Effect of the one-shot cognitive behavioral therapy on insomnia and heart rate variability of health care workers at the time of Covid-19 pandemic: A randomized controlled trial

doi:10.21203/rs.3.rs-2067887/v1

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Effect of the one-shot cognitive behavioral therapy on insomnia and heart rate variability of health care workers at the time of Covid-19 pandemic: A randomized controlled trial

https://doi.org/10.21203/rs.3.rs-2067887/v1

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Objectives

The emergence of sleep disturbances in response to major stressful events has been documented previously. Insomnia and Heart rate variability (HRV) is an objective marker that provides insight into autonomic nervous system dynamics. The aim of the present study was to examine the preliminary efficacy and effectiveness of a one-shot session of cognitive behavioral therapy for insomnia (CBT-I) for frontline healthcare providers with acute insomnia.

Methods

This study was conducted from in 2020–2021 on fifty health care workers with insomnia, that were randomly allocated to receive one shot cognitive behavioral therapy or routine care. Insomnia Severity Index (ISI) and HRV were assessed before and one month after the interventions.

Results

ISI score decreased in the intervention group (from 13.32 to 6.74, P = 0.0001). The change before and after the intervention was significant between two groups for HFnu and LF/HF.HF nu increase in the intervention group (35.8 ± 21.5 vs 45.6 ± 19.79 before and after the intervention respectively), and decrease in the control group (43.9 ± 16.46 vs 39.8 ± 18.49, before and after the intervention respectively )

Conclusion

A single-shot session of CBT-I is effective in managing acute insomnia symptoms in health workers.

COVID-19

insomnia

behavioral therapy

COVID-19 is a disease currently known as the coronavirus causing Respiratory Distress Syndrome 2 (SARS-Cov-2) [1]. The virus was first discovered in Wuhan, China, and soon led to an epidemic around the world [2]. The incubation period of the disease is reported to be between 2 and 14 days. So far, a wide range of clinical symptoms have been seen in people infected with the virus from mild upper respiratory symptoms to severe respiratory distress, respiratory failure and death [3].

Epidemics, health disasters, and incidents have always been critical sources of stress and anxiety for people who face them. Many studies have shown a rise in the prevalence of anxiety disorders, including sleep disorders, amid such disasters [1, 2]. The COVID-19 pandemic is a perfect example of a stressful disaster. COVID-19 has caused anxiety disorders, depression, and insomnia among the general population and, in particular, the health care workers (HCW) [3]. The frontline HCWs are under a massive amount of pressure. Studies have reported that these mental pressures could be due to the concern for the health of their families and coworkers, an stressful work environment, extreme fatigue due to high working hours or heavy workload, harsh quarantine conditions, and also the following of mortality statistics in the news [3].

Furthermore, it has been indicated that moderately severe insomnia, anxiety, depression and poor sleep quality are very common among HCWs who had experienced COVID-19 -like symptoms [4]. Hyperarousal is a physiologic reaction and is the main feature of insomnia. Insomnia is associated with autonomous system pathologies and cause multiple findings in patients such as increased body temperature, increased metabolic rate, and decreased heart rate variability (HRV) [5]. HRV shows a quantitative difference between two consecutive heartbeats and is highly affected by the parasympathetic system. A high HRV indicates the healthy activity of the cardiovascular autonomous nervous system and low HRV indicates possible associated diseases, including cardiovascular diseases [6]. Insomnia, especially if left untreated, could cause an increased risk of cardiovascular disorders and their risk factors [7]. Studies show autonomous system changes in insomnia are mainly in respect of decreased HRV and high sympathetic nervous system activity [8].

Based on some studies patients with insomnia may benefit from hyperarousal treatment [9]. One of the non-pharmacological treatment methods for insomnia is one-shot cognitive behavior therapy (CBT). CBT sessions are a distinctive non-pharmacological therapeutic method [10, 11] that could eliminate the factors that cause long-term persistence of insomnia usch as sleep incompatible thoughts, beliefs, and behaviors [12]. The customary CBT sessions are often time-consuming and tedious [13, 14]. Therefore, efforts have been made to shorten and simplify this method [15–18].

Based on previous studies, CBT could be effective and associated with beneficial results in patients with insomnia that might suffer from HRV. However, the existing data seem insufficient for providing an absolout treatment strategy. Considering the prevalence and importance of COVID-19 epidemic and its enoumous psycholohical stress on HCWs, The aim of this study was to examine the efficacy of one-shot CBT in the treatment of insomnia amongst the HCWs in Iran during the COVID-19 pandemic.

