Who is at risk for dropout from group cognitive-behavior therapy for insomnia?

Predictors of Adherence to Psychological Treatment for Insomnia and Pain: Analysis from a Randomized Trial

OBJECTIVES

Poor adherence to psychological treatment for insomnia is common and limits treatment gains. Very little is known about predictors of adherence among patients with chronic pain, although adherence is theorized to be more critical and more challenging for these patients. This secondary data analysis examines predictors of drop-out and therapy nonattendance in an osteoarthritis population receiving psychological treatment for insomnia and pain.

METHODS

Data were analyzed from the "Lifestyles" trial, a randomized controlled trial of a 6-week group cognitive behavioral pain coping skills intervention (CBT-P), group cognitive-behavioral therapy for pain and insomnia (CBT-PI), and an education only attention control group (EOC). The current analysis focuses on 122 participants randomized to CBT-PI from 6 primary care clinics. Measures of treatment acceptability, demographics, and symptoms were collected at baseline. Factor analysis was used to clarify the boundaries of these domains, and hierarchical regression was used to examine the incremental predictive power of these patient characteristics on therapy attendance.

RESULTS

Ratings of treatment acceptability were distinct from demographic and medical variables and baseline symptoms. Treatment acceptability was significantly related to session attendance and drop-out (rs ranging from 0.24 to 0.32) and was also one of the strongest predictors of session attendance (β=0.20; P<0.05).

DISCUSSION

Perceptions of treatment acceptability early in treatment represent a potentially modifiable target to enhance adherence to psychological treatment for insomnia and pain among patients with chronic pain. This work represents an important step towards understanding how to best maximize sleep treatments for this patient population.

Delivering Cognitive Behavioral Therapy for Insomnia in the Real World: Considerations and Controversies

Cognitive-behavioral therapy for insomnia (CBT-I) has emerged as the first-line treatment for chronic insomnia but remains massively underused relative to the prevalence of insomnia disorder. This article focuses on 3 key issues in the delivery of CBT-I in the real world. First, where and how should CBT-I be delivered and who should deliver it? Second, who is an appropriate candidate for CBT-I? Third, how do you measure quality care with CBT-I? These issues give rise to targets for future research aimed at improving the implementation science of CBT-I in the real world.

Online Delivery of Cognitive Behavioral Therapy-Insomnia: Considerations and Controversies

This article reviews the current state of research and clinical use of online delivery of cognitive behavioral therapy for insomnia. Strengths and limitations of this treatment modality are discussed, as well as exploration of some of the controversies in the field that are still under exploration. In addition, the article explores future areas of research to test out the role of this treatment as an entry level into a stepped care model of insomnia.

Predictors of treatment attendance and adherence to treatment recommendations among individuals receiving Cognitive Behavioral Therapy for Insomnia

Insomnia disorders affect up to 10% of adults and are associated with other health problems and poor quality of life. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment; however, its effectiveness is hindered by poor attendance and adherence to treatment recommendations. The present study sought to identify predictors of attendance and adherence in CBT-I. Participants were 108 adults with insomnia disorder. Participants were primarily female (71.3%), middle aged (mean age = 50.5), and Caucasian (92.6%). Demographic variables, physical health problems, Beck Anxiety Inventory, Center for Epidemiologic Studies Depression-Revised scale, and Insomnia Severity Index were used to predict attending three or more sessions and adherence to consistent bedtime and waketime. Higher age was associated with better attendance and less deviation in bed and wake times. Anxiety and depression symptoms were associated with less attendance, and depression was also associated with more deviation in waketimes. To promote better attendance and adherence in treatment, depression or anxiety symptoms should be addressed before or during CBT-I. Identifying and tailoring CBT-I treatments toward the needs of different age groups may also improve attendance and adherence.

