Introduction
Insomnia is estimated to affect approximately 33% of adults (Gallup, 1991; Ohayon, Reference Ohayon2002) and often co-occurs with anxiety and depression (Ohayon, Caulet and Lemoine, Reference Ohayon, Caulet and Lemoine1998), with depression being the most common co-morbid problem (Buysse et al., Reference Buysse, Reynold, Kupfer, Thorpy, Bixler, Manfredi, Kales, Vgontzas, Stepanski, Roth, Hauri and Mesiano1994). The relationship between insomnia and common mental disorders has not been clear. Insomnia has been suggested as a precursor of anxiety and depression problems (Ford and Kamerow, Reference Ford and Kamerow1989). Indeed, two meta-analyses suggest that pre-existing insomnia raises the risk of first episode depressive disorder, and of recurrence by up to four-fold (Hohagen et al., Reference Hohagen, Rink, Käppler, Schramm, Riemann, Weyerer and Berger1993; Breslau, Roth, Rosenthal and Adreski, Reference Breslau, Roth, Rosenthal and Adreski1996).
CBT-I interventions have been shown to be efficacious in the longer-term, for 70–80% of patients treated (Morin et al., Reference Morin, Hauri, Espie, Spielman, Buysse and Bootzin1999, Reference Morin, Bootzin, Buysse, Edinger, Espie and Lichstein2006). CBT-I is also preferred by patients over drug treatment (Morin, Gaulier, Barry and Kowatch, Reference Morin, Gaulier, Barry and Kowatch1992; Vincent and Lionberg, Reference Vincent and Lionberg2001) and has been shown to be clinically effective in routine general practice care when delivered by non-specialists using a treatment manual (Espie, Inglis, Tessier and Harvey, Reference Espie, Inglis, Tessier and Harvey2001). In addition, CBT-I has also been offered in less intensive but effective ways. Such methods have included brief individual telephone consultations (Bastien, Morin, Ouellet, Blais and Bouchard, Reference Bastien, Morin, Ouellet, Blais and Bouchard2004) and self-help through mailed booklets (Mimeault and Morin, Reference Mimeault and Morin1999). Promising results have also been obtained from Televised Behavioural Training Programme (Oosterhuis and Klip, Reference Oosterhuis and Klip1997).
Despite its high prevalence, relatively few people with insomnia seek help from their primary care physicians. Morin, LeBlanc, Daley, Gregoire and Merette (Reference Morin, Bootzin, Buysse, Edinger, Espie and Lichstein2006) reported that, in the general population, only 13% had done so but this rate increased to 42.3% if they had diagnosable insomnia. This particularly appears to be the case for men, with women being much more likely to seek help, even when the higher prevalence rate among women is taken into account (Morlock, Tan and Mitchell, Reference Morlock, Tan and Mitchell2006). This is a finding consistent with more general patterns of help-seeking. One hypothesis suggested to explain men's reluctance to seek help is that such behaviour represents an admission of emotional vulnerability and may be in direct conflict with the Western culture of masculinity (Rochlen and Hoyer, Reference Rochlen and Hoyer2005).
One approach that has been successful in increasing access to CBT-based treatments for a range of other mental health needs is the 1-day self-referral psycho-educational workshop format (Brown, Cochrane and Cardone, Reference Brown, Cochrane and Cardone1999). Workshops using this format, each for up to 25 people, and originally developed for stress problems, have been run in community settings to reduce the possibility of stigmatization (Hayward and Bright, Reference Hayward and Bright1997). A consistent finding from this work is that approximately 40% of participants have not previously consulted their GPs about their psychological problems (Brown et al., Reference Brown, Cochrane and Cardone1999).
Our experience is that the “marketing” of such services is especially important when improving access. For example, Watkins et al. (Reference Watkins, Elliott, Stanhope, Button, Williams and Brown2000) reported that when self-referral workshops were run to target “depression”, only 10% were GP non-consulters. However, given the strong relationship between depression and self-esteem (Beck, Rush, Shaw and Emery, Reference Beck, Rush, Shaw and Emery1979), similar workshops, when given the non-diagnostic title, “How to Improve Your Self-Confidence” were found to attract a greater proportion of participants (39%) who were GP non-consulters (Brown, Elliott, Boardman, Ferns and Morrison, Reference Brown, Elliott, Boardman, Ferns and Morrison2004).