This is a randomized controlled trial that was performed in 2021 in Alzahra and Khorshid hospitals affiliated to Isfahan University of Medical Sciences. The current study was conducted on HCWs who suffer from acute insomnia. The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences and the Ethics committee has confirmed it (Ethics code: IR.MUI.MED.REC.1399.1153, Iranian Registry for Clinical Trials (IRCT) code: IRCT20171219037964N4). The declaration of Helsinki was followed in every step. We report the results following the Consolidated Standards for Reporting Trials (CONSORT).

The inclusion criteria were age over 18 years, HCWs in Alzahra and Khorshid hospitals, having Insomnia Severity Index (ISI) score of 8 or higher and signing the written informed consent to participate in this study. The exclusion criteria were having any previous history of heart disease, seizure, bipolar disorders, narcolepsy, and other sleep disturbance disorders, or desire to start physical activity in the following months, or undergoing treatment with antiarrhythmic or beta-adrenergic blockade medications.

Considering a significance level of 0.05, an 80% power, and an insomnia severity index of 9.6 ± 4.99 for the intervention group and 12.56 ± 3.51 for the control group, the sample size was calculated as 31 per group [12].

An advertisement was published online in Alzahra and Khorshid hospitals' online channels, inviting HCWs who suffer from acute insomnia to participate in this study. After describing the study for those who enrolled, participants were recruited baed on the mentioned criteria.

Participants were randomly allocated into two groups of intervention and control using a simple randomization method (ratio, 1:1). A random sequence was produced using "randomization.com", available to the research assistant. Each person was given a unique code. The research assistant placed the person in the relevant groups by matching the person's code with the random sequence. The person in charge of follow-up and the one in charge of data analysis were unaware of the study groups.

Data on demographic variables including age, sex (male/ female), job (nurse/ physician or medical student/ other healthcare workers), education (diploma and less/higher education), having any comorbidities (yes/no), and using any medication (yes/ no) were gathered at the beginning of the study.

Participants in the intervention group were asked to complete a sleep diary sheet considering their sleep patterns in the previous two weeks. Then they were divided into groups of 2–3 to receive the one-shot CBT-I session. In the CBT-I session, the therapist evaluated the diaries, took a brief history, then explained the stimulus control and some cognitions about insomnia and maladaptive behaviors that may convert acute insomnia into chronic type. Sleep restriction strategy is applied, and some pamphlets that included information about insomnia and its treatment were given to them. No interventions were performed for the participants in the control group. Primary outcomes, including insomnia state and HRV, were evaluated before and one month after the intervention.

Insomnia state: The Iranian version of ISI was used to measure insomnia [19]. The ISI is a self-assessment scale designed by Morin et al. [20]. This scale consists of seven questions in a Likert scale (0: not at all, 5: all the time). The total score varies from zero to 28 and is divided into four categories; 0–7: no insomnia, 8–14: mild insomnia, 15–21: Moderate, and 22–28: severe insomnia.

HRV: During polysomnography (PSG), continuous raw ECG data were derived from a modified Lead-II configuration. ECG data from the PSG device were taken after 30 min of sitting in a relaxed situation. During recording the participant were lying down in a silent room. We recorded for 5 min and then the data were exported in European Data Format (EDF) format and was analyzed with MATLAB software that was capable of analyzing HRV for HRV analysis (Fig. 2) [21].

As recommended by the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology [20], 5-min HRV epochs were analyzed to obtain Power spectral estimates included low-frequency (LF) HRV (0.04–0.15 Hz) in ms2, normalized unit (NU), high-frequency (HF) power band (0.15–0.40 Hz) in ms2, NU, and the ratio of low frequency to high frequency (LF/HF ratio).

Data analysis:

Data were analyzed using SPSS version 22 (SPSS Inc., Chicago, IL, USA). Mean, and Standard deviation (SD) were used to describe continuous variables. Frequency was used to describe categorical variables. The Chi-square test was used to compare qualitative variables between two groups. The Mann-Whitney test was used to compare quantitative variables between two groups and before and after the intervention. The level of significance was set at 0.05.

From 102 HCWs who voluntarily enrolled in this study, 64 participants with the inclusion and exclusion criteria were randomly assigned into two groups. One participant in the intervention group declined to attend the CBT-I session. Six participants in the control group refused to participate in the monitoring session. Finally, data of 31 participants in the intervention group and 26 participants in the control group were analyzed (Fig. 2).

