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Couples' Treatment Preferences for Insomnia Experienced During Pregnancy.

Insomnia symptoms and poor sleep quality are common among pregnant women (Mindell, Cook, & Nikolovski, 2015; Sedov, Cameron, Madigan, & Tomfohr-Madsen, 2018). Trajectory analyses show that the majority of pregnant women report declines in sleep quality during pregnancy and that these persisted up to six months postpartum (Tomfohr, Buliga, Letourneau, Campbell, & Giesbrecht, 2015). Addressing sleep problems of pregnant women is important as symptoms of insomnia and poor sleep quality have been associated with a number of adverse maternal and obstetric outcomes (Okun, Schetter, & Glynn, 2011; Sk-outeris, Germano, Wertheim, Paxton, & Milgrom, 2008; Tomfohr et al., 2015).

Treatment of Insomnia

The American Academy of Sleep Medicine has endorsed cognitive--behavioral therapy for insomnia (CBT-I) as the first line treatment for this disorder (Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008). Pharmacotherapies are often used as an effective short-term treatment of insomnia in the general population (Asnis, Thomas, & Henderson, 2015); however, their safety profile in pregnancy is unclear (Okun, Ebert, & Saini, 2015). In addition, CBT-I is associated with longer term maintenance of gains than medications (Okajima, Komada, & Inoue, 2011). Similar to pharmacotherapy, little is known about the effectiveness of CBT-I for pregnant women. This lack of investigations is important as sleep disturbances during pregnancy are often driven by biological changes such as reduced bladder capacity, aches and pains, as well as feeling too hot/too cold (Min-dell & Jacobson, 2000). As such, investigating whether CBT-I is efficacious in a pregnant population is important. Results from one small open trial provided promising support for CBT-I being efficacious in reducing symptoms of insomnia in pregnant women (Tomfohr-Madsen, Clayborne, Rouleau, & Campbell, 2017); however, larger trials with a control group are required.

Treatment Preferences During Pregnancy

Treatment preferences are an important component of evidence-based practice (Spring, 2007). For example, delivery of preferred treatments for various problems, including mood and sleep disorders, has been shown to improve adherence and outcomes (Lin et al., 2005; Vincent & Lionberg, 2001). Pregnant women's preferences for treatment of depression and anxiety have been well studied, with results showing a strong preference for psychotherapy over pharmacotherapy (Dimidjian & Goodman, 2014; Goodman, Dimidjian, & Williams, 2013; Sedov, Goodman, & Tomfohr-Madsen, 2017). One study of insomnia treatment preferences during pregnancy found that pregnant women preferred nonpharmacological treatments to pharmacotherapy for treating insomnia (Sedov et al., 2017). In the current investigation, we address one limitation of the previous study, which was that participants had not been provided the option to select no treatment or other treatment, which may constrain the validity of the choice.

Surprisingly little attention has been paid to demographic and clinical correlates of pregnant women's treatment preferences. Results of investigations of treatment preferences of nonpregnant samples and for conditions other than insomnia indicate that depressive symptoms (Dwight-Johnson, Sherbourne, Liao, & Wells, 2000; Goodman, 2009), ethnicity (Dwight Johnson, Apesoa-Varano, Hay, Unutzer, & Hinton, 2013; Dwight-Johnson et al., 2000; Goodman et al., 2013), and prior use of the treatment (Goodman, 2009) were associated with treatment preferences. Severity of insomnia symptoms may be related to the insomnia treatment preference, but this relationship has not been explored. Developing our understanding of demographic and clinical correlates of treatment preference is important as various subgroups have been shown to be less likely to access treatment for mental health conditions (Brown et al., 2010; Grella, Greenwell, Mays, & Cochran, 2009; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011), which may in part be due to differences in treatment preferences.

Partner Influences on Health Behavior

Attention to partner preferences is important given the influence that partners exert on each other's health-related behavior (Lewis & Butterfield, 2007; Umberson, 1992), including exercise (Barnett, Guell, & Ogilvie, 2013), diet (Dailey, Romo, & Thompson, 2011), smoking (Homish & Leonard, 2005), medication adherence (Remien et al., 2005), and breastfeeding intent and behavior (Giugliani, Caiaffa, Vogel-hut, Witter, & Perman, 1994; Rempel & Rempel, 2004). Understanding partners' perceptions of CBT-I is particularly important as sleep is increasingly recognized as a dyadic process in romantic relationships, prompting researchers to encourage clinicians to incorporate partners into psychotherapy for insomnia (Rogojanski, Carney, & Monson, 2013). Subjective and objective sleep patterns have been reported to be concordant within couples, suggesting that the experience of poor sleep in one partner likely impacts the other (Meadows, Arber, Venn, Hislop, & Stanley, 2009). Because of the strong influence of partner support on initiation of and adherence to health behavior, and the dyadic nature of sleep and sleep disorders (Troxel, 2010), partners may be an important influence on treatment-seeking behavior of pregnant women. As such, we also explored which insomnia treatment pregnant women's partners preferred for treatment of maternal insomnia.

