Mediators of cognitive-behavioral therapy for insomnia: A review of randomized controlled trials and secondary analysis studies

CBT-I and HT-I group therapy for adults with insomnia in comparison to those with insomnia and comorbid depression - a pilot study

PURPOSE

The aim of this study was to examine the effectiveness of a combined cognitive-behavioral therapy for insomnia (CBT-I) and hypnotherapy for insomnia (HT-I) program for insomnia patients with or without additional depression regarding depressive symptoms and various sleep parameters.

PATIENTS AND METHODS

A sample of 63 patients suffering from insomnia received a six-session sleep intervention, which combined cognitive-behavioral and hypnotherapeutical elements. Due to violating exclusion criteria, data of 37 patients were analyzed. Ten patients had insomnia comorbid with depression, whereas 27 patients had insomnia only. Sleep diaries were implemented to measure various sleep parameters, whereas depressive symptomatology was assessed with the anxiety and depression scale and Symptom-Checklist-90-R at baseline, before and after the intervention, as well as at 3-months follow-up.

RESULTS

Depressive symptoms decreased from pre to post measurement and follow-up for patients with insomnia comorbid with depression, whereas scores of patients with only insomnia remained relatively on a low level. Both groups showed a significant increase of sleep efficiency and a significant decrease of the duration of wake after sleep onset. However, only patients with insomnia and depression revealed a significant reduction of sleep-onset latency and a higher level of regeneration. Nondepressive insomniacs, on the other hand, showed a significant increase of performance from post measurement to follow-up. For both groups, no change over time was found for number of wake after sleep onset, total sleep time, mood in the morning and evening.

CONCLUSION

Combining CBT-I and HT-I is effective in reducing depressive symptoms and improving sleep. Therefore, nonresponders to other forms of therapy, eg, pharmacological, interpersonal, or cognitive-behavioral therapy, might benefit from the combined CBT-I/HT-I intervention.

Usefulness of psychoeducational intervention in chronic insomnia: an actigraphic study

Background: Chronic Insomnia is a severe and disabling condition characterized by difficulty in initiating or maintaining sleep, waking up too early, despite adequate opportunity and circumstances for sleep. Maladaptive thoughts and dysfunctional beliefs about sleep are considered crucial factors in developing and perpetuating this disorder.Aims: The aim of the study was to explore the usefulness, in patients with chronic insomnia, of a one-session psychoeducational intervention on sleep-related maladaptive thoughts and beliefs, and on sleep perception.Methods: Thirty-eight patients with chronic insomnia were enrolled in the study and randomly assigned to receive psychoeducational intervention (PI+) or to act as controls (PI-). Patients wore an actigraph and compiled a sleep diary for 14 d. After the first 7 d, only PI+ patients received one session of psychoeducational intervention.Results: A significant reduction of sleep related preoccupations, a reduction of dysfunctional beliefs about sleep, and an improvement of subjective perception of sleep were observed in the PI+ group, but not in the PI- group. No significant modification was observed for objective total sleep time.Conclusions: Our results suggest that one-session psychoeducational intervention is associated with a decrease of sleep-related maladaptive thoughts and beliefs, and with an improvement on subjective sleep perception.

Cognitive mechanisms of sleep outcomes in a randomized clinical trial of internet-based cognitive behavioral therapy for insomnia

OBJECTIVE

The aim of this study was to investigate in a randomized clinical trial the role of sleep-related cognitive variables in the long-term efficacy of an online, fully automated cognitive behavioral therapy intervention for insomnia (CBT-I) (Sleep Healthy Using the Internet [SHUTi]).

METHOD

Three hundred and three participants (M_age = 43.3 years; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline, postintervention (nine weeks after baseline), and six and 12 months after the intervention period. Cognitive variables were self-reported internal and chance sleep locus of control, dysfunctional beliefs and attitudes about sleep (DBAS), sleep specific self-efficacy, and insomnia knowledge. Primary outcomes were self-reported online ratings of insomnia severity (Insomnia Severity Index), and sleep onset latency and wake after sleep onset from online sleep diaries, collected 12 months after the intervention period.