The mean (± SD) age of participants in the intervention and control group was 34.6 (± 9.53) and 36.6 (± 6.95), respectively. Most of the participants in both groups were female (80.6% and 65.4% in the intervention and control group, respectively; p-value, 0.1). The distribution of job positions was not statistically different between the two groups, and most of the participants in both groups were nurses (54.8% in the intervention group, 53.8% in the control group; p-value, 0.8). Considering the education level, most of the participants had higher education, and the education level was the same between the two groups (p-value, 0.3). Other demographic variables are presented in Table 1.

Table 1

Baseline demographics of intervention and control group
	Intervention (N = 31)	Control (N = 26)	p-value
Age	34.65 ± 9.53	36.65 ± 6.95	0.2*
Sex			0.1**
Male	6 (19.4)	9 (34.6)
Female	25 (80.6)	17 (65.4)
Job			0.8**
Nurse	17 (54.8)	14 (53.8)
Medical student and physician	8 (25.8)	8 (30.8)
Other healthcare workers	6 (19.4)	4 (15.4)
Education			0.3**
Diploma and less	11 (35.5)	6 (23.1)
Higher education	20 (64.5)	20 (76.9)
Any past medical history			0.2**
Yes	9 (29.0)	4 (15.4)
No	22 (71.0)	22 (84.6)
Any medication			0.3**
Yes	13 (41.9)	8 (30.8)
no	18 (58.1)	18(69.2)
All data are presented in number (percent), except for age which is mean ± SD
Mann-Whitney test, *chi-square

Insomnia

The mean of ISI score before the intervention was not statistically different between groups (13.3 ± 3.72 vs. 13.3 ± 4.4 in the intervention and control group, respectively; p-value, 0.9). The mean score of all seven questions was also the same between the two groups before the intervention (p-value > 0.05). The ISI score after the intervention was lower in the intervention group in comparison to the control group (6.7 ± 4.51 vs. 13.6 ± 6.29, respectively; p-value < 0.0001(; the difference in ISI score before and after the intervention was also statistically significant comparing two groups (p-value < 0.0001). Results for all seven questions are presented in Table 2.

Table 2

Insomnia severity index in the intervention and control group before and after the intervention
		Intervention (n = 31)	Control (n = 26)	p-value comparing before and after the intervention	p-value comparing the mean difference between two groups
ISI					0.000
	Before	13.3 (3.72)	13.3 (4.38)	0.9
	After	6.7 (4.51)	13.6 (6.29)	0.000
Difficulty falling asleep					0.000
	Before	2.1 (0.95)	2.0 (0.87)	0.8
	After	1.0 (0.77)	2.0 (1.13)	0.001
Difficulty staying asleep					0.001
	Before	1.6 (0.91)	1.3 (1.09)	0.3
	After	0.81 (0.98)	1.3 (1.12)	0.05
Problem waking up too early					0.017
	Before	0.9 (0.85)	1.1 (1.09)	0.3
	After	0.4 (0.62)	1.3 (1.01)	0.000
Satisfaction with the current sleep pattern					0.000
	Before	2.7 (0.76)	2.6 (0.97)	0.7
	After	1.3 (0.74)	2.3 (1.08)	0.000
Interfering with daily function					0.000
	Before	2.4 (0.88)	2.2 (0.96)	0.6
	After	1.4 (1.17)	2.6 (1.23)	0.001
Noticeable for others in terms of impairing the quality of life					0.025
	Before	1.4 (1.08)	1.9 (1.14)	0.07
	After	0.7 (0.78)	2.0 (1.31)	0.000
Worried/distressed about a current sleep problem					0.000
	Before	2.0 (0.98)	1.8 (1.03)	0.4
	After	0.9 (0.98)	2.0 (1.38)	0.002
ISI: insomnia severity index. P-values are estimated using a Mann-Whitney test.

Heart Rate Variability

Considering frequential indexes, all indexes were the same between the two groups at baseline (p-value > 0.05). The mean (± SD) of LF after the intervention in the intervention group was 613.9 (± 433.16), and in the control group was 364.2 (± 344.59), which was statistically significant (p-value, 0.01). Also, the mean of HF after the study in the intervention group was higher than the control group (1166.4 ± 1505.67 vs. 294.4 ± 257.59, respectively; p-value, 0.01).