Objectives

First, we investigated treatment preferences for insomnia in pregnant women and partners. Based on past research, we predicted that both partners and pregnant women would prefer CBT-I to pharmacotherapy. In addition, we explored preferences for method of delivery (i.e., individual, group, couples, and Internet/phone). Because of the exploratory nature of this aim, we made no hypotheses. Second, we tested the association between established correlates of treatment preference (depressive symptoms, ethnicity, and current/past use of treatment) as well as insomnia symptom severity. Finally, we tested the association between pregnant women's and partners' treatment choice. As these analyses were exploratory, we made no hypotheses.

Method

Design

The current study was a cross-sectional online survey.

Participants

Pregnant women and their partners at various stages of pregnancy were recruited from a perinatal clinic in Calgary, AB, Canada between September 2015 and June 2016. Participating couples were eligible if the woman was pregnant, and both partners were 18 years or older, and able to speak and read English. In total, 284 pregnant women were approached, 201 indicated an interest in participation, and 156 pregnant women and 126 partners completed the survey. Once participants were matched into couples, 106 total couples remained.

Procedure

We approached and invited women to participate in a waiting room of a low-risk maternity clinic. If a partner was present, we invited him to participate. We asked women whose partners were not present to provide their partners' emails or phone number, so we could invite them to participate. Each participant received a $10 CAD e-gift card. The Institutional Review Board approved the study protocol and informed consent process.

Materials

The treatment preferences survey was adapted from similar research focused on treatment preferences for depression during pregnancy (Dimidjian & Goodman, 2014; Goodman et al., 2013). Descriptions of each of the two treatment approaches were drafted and then reviewed by an expert in the field of that intervention (i.e., Ph.D. level clinical psychologist specializing in behavioral sleep medicine and a medical doctor specializing in low risk obstetrics). Modifications to the descriptions were made until the experts endorsed the statements. Descriptions provided participants with six pieces of information: What is the approach? How does the approach conceptualize insomnia? How does the approach work? What will I do in this approach? How much time is involved? What are the risks? Both descriptions are equivalent in length and were presented to participants in randomized order to control for potential biases created via the serial position effect. (1)

Measures

Participating women indicated their treatment choice between the two approaches by responding to the question, "If you were to select a treatment for insomnia right now, which would you choose?". Participants were given options of "no treatment" or "other." Partners were asked a similar question regarding which treatment they prefer their pregnant partner selects. Participants who chose CBT-I were further asked to specify, via yes/no checkboxes, if they would be open to individual, couples, group, and online/over-the-phone delivery.

The Insomnia Severity Index was used to assess subjective symptoms of insomnia and the degree of impairment or distress created by the symptoms in pregnant women. Each item was rated on a scale from 0 to 4, with total scores ranging from 0 to 28. Higher scores reflect more severe insomnia symptoms, with scores of 8 to 14 indicative of subthreshold insomnia and 15 or above clinically significant insomnia (Bastien, Vallieres, & Morin, 2001). Cronbach's alpha in our sample for this measure for pregnant women was 0.89.

The Edinburgh Postnatal Depression Scale (EPDS) was used to measure severity and frequency of depressive symptoms in pregnant women. The EPDS consists of 10 items, each rated on a scale from 0 to 3, with higher scores indicating higher symptom frequency and severity (Cox, Holden, & Sagovsky, 1987). The EPDS has been validated for use with pregnant samples (Eberhard-Gran, Eskild, Tambs, Opjordsmoen, & Samuelsen, 2001; Murray & Cox, 1990). Cronbach's alpha in our sample was 0.87 for pregnant women.

Statistical Analyses

Chi-square analyses were conducted to determine whether pregnant women or their partners selected either CBT-I or pharmacotherapy more frequently than the other, or than another preference, including no treatment. We calculated kappa coefficients to examine whether there was significant agreement between partners in their choice. The associations between pregnant women's treatment choice and our expected correlates of treatment preference--including depressive symptoms, ethnicity, prior use of the treatment, and insomnia symptom severity were tested using a multinomial logistic regression. For this model, participants who selected other and no treatment were combined into one group. We followed up each omnibus test by examining individual predictors.

