INTRODUCTION
More than 58% of patients with alcohol use disorder (AUD) have insomnia, and as the condition becomes chronic, 31~91% of patients complain of sleep problems [1]. However, interventions for patients with AUD primarily focus on abstinence programs, with insufficient attention given to the management of sleep disorders, which are a major factor in relapse [2]. Moreover, the treatment team often has little interest in their complaints of sleep disorders, and insomnia education and intervention programs are insufficient [3]. Individuals with AUD frequently self-prescribe alcohol to facilitate sleep, a behavior that is often associated with relapse in patients who use alcohol as a sleep aid post-discharge [4]. This underscores the significance of sleep interventions. This is because the relationship between insomnia treatment and drinking significantly affects the prevention and treatment of AUD.
Currently, the most commonly used sleep intervention program is Cognitive Behavioral Therapy for Insomnia (CBT-I), which has been mainly administered to patients with depression, insomnia, and post-traumatic stress disorder [5,6]. Although CBT-I has been shown to reduce sleep disorders and the tendency to rely on sleeping pills when administered to patients with alcohol-related disorders, very few studies have administered it to these patients [5]. When CBT-I was administered to individuals with AUD who were abstinent, insomnia was improved, sleep latency was reduced, dysfunctional beliefs and attitudes about sleep were changed, and the treatment effect was maintained for a long time [7]. However, CBT-I research on patients with AUD is extremely lacking, and sleep intervention provision is insufficient [6,8]. In South Korea, there is a paucity of research on CBT-I for individuals with AUD, which may be due to cautious approaches towards the target population, spatiotemporal limitations, and the perception that only experts can conduct the program [9-11]. Therefore, this study aims to apply CBT-I to hospitalized patients with AUD.
A total of 66.5% of patients with substance use disorder hospitalized for detoxification have insomnia, and 84.3% of abusers actively experience insomnia [12]. Therefore, the objective of this study was to evaluate the efficacy of CBT-I by applying it to hospitalized patients with AUD. In clinical practice, it is important to address the causal relationship between alcohol consumption and sleep, as patients who first develop sleep disorders are more likely to subsequently develop alcohol-related disorders [13].
Impulsivity has been identified as a significant predictor of alcohol control failure and a major risk factor for relapse and is closely related to the severity of insomnia [14]. Treating insomnia in patients with AUD reduces impulsivity [15], but this has rarely been studied in CBT-I for AUD [5,6]. Therefore, impulsivity will be used as a measure of CBT-I effectiveness in this study.
CBT-I was developed for insomnia and is based on cognitive behavioral therapy, which guides latent negative thoughts in a positive and rational direction [16]. CBT-I was developed to correct inappropriate thoughts and habits about sleep using cognitive therapy to target sleep-disturbing thoughts and behaviors caused by cognitive distortions. It is an integrated intervention program comprising education of sleep hygiene, stimulus control, relaxation training, and cognitive therapy [17]. In particular, CBT-I, which focuses on correcting motivation and cognitive distortions, has been confirmed to have a sustained effect on improving sleep when delivered through group therapy rather than individual therapy [5]. Thus, CBT-I is thought to be suitable for application to hospitalized patients with AUD. These patients have a strong tendency to avoid treatment using defense mechanisms such as projection, denial, and rationalization [18]. It is predicted that cognitive distortions and sleep problems can both be corrected through CBT-I.
CBT-I for AUD is a therapeutic approach that aims to educate patients on the effects of alcohol use and withdrawal symptoms on insomnia, and on the relationship between the importance of abstinence and sleep [7,12]. Epstein and McCrady's [19] CBT-I was designed for individuals with alcohol problems to reflect these factors and include motivational enhancement training to modify excessive drinking. This program has been demonstrated to be valid and effective [19]. Accordingly, the current study will be based on the existing CBT-I program and Epstein and McCrady's CBT-I.