The change of frequencial indexes before and after the intervention was not statistically significant between two groups for all indexes except for HFnu and LF/HF. HFnu increases in the intervention group (35.8 ± 21.5 vs. 45.6 ± 19.79 before and after the intervention, respectively), and decreases in the control group (43.9 ± 16.46 vs. 39.8 ± 18.49, before and after the intervention, respectively). The mean of the difference before and after the intervention was statistically significant between groups (p-value = 0.01). The mean of LF/HF decreases in intervention group (2.3 ± 2.20 vs. 1.1 ± 0.81 before and after the intervention, respectively) and increases in the control group (1.1 ± 0.92 vs. 1.2 ± 0.82 before and after the intervention, respectively). This change was statistically significant (p-value, 0.001). Table 3 demonstrates HRV indexes for intervention and control group, before and after the intervention.

Table 3

Comparison of outcome variables before and after the intervention and between two groups
		Intervention (n = 31)	Control (n = 26)	p-value* comparing before and after the intervention	p-value* comparing the mean difference between two groups
Frequencial	Vlf				0.3
	Before	743.3 (639.47)	551.9 (401.31)	0.5
	after	898.2 (630.92)	667.9 (701.70)	0.07
	LF				0.8
	Before	663.6 (559.49)	408.8 (436.13)	0.07
	after	613.9 (433.16)	364.2 (344.59)	0.01
	HF				0.07
	Before	760.1 (1053.92)	733.1 (1146.54)	0.7
	after	1166.4 (1505.67)	294.4 (257.59)	0.01
	LFnu				0.6
	Before	47.6 (19.01)	39.6 (11.73)	0.05
	after	40.2 (17.47)	41.4 (14.61)	0.9
	HFnu				0.01
	Before	35.8 (21.50)	43.9 (16.46)	0.07
	after	45.6 (19.79)	39.8 (18.49)	0.4
	LF/HF				0.001
	Before	2.3 (2.20)	1.1 (0.92)	0.05
	after	1.1 (0.81)	1.2 (0.82)	0.7
*Mann-Whitney test
Vlf:…………..; LF:………….; HF:…………..; LFnu:……………; HFnu:………………

The primary aim of this study was to determine the effectiveness of a "single-shot" CBT-I, with an accompanying information pamphlet, in the treatment of acute insomnia of HCWs. The results of our study suggested that this variant of CBT-I is suitable for most HCWs with acute insomnia and can improve all insomnia symptoms based on ISI score.

These finsings could have high importance and are in line with the previous literature on the impact of a single-shot CBT-I intervention for acute insomnia [11, 12]. The identification and management of insomnia is fundamental for the health worker. An important point is that previous studies have also reported higher rates of insomnia (34–36%), anxiety (45%), and depressive symptoms (50%) among individuals at high risks of COVID-19 infection compared to general population [3, 22]. Additionally, many studies have established that insomnia itself is a risk factor for developing depression, anxiety, and suicide [23]. The findings from the present study suggest that a single shot of CBT-I, with an accompanying self-help pamphlet, has some promise in this setting for individuals with acute insomnia and probably its subsequent adverse effects.

In the Spectral analysis of HRV, the LF band region was previously called the baroreceptor range because it mainly reflects baroreceptor activity during resting conditions [24]. LF power may be produced by both the PNS and SNS, and BP regulation via baroreceptors [24–26]. In resting conditions, the LF band reflects baroreflex activity and not cardiac sympathetic innervation [12]. By evaluating the neurophysiology, it should be noted that the efferent vagal activity contributes significantly to the HF component, as seen in clinical and experimental observations of autonomic maneuvers such as electrical vagal stimulation, muscarinic receptor blockade, and vagotomy [25, 27, 28].

About LF/HF ratio, there are some studies [29] that challenged the belief that the LF/HF ratio measures "sympatho-vagal balance" [30, 31]. They say that LF power is not a pure index of SNS drive. Half of the variability in this frequency band is due to the PNS, and unknown factors produce a smaller proportion. PNS and SNS interactions are complex, non-linear, and frequently non-reciprocal. Additionally, confounding by respiration mechanics and resting HR creates uncertainty regarding PNS and SNS contributions to the LF/HF ratio during the measurement period [32].

Shaffer et al. [33] warned that the LF/HF ratio is controversial because of different processes for example, the SNS contribution to LF power varies profoundly with testing conditions.

In our evaluation, this ratio decreased after the intervention compared to the control group. By frequency domain analysis of HRV, comparison of two groups after one month shows the significant decrease of LF value in the control group. If, like the first study's belief we assume the LF as a sympathic activity. The results are in favor of disability of intervention for SNS suppression that is against our hypothesis but based on recent studies [33]. It may be due to our method of HRV recording (people were lying down), or since the LFnu values had not changed, it is not important.