Impact Of Phenotypic Heterogeneity Of Insomnia On The Patients' Response To Cognitive-Behavioral Therapy For Insomnia: Current Perspectives

Insomnia is one of the most common mental disorders and the most frequent sleep disorder encountered in clinical practice, with a prevalence of about 7% in the European population. Insomnia Disorder (ID) is defined as a disturbance of sleep initiation or maintenance, followed by a feeling of non-restorative sleep and several diurnal consequences ranging from occupational and social difficulties to cognitive impairment. Cognitive-Behavioral Therapy for Insomnia (CBT-I) is considered the first-choice therapy for this disorder because its effectiveness has been proven to be greater in the long term with fewer side effects in comparison to pharmacotherapy. Although its effectiveness has been well established, it has been reported that nearly 40% of patients do not achieve remission after treatment. This finding could be the consequence of heterogeneity of ID between patients. It has been proposed that this heterogeneity might be ascribable to indices that are not related to sleep quality and quantity, such as comorbidities, life events, and personality traits. However, several works focused on the role of sleep markers, in particular objective total sleep time, for the phenotypization of ID and treatment response. The aim of this work is to summarize the available scientific literature regarding the impact of ID subtype on CBT-I response.

Clinical Feasibility of a Just-in-Time Adaptive Intervention App (iREST) as a Behavioral Sleep Treatment in a Military Population: Feasibility Comparative Effectiveness Study

Background

Although evidence-based cognitive behavioral sleep treatments have been shown to be safe and effective, these treatments have limited scalability. Mobile health tools can address this scalability challenge. iREST, or interactive Resilience Enhancing Sleep Tactics, is a mobile health platform designed to provide a just-in-time adaptive intervention (JITAI) in the assessment, monitoring, and delivery of evidence-based sleep recommendations in a scalable and personalized manner. The platform includes a mobile phone–based patient app linked to a clinician portal.

Objective

The first aim of the pilot study was to evaluate the effectiveness of JITAI using the iREST platform for delivering evidence-based sleep interventions in a sample of military service members and veterans. The second aim was to explore the potential effectiveness of this treatment delivery form relative to habitual in-person delivery.

Methods

In this pilot study, military service members and veterans between the ages of 18 and 60 years who reported clinically significant service-related sleep disturbances were enrolled as participants. Participants were asked to use iREST for a period of 4 to 6 weeks during which time they completed a daily sleep/wake diary. Through the clinician portal, trained clinicians offered recommendations consistent with evidence-based behavioral sleep treatments on weeks 2 through 4. To explore potential effectiveness, self-report measures were used, including the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI), and the PSQI Addendum for Posttraumatic Stress Disorder.

Results

A total of 27 participants completed the posttreatment assessments. Between pre- and postintervention, clinically and statistically significant improvements in primary and secondary outcomes were detected (eg, a mean reduction on the ISI of 9.96, t₂₆=9.99, P<.001). At posttreatment, 70% (19/27) of participants met the criteria for treatment response and 59% (16/27) achieved remission. Comparing these response and remission rates with previously published results for in-person trials showed no significant differences.

Conclusion

Participants who received evidence-based recommendations from their assigned clinicians through the iREST platform showed clinically significant improvements in insomnia severity, overall sleep quality, and disruptive nocturnal disturbances. These findings are promising, and a larger noninferiority clinical trial is warranted.

Program Evaluation of Group-based Cognitive Behavioral Therapy for Insomnia: a Focus on Treatment Adherence and Outcomes in Older Adults with Co-morbidities

OBJECTIVE

To describe a program evaluation of the interrelationship of adherence and treatment outcomes in a sample of veteran older adults with co-morbidities who participated in group-based cognitive behavioral therapy for insomnia.

METHODS

Retrospective data extraction was performed for 14 older adults. Adherence measures and sleep outcomes were measured with sleep diaries and Insomnia Severity Index. Demographic and clinical information was extracted through chart review.

RESULTS

Adherence with prescribed time in bed, daily sleep diaries, and maintaining consistent time out of bed and time in bed was generally high. There were moderate, though not significant, improvements in consistency of time in bed and time out of bed over time. Adherence was not significantly associated with sleep outcomes despite improvements in most sleep outcomes.

CONCLUSIONS

The non-significant relationship between sleep outcomes and adherence may reflect the moderating influence of co-morbidities or may suggest a threshold effect beyond which stricter adherence has a limited impact on outcomes.

