This summer, my leadership in action project was in Dr. Daniel Hall’s Lab at Massachusetts General Hospital, in the Health Promotion and Resiliency Intervention Research Program. In Dr. Hall’s lab, I was a clinical research intern and worked on various tasks and projects focused on addressing insomnia and fear of cancer recurrence among cancer survivors.
After primary treatment such as chemotherapy, radiation, and surgery, cancer survivors can face additional challenges. Cancer survivors experience a higher prevalence of insomnia at 50-60% compared to the general population at 12-25%, which may lead to serious health problems including tumor growth and increased mortality (Savard et al., 2001). This likely stems from a variety of factors including psychological issues such as anxiety and depression and treatment-induced side effects like fatigue (Johnson et al., 2016).
The insomnia project in the Hall lab is an intervention called the Survivorship Sleep Program (SSP) for addressing insomnia in cancer survivors through a virtual Cognitive Behavioral Therapy for insomnia (CBT-I). This intervention is adapted from existing CBT-I protocols and contains four 45 minute weekly, virtual, synchronous sessions with 15 minute check-ins between sessions facilitated by trained psychologists (Hall et al., submitted).
CBT-I is the most optimal non-drug treatment for insomnia and is composed of 5 main components. These include sleep restriction, sleep hygiene, stimulus control, relaxation techniques, and cognitive therapy techniques (Hall et al., submitted). Stimulus control includes using the bed only for intimacy and sleep, sleep restriction involves restricting the amount of time spent in bed, sleep hygiene includes implementing a regular sleep schedule, avoiding coffee before bed and other lifestyle changes, and cognitive therapy involves reframing negative thoughts surrounding sleep (Hall et al., submitted). Evidence has shown that CBT-I can lead to improvements in insomnia, including improved sleep efficiency (Johnson et al., 2016).
Although CBT-I is an effective treatment, there are still barriers in adhering to treatments for certain socio-economic and demographic populations (Matthews et al., 2013). There is a lack of systematic literature reviews on assessing CBT-I in non-white populations or individuals with vulnerable medical characteristics but there are a few individual studies with mixed results in identifying differences between socio-demographic factors. Cheng et al. (2019), found that digital CBT-I yielded no differences between participants depending on race/ethnicity, income, and education while other studies have found that non-white participants have lower rates of treatment initiation and experienced less treatment efficacy (Rangel et al., 2018, Garland et al., 2019, El-Solh et al., 2019). Most CBT-I studies have been conducted in high-income settings with white participants, indicating that the therapy’s costs may pose barriers for low and middle income patients to participate (Natsky et al., 2020). There is a significant need for more studies to incorporate diverse populations and study the effects of CBT-I in these individuals.
During my time in Dr. Hall’s lab, I have worked on a number of tasks that have included manuscript writing, creating presentation slides, and conducting exit interviews for our fear of cancer recurrence study. One of my significant projects during my internship was transcribing and coding 18 exit interviews from our insomnia project with other research staff members focused on assessing participants’ perceptions of the Survivorship Sleep program at the end of the program. In my independent project for my senior honors thesis, I am analyzing these exit interviews to examine whether survivors experience different benefits or challenges from the program based on their background characteristics. This project will culminate into my senior honors thesis in community health.
The research question I am examining in my senior honors thesis is “how do the experiences and outcomes from a CBT intervention vary among cancer survivors?” Since this area of the literature is understudied, I will examine whether some subgroups experience benefits or barriers from the intervention differently from other groups. Specifically, I will look at the level of education (whether participants completed college) and whether comorbid medical illness or psychiatric illness is present. The literature has thus far shown that CBT-I is effective for participants with insomnia and comorbid psychiatric and medical conditions but there is limited research surrounding the efficacy of CBT-I in cancer survivors with comorbidities beyond insomnia (Zhou et al., 2020).
In my methods, I will be examining 5 questions from our interview guide and code the responses on Nvivo, a qualitative research software tool that I will be using to identify themes in the interviews. Questions 1, 2, and 5 are related to program components and will be consolidated together for coding. Question 3 relates to adherence and asks about barriers in attending sessions and practicing techniques. Finally, question 4 inquires about changes or improvements in sleep.
I have also built many Laidlaw Leadership attributes over my experiences this summer including developing my leadership abilities, effective communication skills, collaboration and team working, and social and cultural intelligence and awareness.
I have developed my leadership abilities by taking the initiative to learn about qualitative research methods for my independent project. I took an online course on qualitative research methods, learned the qualitative research coding software Nvivo, and am currently taking a qualitative research methods class in the Community Health department at Tufts. I have also provided mentoring to junior interns in the lab. Over the course of this year, this leadership attribute will be strengthened as I write my honors thesis.