In two RCT studies, when experimental and control group participants were compared at 3-month follow-up, stress workshops were shown to lead to lower anxiety and distress scores (Brown, Cochrane and Hancox, Reference Brown, Cochrane and Hancox2000) and, similarly, self-confidence workshops were shown to lead to lower depression scores (Brown et al., Reference Brown, Elliott, Boardman, Ferns and Morrison2004).
The aim of the present study was to develop and evaluate a psycho-educational CBT-I programme, designed to be particularly acceptable to men. To reduce the possible conflict between an admission of emotional vulnerability and the Western culture of masculinity, workshops were only made available to men.
The main hypotheses were:
a) That, of those men self-referring to the CBT-I workshop, at least 40% would not have sought help previously. This is based on previous figures of GP non-consultation among workshop participants (Brown et al., Reference Brown, Elliott, Boardman, Ferns and Morrison2004).
b) That participants would find the CBT-I workshops acceptable as measured on satisfaction ratings after the workshop.
c) That CBT-I workshops would be effective in reducing symptoms of insomnia at 6-week follow-up.
Finally, given the link between insomnia and depression, we asked the research question whether this workshop approach would attract, and prove effective for, men with co-morbid depression problems.
Method
Participants
One hundred and eleven men enquired about the workshop, of whom 74 attended the baseline session (Introductory Talks). Six declined further participation, leaving 68 in the study. Sixty-two men attended the workshops and 50 (80.6%) provided follow-up data.
Design
Given its exploratory nature, a one group pretest-posttest design was used. No control groups were used because the short term funding was designed to provide a service rather than to run a study. Participants were assessed at the Introductory Talks before the workshop (Time 1) and 6 weeks after the workshop (Time 2).
Workshops were run over a 6-month period as part of a Men's Health Programme for a London Borough in England (population 244,866). The only exclusion criteria used were that men needed to be aged 18 and over and living and/or working in the borough. Otherwise, all those who enquired about the workshops were offered a place at the Introductory Talks. A screening questionnaire was used to identify men who might have a sleep disorder other than insomnia (e.g. sleep apnea); those identified were not excluded but were also advised to consult with their physician or GP.
Publicity and recruitment
Flyers were distributed widely to outlets throughout the borough, including GP surgeries, leisure centres, and libraries, using the non-diagnostic title “How to Improve Your Sleeping” Workshops, rather than the term “insomnia”. In addition, ease of access was highlighted by emphasizing the non-mental health venue for the workshops (leisure centre), as well as the opt-in system, with contact details provided for potential participants to self-refer directly, either by telephone or e-mail.
Content of workshops
The programme was derived from Morin and Espie (Reference Morin and Espie2003) and adapted into the one-day large-group format. Sessions were led by two clinical/counselling psychologists, with general expertise in CBT, and a project worker. The seven workshop sessions included Sleep basics, CBT model of insomnia, Sleep hygiene, Sleep scheduling (including Sleep restriction and Stimulus control), Sleep thoughts, Preparation for sleep, and Action planning. More general psychological problems (e.g. anxiety/depression) were not specifically addressed. Participants were expected to attend the complete workshop and use methods described as part of their homework in the gap between the workshop and follow-up. Each method was explained and discussed with participants (e.g. sleep scheduling), in as engaging a way as possible with, on average, each method taking about half an hour. To reduce possible boredom and fatigue during the workshop, various strategies were used. These included regularly varying the programme content and teaching format (e.g. small and large group exercises). Contents were simultaneously presented on brightly coloured slides (approximately 9 per session) corresponding to the contents of the 35 page manuals that were given to participants.
Assessments used
Given the community nature of this study, it was decided to use self-report measures because stringent diagnostic measures of insomnia were not practical to use with this client group.
Insomnia Severity Index (ISI; Bastien, Vallieres and Morin, Reference Bastien, Vallieres and Morin2001) is a self-rated 7-item measure of impaired sleep. Scores were categorized into no clinically significant insomnia (0–7), subthreshold insomnia (8–14), clinical insomnia, moderate severity (15–21) and clinical insomnia, severe (22–28). Good validity and reliability have been demonstrated (Smith and Wegener, Reference Smith and Wegener2003).
Dysfunctional Beliefs and Attitudes about Sleep Scale (Morin, Reference Morin1994) is a 30-item questionnaire measuring accuracy of participants' understanding of sleep. A higher score indicates a higher degree of dysfunctional thinking. Reasonable validity and reliability have been demonstrated (Morin, Vallieres and Ivers, Reference Morin, Vallieres and Ivers2007).
