibility Expectancy Questionnaire scores. No significant differences between the CBTA and CBT groups were identified in all outcome measures from baseline to week 7 and week 11 assessments (P >.05).

“In particular, significant improvements in overall fatigue and physical fatigue were only found in the CBTA group,” lead author Fiona Yan-Yee Ho, PhD, MPhil, professor, Department of Psychology, The Chinese University of Hong Kong, and colleagues wrote. “Such improvement in fatigue symptoms brought upon by CBT-insomnia with acupressure was consistent with our speculation that acupressure could address pronounced fatigue symptoms associated with CBT-insomnia. Although both treatment groups obtained significantly superior findings relative to the waitlist group, no significant difference was detected in the comparison of CBTA and CBT groups at week 7 and week 11. The findings of the current study appeared to be superior to that of existing literature regarding the effects of CBT-insomnia and acupressure separately on sleep quality.”

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A somewhat significant difference among the 3 groups was identified at week 7 in the proportion of participants who attained a clinically significant improvement in insomnia symptoms, defined as Insomnia Severity Index (ISI) score ≤8 (P <.05). Post-hoc tests revealed that only the CBTA group was significantly better than the WL in achieving this significance at week 7 (P <.05), but no significant difference was observed between the CBTA and CBT groups in the proportion of achieving clinical significance in ISI at Week 7 or Week 11 (P >.05).

Ho et al did note that despite the promising results of this pilot study, the evidence is still preliminary, and therefore future trials with larger sample sizes and longer follow-ups are needed to replicate the current data.

Participants in the CBTA group attended a 2-hour integrated CBT and self-administered acupressure group treatment once per week for 6 consecutive weeks, while participants in the CBT group attended 6 weekly, 2-hour CBT for insomnia. Sleep, mood, daytime impairments, quality of life, and treatment credibility and adherence were measured at baseline, immediately post-treatment (week 7), and 4-week post-treatment (week 11).The mean age was 37.9 years (standard deviation [SD], 13), and the majority of them were women (77.5%). The mean age of the onset of insomnia was 22.9 years (SD, 13.1), and the mean duration of insomnia was 12.3 years (SD, 11.4).

Attrition rates for the CBTA, CBT, and WL groups were 16.7% (n = 2), 38.5% (n = 5), and 38.5% (n = 5), respectively, with the majority of dropouts not responding to email and phone reminders (53.8%; n = 7), while the rest withdrew due to incompatible schedule (23.1%; n = 3) and personal reasons (15.4%; n = 2).

Notably, Ho et al suggested that this CBTA approach might be particularly relevant for the Chinese population—which this study assessed—because of societal and cultural aspects of care. “A qualitative focus group study was conducted in Hong Kong to assess the experience of chronic insomnia in the Chinese adult population. This study found that adults with insomnia held negative attitudes toward pharmacological interventions and showed a preference toward traditional Chinese medicine. A culture-specific treatment for insomnia, which takes the advantages of CBT-I and incorporates longstanding Chinese cultural beliefs and values, may be a feasible treatment approach to facilitate treatment acceptability and help-seeking behaviors,” Ho et al wrote.

Around one-third of the study participants reported having sought professional help prior to the study, mostly from Chinese medicine practitioners (12.5%; n = 5) and psychiatrists (12.5%; n = 5), though many had also visited general practitioners (7.5%; n = 7). In total, 40% (n = 16) of the study population had tried various treatments for insomnia, with the most common attempt being Chinese medication (20%; n = 8), followed by prescribed Western medications (15%; n = 6), acupuncture, hypnotics (5.0%; n = 2), acupressure or reflexology (2.5%; n = 1), and Western herbs or vitamins (2.5%; n = 1).

CBT for insomnia (CBT-I) has been evaluated frequently in recent years, mostly with success. In June, new guidelines for its use in clinical practice were presented at the American Academy of Sleep Medicine (AASM) annual meeting, SLEEP. The presentation offered recommendations that its task force of experts in sleep medicine have developed regarding the clinical practice use of behavioral and psychological treatments for chronic insomnia disorder in adults.The group assessed 6 total interventions, offering a strong recommendation for CBT-I. Ultimately, the task force offered up a recommendation for each of the 6, of which CBT-I was the only strong endorsement, with the remaining 5 being conditional.²

In light of the rapid move to telemedicine-based approaches, in September 2021, work by Derose et al assessed a population health approach to treating insomnia with internet-based CBT-I. Ultimately, they deemed it ineffective, as engagement in the program was low and did not initiate a reduction in health care visits or use of insomnia medication.The pragmatic trial had a hybrid design and enrolled a total of 136,630 individuals with insomnia (diagnosed or insomnia medication dispensation) or at high risk of insomnia (diagnosed with anxiety or depression). Participants were randomized into either the intervention arm to be treated with an ICBT-I program (n = 66,712), or the usual-care arm to attend in-person classes on insomnia (n = 66,690). Over the course of 12 months, investigators evaluated the dispense of insomnia medication and the amount of provider encounters, finding no difference between the intervention and usual care arm. A total of 638 participants (0.96%) accessed the ICBT-I program, Sleepio, within 8 weeks of outreach, whereas 505 participants (0.76%) attended 1 or more in-person Sleep Well, Live Well sessions.³

REFERENCES
1. Ho FYY, Choi WT, Yeung WF, Lam HK, Lay WY, Chung KF. The efficacy of integrated cognitive behavioral therapy (CBT) and acupressure versus CBT for insomnia: a three-arm pilot randomized controlled trial. Sleep Med. 2021;87:158-167. doi:10.1016/j.sleep.2021.08.024
2. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and Psychological Treatments for Chronic Insomnia Disorder in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Presented at SLEEP 2021 Annual Meeting; June 10-13. Abstract LBA001.
3. Derose SF, Rozema E, Chen A, Shen E, Hwang D, Manthena P. A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2021;17(8):1675–1684. doi:10.5664/jcsm.9280