Another finding of this study was that we observed significantly increased PNS activity (according to HFnu and HFvalue), compared with baseline and control groups, after CBT–I in the intervention group. There was evidence that CBT positively impacts changes in inflammation in insomnia patients [34] significant HRV changes in the responders group suggesting successful insomnia treatment reduces sympathetic hyperactivity and stimulates parasympathetic activity. These are consistent with our results.

Although previous evaluation of CBT–I's effect on HRV that was done by Denise C et al [32], show no significant differences in mean HRV changes between responders and nonresponders or between remitters and non remitters in either S2 or REM. Still, there were some fundamental differences between the methodologies of these two studies. These differences could be justified in the way that our samples were taken from acute sleepless health workers with probably high levels of anxiety, especially during the COVID-19 pandemic, not patients with chronic insomnia. Furthermore, we assess the ECGs of our samples at wake in lying position, not during sleep. We should note that one-shot CBT-I was done for the intervention group instead of full CBT-I, which is more time-consuming. Therefore, it is belived that long-term treatment in the other study may be responsible for different results.

We found that one shot CBT-I is an effective treatment for acute insomnia of COVID-19 in frontline health workers and can cause an increment of parasympathetic activity and changes the autonomous system balance towards lower SNS and higher PNS activity in 1 month after therapy. Accordingly, future research is needed to examine whether treatment is associated with improvements in other cardiovascular biochemistry and physiology (e.g., lipids, endothelial function), because this data would support the notion that CBT-I reduces the risk of future CVD and its precursors. Further, it would be valuable to (a) include longitudinal, randomized clinical trials to establish whether treatment produces cardiovascular safeguard (e.g., longer follow-ups); (b) use a large sample of patients and controls.

Funding: The current research was granted by the Isfahan University of Medical Sciences.

Conflicts of interest: The authors have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript

Availability of data and material: The data are available in a Zip file and could be uploaded when requested.

Code availability: not applicable.

Additional declarations for articles in life science journals that report the results of studies involving humans and/or animals: not applicable.

Ethics approval: All procedures performed in study were in accordance with the ethical standards of the Isfahan university of medical science research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was confirmed by the Ethics Committee of Isfahan University of Medical Sciences: IR.MUI.MED.REC.1399.1153, Iranian Registry for Clinical Trials (IRCT) code: IRCT20171219037964N4).

Consent to participate: Freely-given, informed consent to participate in the study was obtained from participants in this study. The informed consents were confirmed by the Ethics Committee of Isfahan University of Medical Sciences.

Consent for publication: not applicable.