RESULTS

Those who received SHUTi had, at postassessment, higher levels of insomnia knowledge (95% confidence interval [CI] = 0.10-0.16) and internal sleep locus of control (95% CI = 0.04-0.55) as well as lower DBAS (95% CI = 1.52-2.39) and sleep locus of control attributed to chance (95% CI = 0.15-0.71). Insomnia knowledge, chance sleep locus of control, and DBAS mediated the relationship between condition and at least one 12-month postassessment sleep outcome. Within the SHUTi condition, changes in each cognitive variable (with the exception of internal sleep locus of control) predicted improvement in at least one sleep outcome one year later.

CONCLUSION

Online CBT-I may reduce the enormous public health burden of insomnia by changing underlying cognitive variables that lead to long-term changes in sleep outcomes.

Night-to-Night Sleep Variability in Older Adults With Chronic Insomnia: Mediators and Moderators in a Randomized Controlled Trial of Brief Behavioral Therapy (BBT-I)

STUDY OBJECTIVES

Sleep variability is a clinically significant variable in understanding and treating insomnia in older adults. The current study examined changes in sleep variability in the course of brief behavioral therapy for insomnia (BBT-I) in older adults who had chronic insomnia. Additionally, the current study examined the mediating mechanisms underlying reductions of sleep variability and the moderating effects of baseline sleep variability on treatment responsiveness.

METHODS

Sixty-two elderly participants were randomly assigned to either BBT-I or self-monitoring and attention control (SMAC). Sleep was assessed by sleep diaries and actigraphy from baseline to posttreatment and at 3-month follow-up. Mixed models were used to examine changes in sleep variability (within-person standard deviations of weekly sleep parameters) and the hypothesized mediation and moderation effects.

RESULTS

Variabilities in sleep diary-assessed sleep onset latency (SOL) and actigraphy-assessed total sleep time (TST) significantly decreased in BBT-I compared to SMAC (Pseudo R² = .12, .27; P = .018, .008). These effects were mediated by reductions in bedtime and wake time variability and time in bed. Significant time × group × baseline sleep variability interactions on sleep outcomes indicated that participants who had higher baseline sleep variability were more responsive to BBT-I; their actigraphy-assessed TST, SOL, and sleep efficiency improved to a greater degree (Pseudo R² = .15 to .66; P < .001 to .044).

CONCLUSIONS

BBT-I is effective in reducing sleep variability in older adults who have chronic insomnia. Increased consistency in bedtime and wake time and decreased time in bed mediate reductions of sleep variability. Baseline sleep variability may serve as a marker of high treatment responsiveness to BBT-I.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02967185.

Mediators and treatment matching in behavior therapy, cognitive therapy and cognitive behavior therapy for chronic insomnia

OBJECTIVE

To examine the mediators and the potential of treatment matching to improve outcome for cognitive behavior therapy (CBT) for insomnia.

METHOD

Participants were 188 adults (117 women; Mage = 47.4 years, SD = 12.6) meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) diagnostic criteria for chronic insomnia (Mduration: 14.5 years, SD: 12.8). Participants were randomized to behavior therapy (BT; n = 63), cognitive therapy (CT; n = 65), or CBT (n = 60). The outcome measure was the Insomnia Severity Index (ISI). Hypothesized BT mediators were sleep-incompatible behaviors, bedtime variability (BTv), risetime variability (RTv) and time in bed (TIB). Hypothesized CT mediators were worry, unhelpful beliefs, and monitoring for sleep-related threat.

RESULTS

The behavioral processes mediated outcome for BT but not CT. The cognitive processes mediated outcome in both BT and CT. The subgroup scoring high on both behavioral and cognitive processes had a marginally significant better outcome if they received CBT relative to BT or CT. The subgroup scoring relatively high on behavioral but low on cognitive processes and received BT or CBT did not differ from those who received CT. The subgroup scoring relatively high on cognitive but low on behavioral processes and received CT or CBT did not differ from those who received BT.