CLINICAL IMPLICATIONS

Development of multi-method adherence measures across all treatment components will be important to understand the influence of adherence on treatment outcomes as monitoring adherence to time in bed and time out of bed had limited utility for understanding treatment outcomes in our sample.

Zolpidem Overdose: A Dilemma in Mental Health

Sleeping pills are one of the most common drugs taken by adults when afflicted by insomnia. Adverse effects of pharmacotherapy, however, should not be overlooked, and monitoring is needed to check for an overdose of sleeping pills. We reviewed zolpidem overdose and patient suicide with benefits and disadvantages of pharmacotherapy. Cases of adverse effects concerning the central nervous system, including delirium and hallucination, as well as abnormal behavior during sleep, are commonly reported among patients who have taken zolpidem for more than 1 year. The serious problem of long-term prescription to medication can lead to a higher mortality rate of insomniac patients. An alternative to medication for treating insomnia is cognitive behavioral therapy, which can improve sleeping habits. Cognitive behavioral therapy induces patients to recognize and change the negative thoughts that affect their sleep. Medical providers should be aware of the adverse effects of sleep inducers and provide sufficient information to their patients about them. When establishing treatment plans, they should encourage patients to make the proper decisions and try to reduce the adverse effects of any medication as much as possible.

An Update on Dual Orexin Receptor Antagonists and Their Potential Role in Insomnia Therapeutics

STUDY OBJECTIVES

Current pharmacological options for the treatment of insomnia insufficiently meet the needs of all insomnia patients. Approved treatments are not consistently effective in improving sleep onset and sleep maintenance, while also having complicated safety profiles. These limitations highlight the unmet need for additional medications and treatment strategies. Initial research suggests that the dual orexin receptor antagonists (DORAs) may offer an additional pharmaceutical option to treat insomnia in some patients.

METHODS

We reviewed the existing literature on dual orexin receptor antagonists in PubMed databases using the search terms "orexin receptor antagonist," "almorexant" "filorexant," "lembroexant" and "suvorexant"; searches were limited to English language primary research articles, clinical trials, and reviews.

RESULTS

Targeting the orexin receptor system for treatment of insomnia offers an additional and alternative pharmacological approach to more common gamma aminobutyric acid agonist sedative hypnotic treatment. Effectiveness is not well established in the current literature; however, the literature does suggest efficacy. Preclinical reports also suggest the potential for treatment in individuals with comorbid Alzheimer disease and insomnia.

CONCLUSIONS

DORAs offer an additional treatment option for insomnia. More clinical trials are needed to robustly evaluate their safety and effectiveness in several subclasses of individuals with insomnia. Given the published literature, head-to-head comparisons to existing treatment for insomnia are warranted.

Factors that shape preference for acupuncture or cognitive behavioral therapy for the treatment of insomnia in cancer patients

PURPOSE

Patient preference is an essential component of patient-centered supportive cancer care; however, little is known about the factors that shape preference for treatment. This study sought to understand what factors may contribute to patient preference for two non-pharmacological interventions, acupuncture or cognitive behavioral therapy for insomnia (CBT-I).

METHODS

We conducted individual, open-ended, semi-structured interviews among cancer survivors who had completed active treatment and met the diagnostic criteria for insomnia disorder. Two forms of codes were used for analysis: a priori set of codes derived from the key ideas and a set of codes that emerged from the data.

RESULTS

Among 53 participants, the median age was 60.7 (range 27-83), 30 participants (56.6%) were female, and 18 (34%) were non-white. We identified three themes that contributed to an individual's treatment preference: perception of the treatment's evidence base, experience with the treatment, and consideration of personal factors. Participants gave preference to the treatment perceived as having stronger evidence. Participants also reflected on positive or negative experiences with both of the interventions, counting their own experiences, as well as those of trusted sources. Lastly, participants considered their own unique circumstances and factors such as the amount of work involved, fit with personality, or fit with their "type" of insomnia.

CONCLUSIONS

Knowledge of the evidence base, past experience, and personal factors shaped patient preference regardless of whether they accurately represent the evidence. Acknowledging these salient factors may help inform patient-centered decision-making and care.