The objective of this study was to assess the impact of CBT-I on insomnia severity, dysfunctional beliefs and attitudes, impulsiveness, and the motivation to change among hospitalized patients with AUD.
METHODS
1. Study Design
This study employed a one-group pre-posttest design to verify the effectiveness of CBT-I for hospitalized patients with AUD.
2. Hypotheses
• Hypothesis 1. Insomnia severity in the experimental group that participated in the CBT-I program will be lower than before program participation.
• Hypothesis 2. Impulsiveness in the experimental group that participated in the CBT-I program will be lower than before program participation.
• Hypothesis 3. Dysfunctional beliefs and attitudes about sleep in the experimental group that participated in the CBT-I program will improve compared to those before program participation.
• Hypothesis 4. Stage of change readiness and treatment eagerness in the experimental group that participated in the CBT-I program will improve compared to that before program participation.
3. Participants
This study included patients with AUD admitted to a psychiatric hospital. The specific selection criteria were as follows.
1) Those diagnosed with AUD by psychiatrists
2) Those who experience drinking due to sleep problems or insomnia
3) Those who have not been dually diagnosed with other mental disorders such as psychosis or anxiety disorders
4) Those who do not have withdrawal symptoms and whose symptoms are stable
5) Those who understand the purpose of this study and agree to participate
The sample size was calculated using the G-power 3.1.9 program (Heinrich Heine University, Dusseldorf, Germany). The sample size for this study was calculated to be a minimum of 16 individuals based on the Wilcoxon Signed-Rank test, with an effect size of .80, significance level of .05, and power of .90, based on previous studies evaluating the effectiveness of the CBT-I program [12]. Considering the dropout rate, 25 individuals were recruited, and five individuals dropped out during the study. Twenty individuals participated in the study, satisfying the sample size requirement.
4. Ethical Consideration
This study was conducted after receiving approval (IRB No. JBNU 2023-11-017-003) from the Institutional Review Board of Jeonbuk National University. The objective of the study was subsequently explained and program progress to the research patients, consent to participate was obtained. It was explained that the data would not be used for any purpose other than research, that participation in the study was voluntary, and that participation could be withdrawn at any time during the research period if the patients did not wish to participate.
5. Measurements
1) General characteristics
General characteristics of the subjects included age, education, marital status, time of onset, presence of physical illness, experience with sleep medication before and after hospitalization, the name of taking hypnotics, and length of stay in the hospital.
2) Insomnia severity
The insomnia severity is a self-report scale developed by Morin [20] to evaluate the severity of insomnia. In this study, we used the Korean version of the Insomnia Severity Index, which was translated and validated by Cho, Song, and Morin [21]. Each ISI item is evaluated on a scale of 0 to 4, and the total score ranges from 0 to 28, with a higher score indicating a higher severity of insomnia. In the study of Cho, Song, and Morin [21], Cronbach’s ⍺ was .92, and in this study, Cronbach’s ⍺ was .86.
3) Impulsiveness
Impulsiveness was measured using Barratt Impulsiveness Scale 11 (BIS-11) [22]. We used the Korean version of BIS-11, which was translated and validated by Lee [23]. This scale consists of 23 items and three subfactors (cognitive impulsiveness, motor impulsiveness, and unplanned impulsiveness). It is a self-report questionnaire rated on a 4-point scale: “not at all” (1 point), “sometimes” (2 points), “often” (3 points), and “always” (4 points). The total score ranges from 23 to 92 points, with higher scores indicating higher impulsiveness. In a study by Lee and Kim [15], Cronbach’s ⍺ was 0.81, and Cronbach’s ⍺ in this study was .71.