CONCLUSION

The behavioral mediators were specific to BT relative to CT. The cognitive mediators were significant for both BT and CT outcomes. Patients exhibiting high levels of both behavioral and cognitive processes achieve better outcome if they receive CBT relative to BT or CT alone. (PsycINFO Database Record

Precision medicine in circadian rhythm sleep-wake disorders: current state and future perspectives

In circadian rhythm sleep-wake disorders precision medicine is less developed than in other medical disciplines mainly because homeostatic sleep and circadian timing have a very complex phenotype with multiple genetic regulation mechanisms. However, biomarkers, phenotyping and psychosocial characteristics are increasingly used. Devices for polysomnography, actigraphy and sleep-tracking applications in mobile phones and other consumer devices with eHealth technologies are increasingly used. Also sleep-related questionnaires and the assessment of co-morbidities influencing sleep in circadian rhythm sleep-wake disorders are major contributors to precision sleep medicine. To further strengthen the (pharmaco-)genetic and biomarker pillar, technology needs to be evolved further. Routinely measuring treatment results using patient-reported outcome measures and clinical neurophysiological instruments will boost precision sleep medicine.

Cognitive Behavioural Therapy for Insomnia in Psychiatric Disorders

Insomnia means difficulties in initiating or maintaining sleep and is commonly comorbid with psychiatric disorders. From being considered secondary to primary psychiatric disorders, comorbid insomnia is now considered an independent health issue that warrants treatment in its own right. Cognitive behavioural therapy for insomnia (CBT-I) is an evidence-based treatment for insomnia. The effects from CBT-I on comorbid psychiatric conditions have received increasing interest as insomnia comorbid with psychiatric disorders has been associated with more severe psychiatric symptomologies, and there are studies that indicate effects from CBT-I on both insomnia and psychiatric symptomology. During recent years, the literature on CBT-I for comorbid psychiatric groups has expanded and has advanced methodologically. This article reviews recent studies on the effects from CBT-I on sleep, daytime symptoms and function and psychiatric comorbidities for people with anxiety, depression, bipolar disorder, psychotic disorders and post-traumatic stress disorder. Future strategies for research are suggested.

Psychometric Comparison of the Full and Abbreviated Versions of the Dysfunctional Beliefs and Attitudes about Sleep Scale

STUDY OBJECTIVES

The different versions of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) have limited comparison and summary of the findings across studies. We aimed to examine which version and which subscales had better psychometric properties.

METHODS

Data were derived from a randomized controlled trial of internet-based cognitive-behavioral therapy for insomnia (CBT-I) vs. waitlist in 312 participants with self-report diagnosis of insomnia disorder. The response distribution, internal consistency, construct and concurrent validity, and sensitivity to change were analyzed.

RESULTS

Floor or ceiling effects were found in 19 of the 30 DBAS items. Item-total correlation was < 0.30 in 43.3%, 31.3%, and 10.0% of the items in DBAS-30, DBAS-16, DBAS-10. Internal consistency was satisfactory for total scores, with Cronbach α ranging from 0.73-0.81, but 2 subscales of DBAS-30 and 1 subscale of DBAS-10 had Cronbach α < 0.35. Factor analysis produced 8, 4, and 3 factors for DBAS-30, DBAS-16, and DBAS-10. Only the factor structure of DBAS-16 was compatible with previous studies. Concurrent validity with insomnia, anxiety, and depressive symptoms was much stronger than with sleep diary parameters. Sensitivities to change of the DBAS scores following CBT-I and with sleep improvement were found, except the DBAS-30 "attributions" subscale and DBAS-16 "medication" subscale.

CONCLUSIONS

The DBAS-16 possesses better internal consistency, a reproducible factor structure, strong concurrent validity, and sensitivity to change, and therefore is recommended for research use. The DBAS-30 and DBAS-10 have their own strengths, but there are limitations in their application as a quantitative measure in research.

Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors

STUDY OBJECTIVES

This study involves the analysis of a secondary outcome of a trial examining whether cognitive behavior therapy for insomnia (CBT-I), a wake-promoting medication (armodafinil), or both results in greater improvement in prospectively assessed sleep continuity and daytime sleepiness than a placebo-alone group among a heterogeneous group of cancer survivors. Whether or not armodafinil alone, and/or when combined with CBT-I, affected adherence with CBT-I was evaluated.

DESIGN

This study is a randomized, placebo-controlled, clinical trial.

SETTING

This study was conducted at two northeastern academic medical centers.

