Among the most common mental illnesses worldwide, particularly in wealthy and upper-middle-class nations, alcohol use disorders are linked to high rates of death and disease burden, primarily due to medical outcomes such as liver cirrhosis or damage [1]. The expression “alcohol problems” refers to a broad spectrum of undesirable events, including health issues, alcohol dependence, and maladaptive, impaired, or hazardous behavior. Alcohol issues can affect those who drink excessively on rare occasions (accidents, violent crimes, poisoning, etc.) as well as those who drink excessively on a regular basis. For instance, there are more records of men than women having alcohol use disorders, heavy drinking, and receiving treatment for alcoholism. The condition has a varied course with high rates of remission and relapse; its manifestation varies in pattern and intensity in response to environmental factors and life events, such as traumas [2].

Moritz and Woodward [3] initially created a series of training modules known as metacognitive training based on theoretical discoveries on cognitive biases and processes. A group intervenCIMtion called “metacognitive training” informs participants about cognitive distortions and raises their awareness of the negative impacts these biases may have on their daily functioning. Previous studies on metacognitive training have reported improvements in depression and quality of life [4]. It also includes metacognitive regulatory functions, such as planning and monitoring task performance, and evaluating the efficacy of these processes. This has led to an increase in the importance of teaching metacognitive skills in various training programs. There are numerous settings and methods in which metacognitive training can be beneficial for a wide range of age groups. Thus, the primary objectives of metacognitive training are to raise metacognitive awareness and gradually teach the individual how to use metacognitive experience and knowledge to question and arrive at more complex conclusions [2].

Sleep is a more complex neurological state whose main purpose is to provide the body with rest and replenish its energy stores. Sleep disruptions that are frequent and persistent have an impact on a person’s health [5]. It has long been recognized that alcohol has a calming effect. However, excessive alcohol consumption impairs sleep quality, and insomnia is a common complaint among people with alcohol use disorders. Sleep difficulties have been linked to a number of chronic illnesses, including obesity, musculoskeletal conditions, depression, anxiety, and restless legs syndrome. Drinking alcohol also has a variety of negative effects on sleep quality. Numerous studies have demonstrated that while drinking temporarily makes people feel drowsier, it eventually leads to numerous nocturnal and early morning awakenings. In an attempt to have a better night’s sleep, people with alcohol use disorders often drink alcohol before bed. If they have insomnia, a lot of moderate drinkers also consume alcohol right before bed [6].

The term “metacognition” describes how people react to their own ideas and beliefs about sleep, which raises their level of hyperarousal in the context of sleep disturbance [7]. According to Sella et al. [8], a person’s metacognitive activity around sleep includes both their employment of thought-control strategies to address any intrusive thoughts about their sleep and their metacognitive beliefs over whether they have difficulty sleeping. Even negative and undesired thoughts may result from it. Consequently, it has been shown that controlling intrusive thoughts metacognitively before bed has a significant effect on sleep quality [9].

This gap underscores the need for empirical evidence to validate the training’s effectiveness in improving sleep quality. This study aims to provide empirical evidence supporting the use of metacognitive-based training in improving sleep quality among persons with alcohol use disorder. Therefore, this study aims to examine the effect of metacognitive-based training to improve sleep quality among persons with alcohol use disorder. It is hypothesized that the intervention group will demonstrate significantly greater improvements compared to the control group.

The study was approved by the Institutional Scientific Review Board of Saveetha College of Occupational Therapy (Ref. No. SCOT/ISRB/045/2025) on 12.02.2025. The recruited participants were informed about the objectives of the study, and written informed consent was obtained.

The research was carried out at Recovery Home Foundation, Chennai, among male patients aged 25–45 years with alcohol use disorder and poor sleep quality. A total of 60 participants were assessed for eligibility. Of these, 5 were excluded for not meeting the inclusion criteria, resulting in 55 eligible participants. Among them, 25 declined to participate due to personal reasons and time constraints. Consequently, 30 participants were allocated equally into the control group (n=15) and the experimental group (n=15). All allocated participants completed the intervention and were included in the final analysis (Figure 1).

Demographic and clinical details, including sleep patterns and sleep quality, were assessed using the Pittsburgh Sleep Quality Index (PSQI) (Supplementary Material) [10]. After baseline data were obtained, the experimental group received metacognitivebased training, whereas the control group received conventional occupational therapy sessions. The intervention for the experiment group was conducted over 12 weeks, with each session lasting approximately 1 hour and 15 minutes (Table 1). A pre-test assessment was conducted before the initiation of the therapy sessions, and a post-test assessment was conducted during the final session. After completion of the 12-week intervention period, the PSQI was administered to both groups to evaluate the effectiveness of metacognitive-based training on sleep quality among persons with alcohol use disorder (Figure 1).