4) Dysfunctional beliefs and attitudes about sleep
Dysfunctional beliefs and attitudes about sleep were measured using the Dysfunctional Beliefs and Attitudes about Sleep Scale-16 (DBAS-16) developed by Morin et al. [24]. We used a Korean version of DBAS-16 that was translated and verified by Yu et al. [25]. DBAS-16 is a scale developed to measure misconceptions related to the causes and effects of insomnia, loss of control and predictability oversleep, unrealistic expectations about sleep needs, and attitudes toward sleeping pills. It consists of a total of 16 items, each rated on a 10-point Likert scale, where 0 indicates “not at all’ and 10 indicates “very much.” Higher scores indicate more dysfunctional beliefs and attitudes about sleep. In the study by Kim and Kim [10], Cronbach’s a was .90, and in this study, Cronbach’s ⍺ was .93.
5) Stage of change readiness and treatment eagerness
The Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES), originally developed by Miller and Tonigan [26], was adapted by Chun [27] into a Korean version (SOCRATES-K) to assess motivation for change in individuals with AUD. The scale consists of 19 items assessing three factors: awareness, practice, and ambivalence related to motivation for change. It is evaluated on a 5-point Likert scale, ranging from 1 (not at all) to 5 (very much). Higher scores indicate higher motivation for change. In Chun’s study [27], Cronbach’s ⍺ was .87, and in this study, Cronbach’s ⍺ was .86.
6. CBT-I for patients with AUD
CBT-I for patients with AUD was designed based on the theoretical framework of Epstein and McCrady [19], and Suh [28]. We then consulted with a psychiatrist working as a cognitive behavioral therapy specialist, a nursing professor who is a sleep research specialist, two nurses specializing in addiction treatment with extensive experience in program implementation in alcohol wards, and two mental health social workers.
The session design and main content were based on a CBT-I textbook and a literature review. Afterwards, six experts reviewed, revised, and supplemented the content. The Content Validity Index (CVI) of 0.8 or higher was confirmed by experts. Since it was CBT-I for AUD, the experts presented various opinions considering the average number of days of hospitalization of the patients, condition of the participating patients, and ward situation. Given the recent increase in the number of patients with AUD staying in hospital for less than three months and the abstinence programs being implemented on the ward, the experts recommended that the program be short-term. Finally, the CBT-I in this study was set to five sessions.
The main content of each session consisted of sleep diary writing, sleep hygiene, relaxation training, sleep restriction, explanations of the relationship between alcohol and sleep, cognitive therapy, and motivational counseling. Since this CBT-I is specifically for patients with AUD, motivational counseling should be conducted in the short term [28]. In addition, the educational content on the relationship between alcohol and sleep should be incorporated, the content was created based on the opinions of experts.
The content of the five CBT-I sessions conducted in this study is presented in Table 1. The program was conducted once a week, and each session lasted 70 minutes, with 10 minutes allocated for introduction, 50 minutes for activity content, and 10 minutes for conclusion. The researchers had a Level 1 mental health nurse license, completed cognitive behavioral therapy training, and had three years of experience conducting programs at a day psychiatric hospital. The program was conducted based on this experience.
The first session included program orientation, a pretest, a sleep pattern check, and the sleep diary writing method. The main contents of the sleep diary were bedtime, number of awakenings during sleep, wake-up time, and whether relaxation training and exercise were performed before sleep. The activity content included the definition of insomnia, experience of insomnia, and analysis and sharing of the external and internal causes of insomnia. Subsequently, the relationship between alcohol, sleep, and CBT-I was explained as a treatment that helps individuals sleep well without relying on sleeping pills or alcohol. Finally, they were encouraged to watch a video of abdominal breathing relaxation training and write a sleep diary as an assignment.
The second session focused on calculating sleep efficiency to teach sleep restriction and stimulus control methods. In the introduction, the sleep pattern for a week was ascertained through the sleep-diary assignment of the first session. The activity content assessed lifestyle habits, food, and environment for sleep hygiene management. Sleep efficiency was calculated based on sleep time recorded in the sleep diary. After explaining the types and chronic process of insomnia so that sleep efficiency could be over 85%, explanations were provided regarding how to take a short nap without sleeping pills or alcohol and why alcohol interferes with a short nap. The participants shared their opinions about the motivation for abstinence, the relationship with sleep, and what drinking means to life. The session ended with a review of the relaxation training and sleep diary assignment.