PARTICIPANTS

Eighty-eight cancer survivors with chronic insomnia were recruited between October 2008 and November 2012. Participants were assigned to one of four conditions: 1) CBT-I and placebo (CBT-I+P); 2) CBT-I and armodafinil (CBT-I + A); 2) armodafinil alone (ARM); or 4) placebo alone (PLA).

INTERVENTIONS

CBT-I was delivered in seven weekly individual therapy sessions (three in person, four via telephone). The armodafinil dosage was 50 mg BID.

MEASUREMENTS AND RESULTS

Sleep continuity was measured with daily sleep diaries assessing sleep latency (SL), wake after sleep onset (WASO), and total sleep time (TST). The Epworth Sleepiness Scale (ESS) measured daytime sleepiness. Compared to the PLA group, the CBT-I+P and CBT-I+A groups reported a significant reduction in SL with effect sizes of 0.67 and 0.58, respectively. A significant reduction was observed in WASO in the CBT-I+A group with an effect size of 0.64. An increasing trend of TST was observed in the CBT-I+P, CBT-I+A, and PLA groups, but not in the ARM group. No statistically significant reductions in daytime sleepiness (ESS) were observed for any of the groups.

CONCLUSION

CBT-I alone and in combination with armodafinil caused significant improvement in sleep continuity. The addition of armodafinil did not appear to improve daytime sleepiness or enhance adherence to CBT-I.

Effects of cognitive behavioral therapy in patients with depressive disorder and comorbid insomnia: A propensity score-matched outcome study

OBJECTIVE

We evaluated the effects of cognitive behavioral therapy for insomnia (CBT-I) in inpatients with a diagnosis of depression and comorbid insomnia.

METHOD

This study used a prospective, parallel-group design. The experimental group received CBT-I for no more than 90 min once weekly for 6 weeks and the control group only have health education manuals for insomnia. The following questionnaires were administered at baseline: the Hamilton Rating Scale for Depression (HAM-D), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), Presleep Arousal Scale (PSAS), Sleep Hygiene Practice (SHP), and Pittsburgh Sleep Quality Index. The questionnaires were readministered after the completion of the 6-wk CBT-I intervention and 1 month following the completion of CBT-I, to determine the effects of the CBT-I intervention over time. The analysis of Generalized Estimation Equations was identified the difference between the experimental group and the control group by controlling for the variables in BZD dose and propensity score of gender, age, and the scores for the DBAS-16, PSAS, SHPS, and HAM-D.

RESULTS

Consequently, the significant difference in the PSQI scores was observed at the 1-month follow-up assessment however, no significant intergroup difference in the PSQI scores was found at the completion of the CBT-I intervention between two groups.

CONCLUSIONS

As a conclusion, we found that overall sleep quality significantly improved in patients who received CBT-I after we controlled for the BZD dose and propensity score, which suggests that CBT-I may represent a useful clinical strategy for improving sleep quality in patients with depression and comorbid insomnia.

Functional capacity and heart rate response: associations with nocturnal hypertension

Background

Absences of normative, 10–20 % declines in blood pressure (BP) at night, termed nocturnal non-dipping, are linked to increased cardiovascular mortality risks. Current literature has linked these absences to psychological states, hormonal imbalance, and disorders involving hyper-arousal. This study focuses on evaluating associations between nocturnal non-dipping and indices of functional cardiac capacity and fitness.

Methods

The current study was a cross-sectional evaluation of the associations between physical capacity variables e.g. Metabolic Equivalent (MET) and Maximum Heart Rate (MHR), Heart rate reserve (HRR), and degree of reduction in nocturnal systolic blood pressure (SBP) or diastolic blood pressure (DBP), also known as ‘dipping’. The study sample included 96 cardiac patient participants assessed for physical capacity and ambulatory blood pressure monitoring. In addition to evaluating differences between groups on nocturnal BP ‘dipping’, physical capacity, diagnoses, and medications, linear regression analyses were used to evaluate potential associations between nocturnal SBP and DBP ‘dipping’, and physical capacity indices.