Sleep Diaries (Morin and Espie, Reference Morin and Espie2003) provide sleep efficiency scores. Participants were asked to keep weekly diaries on an ongoing basis. Of these, only two were used for the evaluation: those at baseline immediately after the Introductory Talk, and those in the week before the follow-up.
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock and Erbaugh, Reference Beck, Ward, Mendleson, Mock and Erbaugh1961), a 21-item measure, indicates level of depression with scores categorized into mild depression (10–18), moderate/severe depression (19–29) and extremely severe depression (30–63); scores below 10 indicate no depression. Good validity and reliability for the BDI have been shown (Beck, Steer and Carbin, Reference Beck, Steer and Carbin1988).
Demographics and Treatment-Seeking Questionnaire: Socio-demographic information and previous help-seeking were gathered.
A short satisfaction survey (Brown et al., Reference Brown, Cochrane and Cardone1999) was administered to participants at the end of the workshop day in order to assess their satisfaction, on a 3-point scale, which covered a number of aspects of the workshop programme including: helpfulness, enjoyability, clarity, materials provided, quantity of information, practicality, the venue, and the comfort of the room.
Procedure
All men who enquired were invited to attend a 1-hour Introductory Talk. This gave further information about the workshops, and offered opportunities to ask questions before inviting the men to participate in the study. If they agreed, they were asked to complete self-assessments. All workshop sessions (introductory talk, workshop, and follow-up) took place in a leisure centre and were held on Saturdays to minimize scheduling problems for those working. The workshops were held one week after the introductory talks from 9.30am to 4.30pm, with breaks for refreshments. Follow-up sessions were held 6 weeks later, with participants having an opportunity to discuss progress, complete self-assessments and have individual feedback time with workshop leaders. Five workshops were held, with an average of 11.8 men in each (range 4 to 13). The attrition rate between baseline and workshop was 13.4%.
Treatment of data
Descriptive statistics were used to summarize the sample characteristics. Since 68.5% of those who attended at baseline continued to follow-up, the missing data mechanism (McKnight, McKnight, Sidani and Figueredo, Reference McKnight, McKnight, Sidani and Figueredo2007) was studied. In order to assess if any observed variable predicted missingness, chi-square tests and independent sample t-tests were used to compare the potential predictors between drop-out and non-drop out groups for dichotomous and continuous variables respectively. The pattern of missing data was first checked. One possible assumption was that if variables were not predictive of drop-out, missingness might be Missing Completely At Random (MCAR). However, if any variable was predictive of follow-up values, the missing process would be classified as missing at random (MAR), and multiple imputation would be used to handle the missing data to provide unbiased estimates under MAR. As no variables were found to predict missingness, it was therefore assumed that missingness was completely at random (MCAR) and paired t-tests were used to compare the pre and post scores.
Results
Characteristics of participants at baseline (n = 68)
The participants were predominantly white (69%); of the remainder, 14.7% were black, leaving 16.2% drawn from other ethnic groups. Of the participants, 61.8% were employed, 17.6% were unemployed, 10.3% were retired, 7.4% were students and 2.9% had other occupations (e.g. voluntary work). The 35–44 year old group (31.7%) was the largest age group, the 45–54 year old group (21.7%) were next, followed by the 25–34 year old group (16.7%) and the 55–64 year old group (13.3%). The rest were either in the 15–24 year old group (3.3%) or in the over 65 year group (13.4%). Thirty-three (49.3%) men had never consulted their GP concerning their sleep problem. In addition, 55.9% of participants had never previously experienced counselling or psychological help. Just under half of participants (47.5%; n = 38) were taking no medication. Of those taking medication, 2.8% (n = 2) were taking sleeping tablets, 8.3% (n = 6) were taking antidepressants, 4.2% (n = 3) were taking benzodiazepines, 5.6% (n = 4) were taking medication for other mental health problems and the remainder (26.4%; n = 19) were taking medication for physical health problems.
Clinical characteristics of participants at baseline are shown in Table 1. Two-thirds (66.2%) of self-referrers scored in the clinical insomnia range on the ISI (48.5% moderate and 17.6% severe insomnia). Sleep diary data (n = 48) indicate an average Sleep Efficiency score of 75.31 (SD 15.154). Over 60% (61.6%) of participants were experiencing elevated depression symptoms (BDI over 10) and, on average, had mild depression.