Sleep quality improved significantly in both the control and experimental groups from pre-test to post-test. In the control group, the mean PSQI score decreased from 9.40±2.13 at pre-test to 8.53±1.69 at post-test (t=2.385, df=14, p=0.032), indicating a statistically significant improvement. Conventional treatment led to a statistically significant improvement in the control group (Table 2).

In the experimental group, the mean PSQI score decreased from 9.53±1.81 at pre-test to 4.87±0.83 at post-test (t=15.380, df=14, p<0.001), demonstrating a highly significant improvement. Metacognitive-based training, therefore, resulted in a highly significant improvement within the experimental group (Table 2).

Post-test scores differed significantly between the groups (t=7.555, df=28, p<0.001), with the experimental group showing a lower mean score than the control group, indicating greater improvement in sleep quality (Table 3).

Table 4 presents the clinical interpretability of PSQI scores based on the established cut-off value (>5 indicating poor sleep quality). At baseline, all participants in both the control and experimental groups (100%) had PSQI scores greater than 5, indicating poor sleep quality. Following the intervention, the control group demonstrated a reduction in mean PSQI scores, suggesting statistical improvement; however, all participants (100%) continued to score above the clinical cut-off of 5, indicating that sleep quality remained within the poor range.

In contrast, the experimental group showed substantial clinical improvement. Post-intervention, only 4 participants (26.7%) remained above the cut-off, while 11 participants (73.3%) achieved PSQI scores ≤5, reflecting a transition from poor to good sleep quality. These findings indicate that although conventional occupational therapy contributed to some improvement, metacognitive-based training resulted in both statistically significant and clinically meaningful changes in sleep quality.

The study was conducted to explore the effect of metacognitive-based training on sleep quality among persons with alcohol use disorder. The research was carried out at Recovery Home Foundation, Chennai, among male patients aged 25–45 years with alcohol use disorder and poor sleep quality.

A total of 30 participants were selected based on the inclusion and exclusion criteria. The participants were divided into two groups using a lottery method, with 15 participants allocated to the control group and 15 to the experimental group. Baseline assessment was conducted using the PSQI for both groups. The control group received conventional occupational therapy, including sleep education, sleep hygiene protocols, and relaxation techniques, whereas the experimental group received metacognitive-based training. Upon completion of the therapy program, a post-test assessment was conducted using the PSQI for both groups.

The post-test comparison between the control and experimental groups revealed a mean score of 8.53 in the control group and 4.87 in the experimental group, indicating a highly statistically significant difference (t=7.555; p<0.001), and the alternate hypothesis was accepted. These findings indicate that metacognitive-based training resulted in significantly greater improvement in sleep quality compared to conventional occupational therapy.

The results are consistent with a previous study conducted by Cheriki et al. [4], which demonstrated the effectiveness of metacognitive-based training in improving sleep quality and reducing insomnia symptoms among nurses. This supports the evidence that metacognitive-based interventions have a greater impact on sleep quality compared to conventional approaches.

Beyond statistical significance, the observed reduction in PSQI scores in the intervention group reflects a clinically meaningful improvement in sleep quality. A global PSQI score >5 is widely used to indicate poor sleep quality. At baseline, the majority of participants in both groups scored above this clinical cut-off, indicating clinically significant sleep disturbance. Following the intervention, mean PSQI scores in the metacognitive-based training group decreased to below the clinical threshold, suggesting a transition from poor to acceptable sleep quality for a substantial proportion of participants. In contrast, post-intervention scores in the control group largely remained above the cut-off, indicating persistent clinically relevant sleep problems. These findings highlight that metacognitive-based training not only produces statistically significant improvements but also yields changes that are likely to be meaningful in real-world clinical practice.

The present study has certain limitations. The sample size was small and included only male participants, which may limit the generalizability of the findings. Gender-based comparisons were not performed, and long-term follow-up was not conducted. Additionally, the study relied on self-reported measures of sleep quality and lacked assessor blinding. Future studies with larger, more diverse samples and longer follow-up periods are recommended.

This study demonstrates the effectiveness of metacognitivebased training in significantly improving sleep quality among persons with alcohol use disorder. Statistical analysis revealed a highly significant improvement in the experimental group compared to the control group following the intervention. These findings suggest that integrating metacognitive-based training can effectively address sleep quality of life in persons with alcohol use disorder. Moving forward, healthcare strategies may consider adopting this approach to enhance outcomes for this population.