The third session examined sleep efficiency for one week using the sleep efficiency calculation method learned in the second session. The activity content involved cognitive therapy for dysfunctional beliefs and attitudes about sleep. Participants were asked to talk about the negative beliefs, thoughts, and attitudes that interfered with sleep. A cognitive restructuring table was provided, and they were asked to record their worries that interfered with sleep while lying in bed, including the probability and frequency of these worries actually occurring. Cognitive therapy was conducted to help the patients fall asleep by changing their distorted thoughts about sleep into realistic and rational ones. To strengthen their motivation to abstain from drinking, they shared their opinions on the aspects of sleep they found important, the goals and values they explored, and the efforts they should make to change. Finally, they reviewed the relaxation training and sleep-diary assignments.
The fourth session was the second in a series of cognitive behavioral therapy sessions focused on changing participants’ thinking about sound sleep. To achieve this, we educated patients on alternative therapies and nonpharmaceutical methods to improve sleep. Specific methods for short naps were explained for stimulus control. The participants checked their sleep hygiene, including caffeine control and regular exercise. They also corrected the idea that drinking alcohol could help them sleep well and recalled what their sleep quality was like after drinking alcohol. After exploring whether this behavior affected the relapse, if sleep restriction failed, we talked about the reasons why it was difficult. Finally, changes were confirmed through abdominal breathing for relaxation therapy and a sleep diary.
The fifth and final session included treatment summary and conclusion. The causes of insomnia identified in the 1st session were reanalyzed, and the process of change was checked. The sleep diary and sleep efficiency were reviewed and their use after discharge was encouraged. There was time to confirm the positive changes in irrational beliefs and attitudes regarding sleep and the motivation for abstinence. Positive coping methods for insomnia after discharge were confirmed, and the effects of relaxation training were discussed. Finally, the participants’ impressions were presented, the application of sleep diaries and relaxation training to life was encouraged, and a posttest was conducted.
7. Data Collection
The data collection period for this study was from May to June 2024. Approval for data collection was obtained from the head of the psychiatric hospital, and patients were recruited with the help of a ward-attending physician, mental health nurse, and mental health social worker. A total of 25 individuals were recruited, 5 of whom dropped out during the program, resulting in a final total of 20 participants.
Two of the five participants withdrew from the study chose not to continue after attending the first session. Three were discharged from the hospital during the program and were therefore unable to continue participating. Two of the five participants withdrew from the study
8. Data Analysis
Data were analyzed using IBM SPSS statistics software (version 25.0; IBM Corporation, Armonk, NY, USA) as follows.
• General characteristics of patients were analyzed using descriptive statistics including real numbers, percentages, means, and standard deviations.
• The patients’ insomnia severity, impulsiveness, dysfunctional beliefs and attitudes about sleep, and stage of change readiness and treatment eagerness before and after the intervention were analyzed using the Wilcoxon Signed-Rank test.
RESULTS
1. General Characteristics
The general characteristics of patients are presented in Table 2. All 20 patients were male, 60.0% were in their 30s and 40s, 65.0% had high school education or lower, and 60.0% were unmarried. The average length of time that the patients had been diagnosed with AUD was 16.60 years, and 75.0% had no physical illness. Fifty-five percent of the patients had taken sleeping pills before hospitalization, and 80.0% had taken sleeping pills after hospitalization. Fifteen percent of the patients knew the names of the sleeping pills they were taking, and the average length of hospitalization was 31 months.
2. Effects of CBT-I Programs
The test results for the first hypothesis—insomnia severity will decrease after the CBT-I program—are shown in Table 3. The participants’ pre-score for insomnia severity was 12.90±6.98, and the post-score was 9.30±3.57, which was statistically significant (Z=-2.06, p=.040), supporting the first hypothesis.