Mean assessment scores at baseline and follow-up, with t-test analyses
Effectiveness of workshops (n = 50)
Insomnia. Compared to baseline, the average ISI score significantly reduced from 16.7 to 10.5 at follow-up (p = .000). The proportion of men in the clinical range for insomnia (ISI) fell from 66% to 22% at follow-up. When changes in severity categories were examined, 67.3% (n = 33) of participants showed improvement. A significant reduction in dysfunctional beliefs was also found (p = .000). Unfortunately, while sleep efficiency did increase to a mean of 84.46, only half the participants (n = 24) provided these data; the one-day workshop format meant that participants had to return their diaries by post, leading to a lower response rate compared to that obtained for other measures (73.5%).
Depression
The average BDI score significantly reduced from 13.1 to 10.0 (p = .002). The proportion of men scoring above 10 on the BDI reduced from 60% to 46% by the follow-up. When severity categories were examined, 28.6% (n = 14) showed improvement.
Satisfaction (n = 52)
Participants who completed ratings at the end of the workshop reported high satisfaction. All participants reported satisfaction with the helpfulness of the workshop leaders and the clarity of information. Ninety-six percent said they had enjoyed the workshops, and 98% were satisfied with the practicality of the advice. In addition, 94% said they had received “enough support” and 98% indicated that they could see themselves “using the advice and methods from the workshops in their own life”.
Discussion
The aim of this study was to evaluate a self-referral one day psycho-educational CBT-I programme developed for men who were experiencing insomnia. Over the 6-month period of the study, 111 men enquired and 73 formally self-referred by attending the talks. Of the latter, almost half (49.3%) had previously never sought help for their insomnia from their GPs, which is broadly consistent with findings from other studies (Morin et al., Reference Morin, LeBlanc, Daley, Gregoire and Merette2006). Notably, the CBT-I workshops successfully engaged men who were suffering from insomnia with two-thirds of participants scoring in the clinical range on the ISI at baseline. Results from the feedback survey were overwhelmingly positive. Notably, the CBT-I workshops were associated with significant reductions in insomnia and dysfunctional beliefs about sleep at 6-week follow-up. Additionally, over 60% of participants demonstrated elevated levels of depression on the BDI. Whilst less marked compared to improvements in insomnia, significant reductions in depression on the BDI were obtained, providing some support for Morawetz's (Reference Morawetz2003) finding that improvements in insomnia also led to improvements in severity of depression.
Clinical implications
Men did self-refer to CBT-I workshops, with almost half of participants never having sought help from their GP. At this stage, it is only possible to speculate on reasons for the positive recruitment rate. One possibility is that the self-referral format was congruent with men's “principles” of appropriate masculine practices (Andreason, Reference Andreason1994) as men were actively encouraged to engage in “self-treatment”, together with other men with similar problems. Consequently, conflict between entering “therapy” and the pervasive culture of masculinity (Rochen and Hoyer, Reference Rochlen and Hoyer2005) was reduced.
CBT-I workshops also attracted men with depressive problems who might otherwise not have accessed help. Since the workshops led to significant reductions in depression, it may be that a key role for the CBT-I workshops is to offer accessible treatment for insomnia as well as “signpost” men to other relevant mental health interventions as appropriate.
Limitations and future research
This was an exploratory study using a one group pretest-posttest design with no control group. Given this, other factors may explain the positive results obtained, such as the effect of time, and the expectancy of the men who self-referred. Because of the short duration of the overall programme, this was a small study with 50 participants and a short 6-week follow-up. The study was also conducted in quite a deprived area of London. Workshops were often only half-full because more workshops were run than were needed during the 6-month period.
Finally, there were no structured assessments permitting diagnostic evaluation of sleep disorders and some problems collecting sleep diary data. However, it can be argued that detailed baseline data for sleep evaluations and diagnoses cannot always be collected, especially from people who are reluctant to access traditional services. However, once the initial decision to self-refer has been made, participants may be more amenable to giving more detailed data at a later stage. An examination of the medication records showed that 19 participants were taking medication for physical health problems, and 13 for mental health problems, suggesting that these workshops attracted those with sleep problems that were secondary to physical illnesses as well as those with psychogenic sleep problems.
This study was confined to men with insomnia. It is reasonable to assume that it would be helpful to broaden this approach to include women. Given the promising results from this exploratory study, further research is needed to replicate these results with a larger sample, and a longer term follow-up in the context of an RCT.
Conclusions
This study shows that a psycho-educational CBT-I programme specially adapted for men, through easy access to men-only workshops run at leisure centres, can attract significant numbers of men who would otherwise not seek help. These workshops appeared very satisfactory and led to significant improvements in insomnia and, to a lesser extent, depression.
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