Askenasy J, Lewin I (1996) The impact of missile warfare on self-reported sleep quality. Part 1. Sleep 19:47–51
Kalayjian A, Kanazi RL, Aberson CL, Feygin L (2002) A cross-cultural study of the psychosocial and spiritual impact of natural disaster. Int J Group Tensions 31:175–186
Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, Du H, Li R, Kang L, Su M (2020) Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry 11:306
Amra B, Salmasi M, Soltaninejad F, Sami R, Nickpour M, Mansourian M, Ghasemi K, Morin CM (2021) Healthcare workers’ sleep and mood disturbances during COVID-19 outbreak in an Iranian referral center.Sleep and Breathing;1–8
Bonnet MH, Arand DL (2010) Hyperarousal and insomnia: state of the science. Sleep Med Rev 14:9–15
Electrophysiology TFotESoCtNASoP (1996) Heart rate variability: standards of measurement, physiological interpretation, and clinical use. Circulation 93:1043–1065
Laugsand LE, Vatten LJ, Platou C, Janszky I (2011) Insomnia and the risk of acute myocardial infarction: a population study. Circulation 124:2073–2081
Farina B, Dittoni S, Colicchio S, Testani E, Losurdo A, Gnoni V, Di Blasi C, Brunetti R, Contardi A, Mazza S (2014) Heart rate and heart rate variability modification in chronic insomnia patients. Behav sleep Med 12:290–306
Bonnet M, Arand D (1997) Hyperarousal and insomnia. Sleep Med Rev 1:97–108
Ellis JG (2019) Cognitive behavioral therapy for insomnia and acute insomnia: considerations and controversies. Sleep Med Clin 14:267–274
Randall C, Nowakowski S, Ellis JG Managing acute insomnia in prison: evaluation of a “one-shot” cognitive behavioral therapy for insomnia (CBT-I) intervention. Behavioral sleep medicine 2018;
Ellis JG, Cushing T, Germain A (2015) Treating acute insomnia: a randomized controlled trial of a “single-shot” of cognitive behavioral therapy for insomnia. Sleep 38:971–978
Gotts Z, Deary V, Newton JL, Ellis J (2016) Treatment of insomnia reduces fatigue in chronic fatigue syndrome in those able to comply with the intervention. Fatigue: Biomed Health Behav 4:208–216
Lamberg L (2008) Despite effectiveness, behavioral therapy for chronic insomnia still underused. JAMA 300:2474–2475
Edinger JD, Sampson WS (2003) A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 26:177–182
Germain A, Moul DE, Franzen PL, Miewald JM, Reynolds CF, Monk TH, Buysse DJ (2006) Effects of a brief behavioral treatment for late-life insomnia: preliminary findings. J Clin Sleep Med 2:407–408
Lovato N, Lack L, Wright H, Kennaway DJ (2014) Evaluation of a brief treatment program of cognitive behavior therapy for insomnia in older adults. Sleep 37:117–126
Troxel WM, Conrad TS, Germain A, Buysse DJ (2013) Predictors of treatment response to brief behavioral treatment of insomnia (BBTI) in older adults. J Clin Sleep Med 9:1281–1289
Yazdi Z, Sadeghniiat-Haghighi K, Zohal MA, Elmizadeh K (2012) Validity and reliability of the Iranian version of the insomnia severity index. Malaysian J Med sciences: MJMS 19:31
Morin CM (1993) Insomnia: Psychological assessment and management. Guilford press
Pichot V, Roche F, Celle S, Barthelemy J-C, Chouchou F (2016) HRVanalysis: a free software for analyzing cardiac autonomic activity. Front Physiol 7:557
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R (2020) Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw open 3:e203976–e203976
Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, Lombardo C, Riemann D (2011) Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord 135:10–19
McCraty R, Shaffer F (2015) Heart rate variability: new perspectives on physiological mechanisms, assessment of self-regulatory capacity, and health risk. Global Adv health Med 4:46–61
Akselrod S, Gordon D, Ubel FA, Shannon DC, Berger AC, Cohen RJ (1981) ; 213: 220–222
Van den Bergh O (2021) Principles and practice of stress management. Guilford Publications
Pomeranz B, Macaulay R, Caudill MA, Kutz I, Adam D, Gordon D, Kilborn KM, Barger AC, Shannon DC, Cohen RJ (1985) Assessment of autonomic function in humans by heart rate spectral analysis. Am J Physiol Heart Circ Physiol 248:H151–H153
Malliani A, Pagani M, Lombardi F, Cerutti S (1991) Cardiovascular neural regulation explored in the frequency domain. Circulation 84:482–492
Billman GE (2013) The LF/HF ratio does not accurately measure cardiac sympatho-vagal balance. Front Physiol 4:26
Pagani M, Lombardi F, Guzzetti S, Sandrone G, Rimoldi O, Malfatto G, Cerutti S, Malliani A (1984) Power spectral density of heart rate variability as an index of sympatho-vagal interaction in normal and hypertensive subjects. J Hypertens Supplement: official J Int Soc Hypertens 2:S383–385
Pagani M, Lombardi F, Guzzetti S, Rimoldi O, Furlan R, Pizzinelli P, Sandrone G, Malfatto G, Dell'Orto S, Piccaluga E (1986) Power spectral analysis of heart rate and arterial pressure variabilities as a marker of sympatho-vagal interaction in man and conscious dog. Circul Res 59:178–193
Jarrin DC, Chen IY, Ivers H, Lamy M, Vallières A, Morin CM (2016) Nocturnal heart rate variability in patients treated with cognitive–behavioral therapy for insomnia. Health Psychol 35:638
Shaffer F, McCraty R, Zerr CL (2014) A healthy heart is not a metronome: an integrative review of the heart's anatomy and heart rate variability. Front Psychol 5:1040
Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Breen EC, Witarama T, Yokomizo M, Lavretsky H, Carroll JE, Motivala SJ (2014) Cognitive behavioral therapy vs. Tai Chi for late life insomnia and inflammatory risk: a randomized controlled comparative efficacy trial. Sleep 37:1543–1552

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Effect of the one-shot cognitive behavioral therapy on insomnia and heart rate variability of health care workers at the time of Covid-19 pandemic: A randomized controlled trial

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