Results

45 males and 14 females or 61.5 % of 96 consented participants met criteria as non-dippers (<10 % drop in nocturnal BP). Although non-dippers were older (p = .01) and had a lower maximum heart rate during the Bruce stress test (p = .05), dipping was only significantly associated with Type 2 Diabetes co-morbidity and was not associated with type of medication. Within separate linear regression models controlling for participant sex, MHR (β = 0.26, p = .01, R² = .06), HRR (β = 0. 19, p = .05, R² = .05), and METs (β = 0.21, p = .04, R² = .04) emerged as significant but small predictors of degree of nighttime SBP dipping. Similar relationships were not observed for DBP.

Conclusions

Since the variables reflecting basic heart function and fitness (MHR and METs), did not account for appreciable variances in nighttime BP, nocturnal hypertension appears to be a complex, multi-faceted phenomena.

Reducing dysfunctional beliefs about sleep does not significantly improve insomnia in cognitive behavioral therapy

The present study examined to examine whether improvement of insomnia is mediated by a reduction in sleep-related dysfunctional beliefs through cognitive behavioral therapy for insomnia. In total, 64 patients with chronic insomnia received cognitive behavioral therapy for insomnia consisting of 6 biweekly individual treatment sessions of 50 minutes in length. Participants were asked to complete the Athens Insomnia Scale and the Dysfunctional Beliefs and Attitudes about Sleep scale both at the baseline and at the end of treatment. The results showed that although cognitive behavioral therapy for insomnia greatly reduced individuals’ scores on both scales, the decrease in dysfunctional beliefs and attitudes about sleep with treatment did not seem to mediate improvement in insomnia. The findings suggest that sleep-related dysfunctional beliefs endorsed by patients with chronic insomnia may be attenuated by cognitive behavioral therapy for insomnia, but changes in such beliefs are not likely to play a crucial role in reducing the severity of insomnia.

Who benefits from CBT for insomnia in primary care? Important patient selection and trial design lessons from longitudinal results of the Lifestyles trial

STUDY OBJECTIVES

Evaluate long-term effects of group interventions on sleep and pain outcomes in a primary care population of older adults with osteoarthritis pain and sleep disturbance.

DESIGN

Double-blind, cluster-randomized controlled trial with 18-mo follow-up.

SETTING

Group Health and University of Washington, Seattle, WA, from 2009 to 2011.

PARTICIPANTS

Three hundred sixty-seven adults age 60 y and older, with osteoarthritis pain and insomnia symptoms.

INTERVENTIONS

Six weekly sessions of group cognitive behavioral therapy for insomnia and pain (CBT-PI), pain alone (CBT-P), and education-only control (EOC) delivered in patients' primary care clinics.

MEASUREMENTS AND RESULTS

There were no significant differences between treatment groups in sleep outcomes at 18 mo. This is a change from published significant 9-mo follow-up results for insomnia severity (Insomnia Severity Index) and sleep efficiency. There were no significant treatment differences in pain at either follow-up. Post hoc analyses of participants with greater insomnia and pain severity at baseline (n = 98) showed significant (P = 0.01) 18-mo reductions in pain comparing CBT-PI versus CBT-P (adjusted mean difference [AMD] = -1.29 [95% confidence interval (CI): -2.24,-0.33]). Moderate, albeit nonsignificant, CBT-PI versus EOC treatment effects for insomnia severity (AMD = -1.43 [95% CI: -4.71, 1.86]) and sleep efficiency (AMD = 2.50 [95% CI: -5.04, 10.05]) were also observed. Possible trial design and methodological considerations that may have affected results are discussed.

CONCLUSIONS

Results suggest patients with higher levels of comorbid pain and insomnia may be most likely to experience sustained benefit from cognitive behavioral therapy interventions over time, and inclusion of insomnia treatment may yield more clinically meaningful improvements than cognitive behavioral therapy for pain alone.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01142349.

From bedside back to bench? A commentary on: "The future of cognitive behavioral therapy for insomnia: what important research remains to be done?"

In this month's issue of the Journal of Clinical Psychology, Vitiello and colleagues articulate an important research agenda that will help advance cognitive-behavioral therapy for insomnia (CBT-I) research and clinical practice. In addition to this ambitious agenda, we also propose that pursuing a parallel research program, focusing on treatment mechanisms and process will help move the CBT-I field forward and optimize therapeutic dissemination and uptake.