Who benefits from adolescent sleep interventions? Moderators of treatment efficacy in a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep intervention for at-risk adolescents

BACKGROUND

The aim of this study was to test moderators of therapeutic improvement in an adolescent cognitive-behavioral and mindfulness-based group sleep intervention. Specifically, we examined whether the effects of the program on postintervention sleep outcomes were dependent on participant gender and/or measures of sleep duration, anxiety, depression, and self-efficacy prior to the interventions.

METHOD

Secondary analysis of a randomized controlled trial conducted with 123 adolescent participants (female = 59.34%; mean age = 14.48 years, range 12.04-16.31 years) who had elevated levels of sleep problems and anxiety symptoms. Participants were randomized into either a group sleep improvement intervention (n = 63) or group active control 'study skills' intervention (n = 60). The sleep intervention ('Sleep SENSE') was cognitive behavioral in approach, incorporating sleep education, sleep hygiene, stimulus control, and cognitive restructuring, but also had added anxiety-reducing, mindfulness, and motivational interviewing elements. Components of the active control intervention ('Study SENSE') included personal organization, persuasive writing, critical reading, referencing, memorization, and note taking. Participants completed the Pittsburgh Sleep Quality Index (PSQI), Spence Children's Anxiety Scale (SCAS), Center for Epidemiologic Studies Depression Scale (CES-D), and General Self-Efficacy Scale (GSE) and wore an actigraph and completed a sleep diary for five school nights prior to the interventions. Sleep assessments were repeated at postintervention. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001177842; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12612001177842&isBasic=True).

RESULTS

The results showed that compared with the active control intervention, the effect of the sleep intervention on self-reported sleep quality (PSQI global score) at postintervention was statistically significant among adolescents with relatively moderate to high SCAS, CES-D, and GSE prior to the intervention, but not among adolescents with relatively low SCAS, CES-D, and GSE prior to the intervention. The results were consistent across genders. However, the effects of the sleep intervention on actigraphy-measured sleep onset latency and sleep diary-measured sleep efficiency at postintervention were not dependent on actigraphy-measured total sleep time, SCAS, CES-D, or GSE prior to the intervention.

CONCLUSIONS

This study provides evidence that some sleep benefits of adolescent cognitive-behavioral sleep interventions are greatest among those with higher levels of anxiety and depressive symptoms, suggesting that this may be an especially propitious group to whom intervention efforts could be targeted. Furthermore, adolescents with lower levels of self-efficacy may need further targeted support (e.g. additional motivational interviewing) to help them reach treatment goals.

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.

Early termination of cognitive-behavioural interventions: literature review

Aims and method

The evidence of the efficacy of cognitive-behavioural interventions is well established. Despite this, clinicians often face a consistent number of not attended appointments or early treatment discontinuation rates. This paper reviews the literature to date regarding the possible causes of early termination of cognitive-behavioural interventions. A literature search was done using Medline, PsycINFO, Embase and the Cochrane Library.

Results

We reviewed 14 articles. Out of these, two were randomised controlled trials, one was a controlled trial and the rest were cohort studies. Drop-out was defined differently across papers. There are many factors that may affect early treatment discontinuation rates and they are described individually.

Clinical implications

There does not appear to be a single strong predictor of early treatment discontinuation. Specific literature relating to cognitive-behavioural therapy is scarce. However, some factors such as young age, education level and psychopathology appear to be more strongly associated with early treatment discontinuation than others.