Results

A total of 106 couples (N = 212) completed the study. The mean age of the mothers was 32.53 (SD = 4.80), most lived in households with an income of $80,000 or more, and most attained a bachelor's degree or a more advanced degree. Most mothers were employed, married/common in law, White, and expecting their first child. Table 1 displays the demographic characteristics of the sample.

Treatment Preference

When asked to select a treatment, the majority of pregnant women selected CBT-I as their preferred treatment, followed by no treatment, pharmacotherapy, or an unlisted treatment (See Table 2). Chi-square analyses indicated that pregnant women chose CBT-I more frequently than pharmacotherapy, [chi square](0 (=) 53.77, p < .001. The majority of partners also selected CBT-I as their preferred treatment for their partner followed by pharmacotherapy, an unlisted treatment approach, or no treatment. Partners chose CBT-I more frequently than pharmacotherapy for their partner, [chi square](1) (=) 48.40, p < .001. Of the 106 couples, although 38 (35.8%) disagreed in their treatment choice, the remaining nearly two thirds (64.2%) agreed on the preferred treatment for the woman's insomnia: 62 (58.5%) agreed on CBT-I, five (4.7%) agreed on pharmacotherapy, one (0.94%) couple agree on an unlisted treatment, no couples agreed on not seeking treatment. More specifically in regard to disagreement on CBT-I, of the 77 pregnant women who preferred CBT-I, four had partners who selected pharmacotherapy. Of the 78 partners who preferred CBT-I, four had pregnant partners who preferred pharmacotherapy. There was significant agreement between partners on treatment choice between the four options ([KAPPA] = 0.19, p = .003) and between CBT-I and pharmacotherapy specifically ([KAPPA] = 0.50, p < .001). Table 3 displays participant agreement between couples. Nearly all women who selected CBT-I indicated that they would consider participating in individual therapy (96.1%), followed by couple therapy (76.6%), phone or Internet delivery (61.0%), or group therapy (32.5%).

Correlates of Maternal Treatment Choice

Previously established correlates of treatment preference were entered as predictor variables (depressive symptoms, ethnicity, insomnia symptoms, and prior pharmacotherapy use) into a multinomial logistic regression analysis with the pregnant women's treatment choice as the dependent variable. Previous experience with CBT-I was not used as a predictor as few participants reported such experience. The overall model did not account for a significant amount of variance, [chi square](8) = 13.34, p = .101; however, there was a statistical trend with large effect sizes showing that ethnic minority participants were more likely to choose pharmacotherapy versus CBT-I (odds ratio [OR] = 11.49, p = .050) and participants who reported having used pharmacotherapy for treatment of insomnia in the past were significantly, and with a large effect size, more likely to endorse it as a preferred treatment (OR = 23.81, p = .013). Individual predictors are displayed in Table 4.

Discussion

In line with other published studies of pregnant women's treatment preferences, our findings suggested that pregnant women strongly prefer psychotherapy--compared to pharmacotherapy--for treatment of insomnia (Dimidjian & Goodman, 2014; Goodman et al., 2013; Sedov et al., 2017). The collection of dyadic data in this study enabled us to extend the findings to partners. Specifically, both pregnant women and their partners preferred CBT-I to pharmacotherapy for treatment of maternal insomnia with nearly two thirds of couples being concordant. Moreover, it appears that a couple-based approach to treating insomnia in pregnancy is highly acceptable with a substantial proportion of pregnant women in our sample indicating an interest in a couples-format of CBT-I delivery.

These findings have important implications given that partners can play an important role in facilitating health behavior change (Lewis et al., 2006; Rogojanski et al., 2013). Bedpartners influence each other's sleep-related thoughts and behaviors, as such, Rogojanski et al. (2013) outlined recommendations for incorporation of partners into all aspects of the CBT-I protocol. Rogojanski and colleagues (2013) recommendations highlighted the fact that partners may encourage each other to follow through with accessing and persevering through challenging aspects of the treatment.

On a parallel basis, with respect to pharmacotherapy, partners' reminders to adhere to the medication protocol and encouragement to persevere despite residual daytime symptoms may facilitate treatment. Conversely, given the unique features of pregnancy, some partners may object to the use of pharmacotherapy due to safety concerns, which may discourage an ambivalent pregnant woman. Of the nine pregnant women in our sample who selected pharmacotherapy, only five (55.6%) had partners who selected the same. In sum, partners' treatment preferences are an important, but often unacknowledged, aspect of insomnia treatment preferences. Our findings indicated that couples often hold concordant preferences.