The test results for the second hypothesis—dysfunctional beliefs and attitudes about sleep will decrease after the CBT-I program. The participants’ pre-score for dysfunctional beliefs and attitudes about sleep was 83.60±3 5.44, and the post-score was 72.00±24.17, which was statistically significant (Z=-2.05, p=.040). Thus, the second hypothesis was supported.
The test results for the third hypothesis— impulsiveness will decrease after the CBT-I program. The participants’ pre-score for impulsiveness was 51.65±7.64, and the postscore was 49.80±6.05, the result was not statistically significant (Z=-1.07, p=.286). Consequently, the third hypothesis was rejected.
The test results for the fourth hypothesis—motivation to change will increase after the CBT-I program. The participants’ pre-score for stage of change readiness and treatment eagerness was 57.40±15.65, and the post-score was 63.50±12.48, which was statistically significant (Z=-2.05, p=.041), supporting the fourth hypothesis.
The values of Cohen's d for the variables are presented in Table 3.
DISCUSSION
This study administered CBT-I to hospitalized patients with AUD and measured its effects on insomnia severity, dysfunctional beliefs and attitudes, impulsiveness, and motivation for change.
The test result of the first hypothesis was statistically significant, thus supporting the first hypothesis. As the purpose of CBT-I is to improve insomnia, this study achieved this goal. Consistent with the findings of previous studies by Chakravorty et al. [7], Miller et al. [29] and Kang [9], this study found that the severity of insomnia in patients with AUD significantly improved. This suggests that insomnia severity can be improved through an intervention program rather than through alcohol or sleeping pills. Recently, community addiction management centers have increased nationwide in Korea, increasing the opportunities for patients with AUD to access centers in the community [30]. In the present study, some participants withdrew from the study due to discharge, even after less than three months of hospitalization. This finding serves to confirm the hypothesis that addiction treatment in Korea is centered on deinstitutionalization. The present study was conducted in a closed ward and comprised of five sessions. However, if CBT-I were to be conducted in community addiction management centers such as an open facility, the number of sessions could be increased and the dropout rate due to discharge could be reduced.
The second hypothesis was also supported. In Kang’s [9] study on participants with substance use disorder, the experimental group showed a significant effect by decreasing scores by more than 14 points after the test, supporting the results of this study. In a CBT-I study targeting nurses [10], the pre-score was 83.08, which was similar to the 83.6 in this study, but the post-score was 62.4, which was lower than the 72 in this study, indicating a better effect. CBT-I studies on patients with chronic insomnia also showed improvement in irrational beliefs about sleep [5,8]. Therefore, CBT-I is effective in correcting false thoughts about sleep in both mentally ill patients and the general population with insomnia. The DBAS-16 scale concerns loss of control and worry related to sleep, along with false expectations and attitudes about sleep. Since CBT-I was developed to correct faulty thoughts and habits about sleep, the effect of this variable is considered positive in most studies. Among the participants with substance use disorder, the control group that did not receive CBT-I showed significantly worse dysfunctional beliefs and attitudes about sleep afterwards [9]. Patients with AUD have high concerns about sleep or fear of insomnia, which can lead to a vicious cycle of alcohol consumption. However, if these incorrect attitudes and beliefs are corrected through CBT-I, it can help with abstinence. In fact, participants expressed that “unnecessary worries about sleep have decreased.” Adjusting distorted beliefs about sleep through this program will help improve insomnia and reduce resistance to treatment in patients with AUD.