I have also improved my ability to effectively communicate through working on manuscripts, writing mentored peer-reviews of other manuscripts, and conducting exit interviews with participants. Specifically writing constructive criticism for manuscripts and helping to consolidate manuscript sections has improved my ability to write clearly. Conducting exit interviews with participants over zoom has increased my skills to listen with understanding, use digital connectivity, and speak more confidently.
Interning at Dr. Hall’s lab has also improved my collaboration and team working skills. From helping to facilitate informational interviews with researchers and oncologists I am interested in learning from to working collaboratively on a variety of projects including recruiting patients, creating presentation slides, and writing manuscripts, I have built upon my teamwork skills to better understand the power of collaboration and diverse voices from clinical research coordinators, interns and principal investigators.
Social and cultural intelligence/awareness: During my time working at MGH, I have also gained new understanding in social and cultural intelligence and awareness. According to MGH’s Annual Report on Equity in Health Care Quality (2020), 77% of MGH’s inpatient and outpatient population are white while only 6% and 5% are Black, respectively. Despite the fact that patients from all over the world and the U.S. come to these Boston institutions for treatment, many local residents of color do not have access to care at the top facilities in Boston due to factors such as lack of quality insurance and a low representation of diverse physicians. As a lab, we have discussed and examined these factors in CBT-I and plan to conduct a systematic review on CBT-I in non-white populations to further understand barriers in access to diverse populations.
Overall, my internship at Dr. Daniel Hall’s Lab at MGH has helped me strengthen a variety of leadership attributes and furthered my interests and goals in conducting clinical research in the future.
References
Cheng, P., Luik, A. I., Fellman-Couture, C., Peterson, E., Joseph, C. L. M., Tallent, G., Tran, K. M., Ahmedani, B. K., Roehrs, T., Roth, T., & Drake, C. L. (2019). Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial. Psychological Medicine, 49(3), 491–500. https://doi.org/10.1017/S0033291718001113
El-Solh, A. A., O’Brien, N., Akinnusi, M., Patel, S., Vanguru, L., & Wijewardena, C. (2019). Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder. Sleep & Breathing = Schlaf & Atmung, 23(2), 635–643. https://doi.org/10.1007/s11325-019-01840-4
Garland, S. N., Xie, S. X., DuHamel, K., Bao, T., Li, Q., Barg, F. K., Song, S., Kantoff, P., Gehrman, P., & Mao, J. J. (2019). Acupuncture Versus Cognitive Behavioral Therapy for Insomnia in Cancer Survivors: A Randomized Clinical Trial. JNCI: Journal of the National Cancer Institute, 111(12), 1323–1331. https://doi.org/10.1093/jnci/djz050
Johnson, J. A., Rash, J. A., Campbell, T. S., Savard, J., Gehrman, P. R., Perlis, M., Carlson, L. E., & Garland, S. N. (2016). A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Medicine Reviews, 27, 20–28. https://doi.org/10.1016/j.smrv.2015.07.001
Massachusetts General Hospital. (2020). Annual Report on Equity in Health Care Quality. Massachusetts General Hospital Disparities Solutions Center and MGH/MGPO Edward P. Lawrence Center for Quality and Safety. https://www.massgeneral.org/assets/MGH/pdf/quality-and-safety/Equity_Report_2020.pdf
Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J., & Aloia, M. S. (2013). Adherence to cognitive behavioral therapy for insomnia: a systematic review. Sleep Medicine Reviews, 17(6), 453–464. https://doi.org/10.1016/j.smrv.2013.01.001
Natsky, A. N., Vakulin, A., Chai-Coetzer, C. L., Lack, L., McEvoy, R. D., & Kaambwa, B. (2019). Economic evaluation of cognitive behavioural therapy for insomnia (CBT-I) for improving health outcomes in adult population: a systematic review protocol. BMJ Open, 9(11), e032176. https://doi.org/10.1136/bmjopen-2019-032176
Savard, J., & Morin, C. M. (2001). Insomnia in the context of cancer: a review of a neglected problem. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 19(3), 895–908. https://doi.org/10.1200/JCO.2001.19.3.895
Zhou, F.-C., Yang, Y., Wang, Y.-Y., Rao, W.-W., Zhang, S.-F., Zeng, L.-N., Zheng, W., Ng, C. H., Ungvari, G. S., Zhang, L., & Xiang, Y.-T. (2020). Cognitive Behavioural Therapy for Insomnia Monotherapy in Patients with Medical or Psychiatric Comorbidities: a Meta-Analysis of Randomized Controlled Trials. The Psychiatric Quarterly, 91(4), 1209–1224. https://doi.org/10.1007/s11126-020-09820-8
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