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Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial



Type of Spiritual Experience

Invisible input - healing

Number of hallucinations: 50


Cognitive behavioral therapy (CBT) is a form of psychotherapy. It was originally designed to treat depression, but is now used for a number of mental disorders

It works to solve current problems and change unhelpful thinking and behavior. The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles. Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought, but rather emerge based on prior conditioning from the environment and other external and/or internal stimuli. CBT is "problem focused" (undertaken for specific problems) and "action oriented" (therapist tries to assist the client in selecting specific strategies to help address those problems), or directive in its therapeutic approach

A description of the experience

Lancet Psychiatry. 2015 Nov;2(11):975-83. doi: 10.1016/S2215-0366(15)00314-4. Epub 2015 Sep 9.

Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial.

Freeman D1, Waite F2, Startup H3, Myers E2, Lister R2, McInerney J2, Harvey AG4, Geddes J2, Zaiwalla Z5, Luengo-Fernandez R6, Foster R7, Clifton L8, Yu LM9.

  • 1Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK. Electronic address: daniel.freeman@psych.ox.ac.uk.
  • 2Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.
  • 3Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Sussex Partnership NHS Trust, Worthing, West Sussex.
  • 4Department of Psychology, University of California, Berkeley, CA, USA.
  • 5Oxford Non-Respiratory Sleep Disorder Service, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK.
  • 6Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK.
  • 7Sleep and Circadian Neurosciences Institute, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.
  • 8Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
  • 9Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.



Sleep disturbance occurs in most patients with delusions or hallucinations and should be treated as a clinical problem in its own right. However, cognitive behavioural therapy (CBT)-the best evidence-based treatment for insomnia-has not been tested in this patient population. We aimed to pilot procedures for a randomised trial testing CBT for sleep problems in patients with current psychotic experiences, and to provide a preliminary assessment of potential benefit.


We did this prospective, assessor-blind, randomised controlled pilot trial (Better Sleep Trial [BEST]) at two mental health centres in the UK. Patients (aged 18-65 years) with persistent distressing delusions or hallucinations in the context of insomnia and a schizophrenia spectrum diagnosis were randomly assigned (1:1), via a web-based randomisation system with minimisation to balance for sex, insomnia severity, and psychotic experiences, to receive either eight sessions of CBT plus standard care (medication and contact with the local clinical team) or standard care alone. Research assessors were masked to group allocation. Assessment of outcome was done at weeks 0, 12 (post-treatment), and 24 (follow-up). The primary efficacy outcomes were insomnia assessed by the Insomnia Severity Index (ISI) and delusions and hallucinations assessed by the Psychotic Symptoms Rating Scale (PSYRATS) at week 12. We did analysis by intention to treat, with an aim to provide confidence interval estimation of treatment effects. This study is registered with ISRCTN, number 33695128.


Between Dec 14, 2012, and May 22, 2013, and Nov 7, 2013, and Aug 26, 2014, we randomly assigned 50 patients to receive CBT plus standard care (n=24) or standard care alone (n=26). The last assessments were completed on Feb 10, 2015. 48 (96%) patients provided follow-up data. 23 (96%) patients offered CBT took up the intervention. Compared with standard care, CBT led to reductions in insomnia in the large effect size range at week 12 (adjusted mean difference 6·1, 95% CI 3·0-9·2, effect size d=1·9). By week 12, nine (41%) of 22 patients receiving CBT and one (4%) of 25 patients receiving standard care alone no longer had insomnia, with ISI scores lower than the cutoff for insomnia. The treatment effect estimation for CBT covered a range from reducing but also increasing delusions (adjusted mean difference 0·3, 95% CI -2·0 to 2·6) and hallucinations (-1·9, -6·5 to 2·7). Three patients, all in the CBT group, had five adverse events, although none were regarded as related to study treatment.


Our findings show that CBT for insomnia might be highly effective for improving sleep in patients with persistent delusions or hallucinations. A larger, suitably powered phase 3 study is now needed to provide a precise estimate of the effects of CBT for sleep problems, both on sleep and psychotic experiences.


Research for Patient Benefit Programme, National Institute for Health Research.

Copyright © 2015 Freeman et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

PMID:  26363701

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