Regarding the third hypothesis, the scores were lower, but not statistically significant. Impulsiveness is a representative characteristic of patients with AUD and is highly related to behavioral control disorders and sleep [14]. Based on this theoretical framework, the researchers aimed to analyze changes in impulsivity in CBT-I. As CBT-I is based on cognitive behavioral therapy that guides latent negative thoughts in a positive and rational direction, it was predicted that it would also affect the psychological variable of impulsivity control. However, this difference was not statistically significant. The measurement of the effect of CBT-I on individuals with AUD has focused on insomnia-related variables and psychological variables, such as depression or anxiety, and no study has measured impulsivity, as in this study [6,8,16]. CBT-I has been widely applied to patients with major depressive disorder and post-traumatic stress disorder [6,8]. However, this study is significant in that it is the first to incorporate impulsivity as a psychological variable for measuring CBT-I in patients with AUD. This may be due to the lack of specific interventions on impulsiveness in this study. These results suggest that, although there was time to discuss drinking and impulsivity through motivational enhancement training in this study, the time allotted was insufficient. Therefore, follow-up study that specifically include impulsivity interventions are needed.
The fourth hypothesis was supported. Unlike the present study, there was no statistically significant difference in stage of change readiness and treatment eagerness in previous studies that applied CBT-I to participants with substance-related disorders [7,9,29]. Although CBT-I does not directly reduce drinking behavior, it can affect the reduction of drinking amount if insomnia is improved [29]. Patients with AUD drink alcohol despite knowing the disadvantages, including a sense of ambivalence about change, conflicts in the family, and deterioration of health. If this way of thinking is not corrected, CBT-I will not be effective; therefore, motivational training is effective when combined with it [28]. In this study, participants discussed the negative consequences of alcohol consumption, including insomnia, family discord, and poor health during the motivational training sessions. It is hypothesized that the content of the training had a significant effect, as the participants were provided with objectives for positive change. Therefore, it is predicted that motivational training will be effective if combined with education on the relationship between sleep and alcohol consumption when administering CBT-I to patients with AUD in the future.
Four to eight CBT-I sessions are appropriate, with each session lasting appropriately 60 to 90 minutes [17,28]. The 5 sessions and 70-minute duration in this study met this theoretical framework. However, in the last session, participants felt that the program sessions were insufficient and that it was the first time they had received direct education on the relationship between sleep and alcohol. Therefore, it is thought that six to eight sessions of CBT-I would be appropriate in the future, and education on the relationship between alcohol, sleep, and motivational counseling needs to be included along with CBT. The CBT-I design proved to be significantly effective in improving the severity of insomnia, dysfunctional beliefs and attitudes about sleep, and motivation for change in participants with AUD. In addition, the fact that the participants responded that it was their first time receiving CBT-I training shows that CBT-I training is rarely applied to patients with AUD, as reported in meta-analyses of CBT-I targeting patients with mental illness [6,8].
The treatment policy for patients with AUD in Korea is to increase the proportion of treatment at day hospitals, such as day centers, and community addiction management centers from the past hospitalization-oriented policy [30]. Since hospitalization facilities are environments where drinking is prohibited, receiving CBT-I intervention while resisting actual temptations to drink after discharge may be helpful for practical treatment and prevention. Therefore, we suggest active implementation of CBT-I in addiction centers. If this program is operated in an open facility, the sleep diary will mainly focus on indicating whether alcohol was consumed and on evaluating the quality of sleep after drinking. In addition, since CBT-I has recently been developed in line with the development of information and communication technologies, such as SNS, the Internet, and mobile applications [10,11], interventions utilizing the latest devices for individuals with AUD should also be developed.
CONCLUSION
Patients with AUD tend to drink alcohol in an attempt to alleviate sleep problems or insomnia. The present study found that cognitive behavioral therapy for insomnia in patients with AUD reduced the severity of insomnia, dysfunctional beliefs, and attitudes about sleep.
This study applied CBT-I to AUD patients hospitalized in a psychiatric hospital, and there are several limitations in generalizing the results. Firstly, the study did not control exogenous variables such as placebo effects or natural recovery. Secondly, the study design exhibited limitations due to its inclusion of solely male participants and the absence of a control group. The hospital where this study was conducted had only one addiction ward, which made it difficult to establish a control group. In addition, there were no female patients admitted to the hospital. Therefore, it is recommended that follow-up studies extend their scope to encompass additional regions and institutions, while also incorporating both male and female participants.
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