Future Directions

Examination of partners' influences on pregnant women' insomnia treatment preferences and useful ways to involve partners in interventions are fruitful areas of further inquiry. More research is needed to delineate mechanisms of partner influence on pregnant women' insomnia treatment decisions in order to inform strategies for partner involvement. In addition, we found no published trials of couple-based or partner-assisted CBT-I, despite a compelling argument for considering sleep to be a social activity and integrating bed partners into treatment (Rogojanski et al., 2013). More data are needed on how partners are currently assisting or impeding pregnant women who participate in CBT-I or take sleep medications and whether such involvement affects treatment outcomes. Investigations of how involved partners are willing to be in insomnia treatment should be conducted, as well as explorations of how much--and what manner of--involvement from partners pregnant women expect and desire. Finally, future studies should examine whether partner agreement with treatment choice enhances pregnant women's treatment adherence and effectiveness.

The current findings indicated that pregnant women and partners preferred CBT-I for pregnant women' treatment of insomnia during pregnancy. However, although evidence exists for the efficacy of CBT-I (Okajima et al., 2011), to date only one small pilot during pregnancy (Tomfohr-Madsen et al., 2017) has tested the feasibility and efficacy of CBT-I as a treatment for pregnant women. Future research examining the efficacy and effectiveness of CBT-I with pregnant samples is needed, particularly given the observed preference for this approach. Similarly, 9% of pregnant women and 11 % of partners indicated that they would want the mother to use pharmacotherapy for treatment of maternal insomnia during pregnancy; however, little is known about the efficacy, effectiveness, and safety of pharmacological agents during pregnancy (Okun et al., 2015). As such, future research should explore the efficacy and safety of various pharmacological agents for insomnia in pregnancy. Continuing to develop safe and effective treatment options for pregnant women, consistent with their treatment preferences, is an important avenue of future research.

Finally, future research should explore women's preference for unlisted treatment and types of treatment pregnant women currently use to manage their sleep in order to further understand pregnant women's treatment seeking behavior. Almost 19% of pregnant women in our sample did not want CBT-I or pharmacotherapy. It would be interesting to know what treatment options these individuals preferred. In addition, a population-based exploration of how pregnant couples are managing sleep concerns is highly warranted, including what factors influence their decisions. The factors motivating couples' treatment preferences and consumption should be explored as well as the way these preferences are associated with treatment adherence and outcomes.

Limitations

A number of limitations are acknowledged when interpreting results from the current study. Hypothetical treatment choice may not adequately reflect how participants would behave if faced with the need to receive treatment for insomnia; people tend to be inaccurate in predicting what they will value and what resources they will be able to utilize in the future (Halpern & Arnold, 2008). Thus the hypothetical treatment choice may not adequately reflect how participants would behave if faced with the need to receive treatment for insomnia, although it does indicate what participants prefer as behavior and preference are not synonymous. We did not assess insomnia via clinical interview and it is possible that women who receive a clinical diagnosis of insomnia may differ in their treatment choice and perceptions; however, severity of insomnia symptoms was not related to preference. We tested ethnicity as White versus other in the multinomial logistic regression. This method of testing the effects of ethnicity likely masks important differences in treatment preferences between non-White backgrounds; however, no non-White group was sufficiently represented to be tested independently. In addition, we did not define for the participants what couples delivery of CBT-I may involve. Although there are calls in the literature to include partners in CBT-I (Ellis, Deary, & Troxel, 2015; Rogojanski et al., 2013), and participants in this study were in favor of that option, no current protocol exists; interest in the couples format of delivery may change depending on the format of the treatment. Finally, our sample was relatively educated, reported a high household income, and may differ from others in which both partners are not willing to participate.

Conclusion

Despite these limitations, findings are in line with other treatment preferences studies (Dimidjian & Goodman, 2014; Goodman et al., 2013; Sedov et al., 2017) and provide strong support for couples preference for psychotherapy during pregnancy. Given the prevalence and consequences of sleep disruption during pregnancy, this study of treatment preferences of pregnant women supports the importance of developing and disseminating evidence-based treatment guidelines for treatment of maternal insomnia.

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Ivan Sedov, MSc, and Joshua W. Madsen, PhD

University of Calgary

Sherryl H. Goodman, PhD

Emory University

Lianne M. Tomfohr-Madsen, PhD

University of Calgary and Alberta Children's Hospital Research Institute for Child and Maternal Health, Calgary, Canada

This article was published Online First December 27, 2018.

Ivan Sedov, MSc and Joshua W. Madsen, PhD, Department of Psychology, University of Calgary; Sherryl H. Goodman, PhD, Department of Psychology, Emory University; Lianne M. Tomfohr-Madsen, PhD, Department of Psychology, University of Calgary, and Children's Hospital Research Institute for Child and Maternal Health, Calgary, Canada.

