失眠認知行為自助方案對輪班員工的睡眠品質提升效果研究
Author(s):
Tai-Wei Wu (Department of In-service Master Program of Psychological Consulation in Psychology, Asia University)
Pei-Yu Wu (MA Program of Counseling and Guidance College of Education, National Chengchi University)
Abstract:
RESEARCH MOTIVATION AND PURPOSE
Prevalence of Shift Work and Associated Insomnia:
‧ Shift work is common in modern workplaces, where non-traditional hours disrupt the natural circadian rhythm.
‧ This disruption often leads to chronic sleep disturbances, significantly affecting both the health and work performance of employees.
‧ Insomnia among shift workers has become a critical issue, prompting the need
Limitations of Conventional Treatments:
‧ Most existing insomnia treatments rely on pharmacological approaches. Although medications can offer quick relief, they come with drawbacks such as side effects, dependency risks, and withdrawal issues.
‧ Long-term medication use is not ideal because of these adverse effects, making non-drug alternatives more appealing.
THE OBJECTIVES
‧ The study aimed to assess whether a self-help Cognitive Behavioral Therapy for Insomnia (CBT-I) program could effectively improve sleep quality among shift workers.
‧ By delivering the intervention in an online, self-guided format, the study intended to provide a low-cost, easily accessible alternative that could reduce reliance on medications.
‧ The program was also designed to incorporate real-time feedback and selfmonitoring through sleep diaries, which might enhance adherence and personalize recommendations.
LITERATURE REVIEW
Impact of Shift Work on Sleep:
‧ Shift workers often experience disrupted sleep patterns, including prolonged sleep onset, fragmented sleep, and lower sleep quality.
‧ Research from various regions (e.g., Taiwan, China, and Europe) shows that a substantial portion of the workforce engages in shift work, making insomnia a widespread issue.
‧ Poor sleep quality is linked to higher risks of chronic conditions such as hypertension, mental health issues, and metabolic disorders.
Comparison of Pharmacological and Non-Pharmacological Approaches:
Pharmacotherapy:
‧ Medications like benzodiazepines and non-benzodiazepines are commonly prescribed; however, their use is limited by potential side effects, dependency, and guidelines that restrict long-term usage.
‧ Clinical recommendations suggest short-term use of hypnotics, usually no longer than 4 to 5 weeks.
Cognitive Behavioral Therapy for Insomnia (CBT-I):
‧ CBT-I is well-supported by evidence as an effective treatment for insomnia, capable of providing sustained improvements in sleep quality without the risks associated with medications.
‧ Traditional CBT-I involves stimulus control, sleep restriction, relaxation training, cognitive restructuring, and sleep hygiene education.
‧ Its effectiveness is further enhanced when tailored to address the specific sleep disturbances associated with shift work.
Rationale for a Self-Help Format:
‧ The shortage of trained professionals makes it challenging to deliver traditional CBT-I to all who need it, particularly in regions with limited mental health resources.
‧ Self-help CBT-I programs, like the “Refresh” module developed at Stanford, offer a practical solution. They provide structured materials covering key topics such as sleep stages, biological clocks, sleep restrictions, and cognitive strategies.
‧ Integrating automated feedback mechanisms and daily sleep diaries into the program allows for personalized guidance, potentially improving adherence and treatment outcomes.
RESEARCH METHODS
Study Design and Participant Recruitment:
‧ A crossover experimental design (ABBA sequence) was employed to control for individual differences.
‧ Participants were recruited from a large factory in Shanghai operating a twoshift system (day and night shifts).
‧ Out of 125 initial recruits, 85 shift workers met the inclusion criteria (e.g., significant sleep onset delays and high scores on either the Insomnia Severity Index [ISI] or the Pittsburgh Sleep Quality Index [PSQI]).
‧ Exclusion criteria eliminated individuals with long-term medication use, substance abuse, significant medical conditions, or major psychiatric disorders.
Intervention Details:
‧ The eight-week intervention consisted of online self-help CBT-I modules (using the “Refresh” materials) covering:
➤ Education on sleep stages, the biological clock, and sleep regulation.
➤ Techniques include sleep restriction, stimulus control, relaxation training, mindfulness, and cognitive restructuring.
➤ Strategies for preventing relapse.
‧ Participants maintained a daily online sleep diary documenting sleep timings, latency, total sleep time, and perceived sleep quality.
‧ An automated feedback system provided rule-based recommendations (e.g., adjusting nap length or sleep times) based on diary inputs.
‧ The crossover design allowed one group to receive the intervention first while the other acted as a waiting-list control, and then switched roles.
MEASUREMENT INSTRUMENTS
‧ Insomnia Severity Index (ISI): Measures the intensity of insomnia symptoms and their impact.
‧ Pittsburgh Sleep Quality Index (PSQI): Assesses overall sleep quality, including subjective quality, sleep latency, and daytime dysfunction.
‧ Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16): Evaluates maladaptive beliefs regarding sleep.
‧ General Self-Efficacy Scale (GSES): Gauges confidence in managing tasks and adhering to behavioral changes.
RESEARCH RESULTS
Overall Improvements:
‧ Significant improvements were observed in the intervention group on the ISI, PSQI, and DBAS-16 total scores.
‧ Key sleep parameters such as sleep onset latency, efficiency, and overall sleep duration improved markedly.
‧ Enhanced daytime functioning was also reported, reflecting better overall sleep quality.
Subscale Findings:
‧ Many subscales (e.g., subjective sleep quality, sleep duration) showed significant positive changes.
‧ However, subscales related to sleep medication use and medication-related beliefs did not change significantly—likely due to the exclusion of long-term medication users from the study.
Maintenance of Effects:
‧ Follow-up assessments at eight weeks post-intervention indicated that the improvements were maintained over time.
‧ The sustained benefits suggest that self-help CBT-I can offer durable improvements in sleep quality.
Dropout Analysis:
‧ Out of 85 participants, 63 completed the study while 21 dropped out.
‧ No significant differences were found between completers and dropouts in baseline sleep measures, although higher self-efficacy was linked with program completion.
‧ Common dropout reasons included the program’s perceived complexity and time demands rather than a lack of effectiveness.
DISCUSSION AND RECOMMENDATIONS
Efficacy and Advantages:
‧ The study demonstrates that self-help CBT-I can significantly improve sleep quality among shift workers, reducing insomnia severity and correcting dysfunctional sleep beliefs.
‧ Its online delivery makes the program accessible, cost-effective, and adaptable to the irregular schedules of shift workers.
‧ The use of automated feedback and sleep diaries aids in personalizing treatment and enhancing participant engagement.
Challenges and Future Directions:
‧ Adherence: High dropout rates indicate that simplifying initial modules and incorporating motivational supports may help improve adherence.
‧ Customization: Future programs could benefit from tailoring content to individual needs and addressing specific beliefs about sleep medication.
‧ Extended Follow-Up: Longer follow-up periods are recommended to assess the durability of treatment effects.
‧ Broader Application: Testing the intervention across different industries and regions could confirm its generalizability and identify potential limitations.
Concluding Remarks:
‧ The study demonstrates that a self-help CBT-I program is a promising, cost effective, and sustainable intervention for improving sleep quality among shift workers.
‧ With refinements to address adherence challenges and further customization of content, such programs have the potential for broader implementation in diverse work settings.
‧ Ultimately, this approach emphasizes the value of non-pharmacological treatments in managing chronic sleep disturbances associated with modern work patterns.
Keywords:
cognitive behavioral therapy for insomnia, crossover experimental design, sleep quality, shift workers