Correspondence concerning this article should be addressed to Ivan Sedov, MSc, Department of Psychology, University of Calgary, 2500 University Drive, NorthWest, Calgary AB, T2N 1N4 Canada. E-mail: isedov@ucalgary.ca

Received July 25. 2018

Revision received October 12, 2018

Accepted November 13, 2018 *

(1) Treatment descriptions are available in the online supplemental material.

http://dx.doi.org/10.1037/fsh0000391
Table 1
Demographic Characteristics of the Sample (N = 212)

                               Mothers'           Fathers'
                               M [+ or -] SD      M [+ or -] SD
Variable                       or n (%)           or n (%)

Age (years)                    32.53 (4.80) (a)   32.35(5.14)
Gestational age (weeks)        29.54 (7.31)       --
Household income
  $0 to $39,999                14 (13.2)          --
  $40,000 to $79,999           16 (15.1)          --
  $80,000 or more              76 (71.7)          --
Education
  Less than high school         2 (1.9)            0 (0)
  High school or equivalent    10 (9.4)           15 (14.2)
  Post-secondary certificate   20 (18.9)          32 (30.2)
  or diploma
  Bachelor's degree            45 (42.5)          37 (34.9)
  Master's degree              24 (22.6)          16 (15.1)
  Doctorate or other            5 (4.7)            6 (5.7)
  professional degree
Employed                       79 (74.5)          95 (89.6)
Married/common law            105 (99.1)          --
Race
  White                        67 (63.2)          75 (70.8)
  Indigenous                    4 (3.8)            2 (1.9)
  Black                         1 (.9)             2 (1.9)
  Asian                        29 (27.4)          21 (19.8)
  Hispanic/Latino               5 (4.7)            2 (1.9)
  Mixed race                    0 (0)              4 (3.8)
Parity (First child)           81 (76.4)          82 (77.4)
Depression (EPDS)               7.64 (5.04)       --
Insomnia (ISI)                  9.67 (5.37)       --
  No insomnia (ISI = 0-7)      39 (36.8)          --
  Subthreshold insomnia        47 (44.3)          --
  (ISI = 8-14)
  Moderate insomnia            20 (18.9)          --
  (ISI = 15-21)
Previously treated insomnia                       --
  Medication                   21 (19.8)          19 (17.9)
  Psychotherapy                 3 (2.8)            3 (2.8)

Note. EPDS = Edinburgh Postnatal Depression Scale; ISI = Insomnia
Severity Index.
(a) One woman reported an impossible age (13 years) and was removed
from the mean age calculation.

Table 2
Percent of Pregnant Mothers' and Fathers' Selecting Each Treatment
Option for Maternal Insomnia

Participant          CBT-I   Pharmacotherapy   Other   No treatment

Pregnant women (%)   72.6        8.5           5.7       13.2
Partners (%)         73.6       11.3           8.5        6.6

Note. CBT-I = Cognitive Behavioral Therapy for Insomnia.

Table 3
Couples' Treatment Choice Agreement: Total Number of Mothers and
Fathers That Chose Each Treatment

Fathers                           Mothers                         Total
                 Pharmacotherapy  CBT-I    Other   No treatment

Pharmacotherapy      5             4        1         2             12
CBT-I                4            62        2        10             78
Other                0             6        1         2              9
No treatment         0             5        2         0              7
Total                9            77        6        14            106

Note. CBT-I = Cognitive Behavioral Therapy for Insomnia.

Table 4
Odds Ration Associated With Demographic and Clinical Variables in
Choosing Either Pharmacotherapy or Other/No Treatment Relative to
Choosing CBT-I

                             Pharmacotherapy        Other/no treatment
Variable                       OR [95% CI]             OR [95% CI]

Depressive symptoms           1.00 [.84, 1.17]       1.02 [.91, 1.14]
Ethnicity                    11.47 [1.00, 131.19]    1.51 [.50, 4.54]
Insomnia symptoms             1.01 [.84, 1.16]       1.00 [.90, 1.11]
Prior use--pharmacotherapy   24.05 [1.97, 293.77]    1.66 [.41, 6.68]

Note. CBT-I = Cognitive Behavioral Therapy for Insomnia; OR = odds
ratio; CI = confidence interval.
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Author:Sedov, Ivan; Madsen, Joshua W.; Goodman, Sherryl H.; Tomfohr-Madsen, Lianne M.
Publication:Families, Systems & Health
Article Type:Report
Date:Mar 1, 2019
Words:5465
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