A randomized clinical trial examining the effects of an anxiety sensitivity intervention on insomnia symptoms: Replication and extension

Insomnia disorder is impairing and prevalent, particularly among individuals with comorbid anxiety disorders. Despite the availability of effective computerized treatments for insomnia, there are few that target both insomnia as well as co-occurring anxiety symptoms. The current study tests the efficacy of a computerized treatment for anxiety sensitivity cognitive concerns, a transdiagnostic risk factor for anxiety, mood, and insomnia symptoms, against a repeated contact control, on reducing insomnia symptoms. Hypotheses were tested in a mixed clinical sample of community individuals presenting for a treatment study (n = 151) who were followed up 1-, 3- and 6-months after treatment. Results indicated that the anxiety sensitivity intervention resulted in reductions in insomnia symptoms and clinically significant insomnia scores at 3- and 6-month follow-ups. These reductions remained significant when covarying for concurrent reductions in depression and anxiety. Models accounted for 15-54% of the variance in follow-up insomnia symptoms. Current findings add to a growing body of literature suggesting anxiety sensitivity may play a causal role in insomnia symptoms. Results also suggest that targeting anxiety sensitivity may be an effective way to reduce insomnia symptoms in a brief and portable intervention that also reduces symptoms commonly comorbid with insomnia disorder.

Pilot study comparing telephone to in-person delivery of cognitive-behavioural therapy for trauma-related insomnia for rural veterans

Introduction

It is estimated that 70% of patients with posttraumatic stress disorder (PTSD) have chronic insomnia. A recent meta-analysis examined cognitive-behavioural therapy for insomnia (CBT-I) in veterans with and without PTSD, and suggested that most studies had questionable methodology, but generally supported its effectiveness in this population. Further, while CBT-I via telehealth (i.e. using telecommunication and information technology to deliver health services) has shown effectiveness for primary insomnia, it has not been applied to PTSD-related insomnia.

Methods

Veterans with insomnia who were diagnosed with PTSD ( n = 12) or having significant subthreshold PTSD symptoms ( n = 6) on the Clinician Administered PTSD Scale were randomly assigned to receive CBT-I in-person ( n = 7) or by telephone ( n = 11), to pilot test the potential effectiveness, acceptability, and feasibility of administering CBT-I in rural veterans. A six-week CBT-I protocol was delivered, and the veteran’s insomnia was assessed at post-treatment and follow-up.

Results

Given the small sample size, Cohen’s d was used to detect group differences, finding large effect sizes favouring the in-person delivery, until three-months post-treatment when this difference diminished. Most veterans found the treatment acceptable, regardless of mode of delivery. Based on the results, a larger project is feasible. Feasibility for a larger project is favourable.

Discussion

In summary, our findings uphold and extend previous research. Specifically, current pilot data suggest that telephone-delivered CBT-I may be able to reduce trauma-related insomnia symptoms. Future trials are needed to assess the effectiveness of CBT-I delivered to rural veterans with posttraumatic insomnia.

Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy

Insomnia and disturbed sleep are common during pregnancy. This study investigated the effectiveness of group cognitive-behavioral therapy for insomnia (CBT-I) delivered in pregnancy. Thirteen pregnant women with insomnia participated in five weekly CBT-I group sessions. All participants completed the study and provided baseline and follow-up data. Significant reductions in insomnia symptoms and increases in subjective sleep quality were observed over the course of the study. Diary and actigraphy assessments of sleep also changed, such that participants reported less time in bed (TIB), shorter sleep onset latency (SOL), increased sleep efficiency (SE), and increased subjective total sleep time (TST). Additionally, symptoms of depression, pregnancy-specific anxiety, and fatigue all decreased over the course of treatment. Effect sizes ranged from medium to large. CBT-I delivered during pregnancy was associated with significant improvements in sleep and mood. The next step in this area of inquiry is to better establish effectiveness via a randomized controlled trial.

Group vs. Individual Treatment for Acute Insomnia: A Pilot Study Evaluating a "One-Shot" Treatment Strategy

Background: Despite undeniable evidence for the efficacy and effectiveness of Cognitive Behaviour Therapy for Insomnia (CBT-I), the potential for its widespread dissemination and implementation has yet to be realised. A suggested reason for this is that traditional CBT-I is considered too burdensome for deployment, in its current form, within the context of where it would be most beneficial—Primary Care. One strategy, aimed to address this, has been to develop briefer versions of CBT-I, whilst another has been to deliver CBT-I in a group format. An alternative has been to attempt to address insomnia during its acute phase with a view to circumventing its progression to chronic insomnia. The aim of the present study was to compare a brief version of CBT-I (one-shot) when delivered individually or in groups to those with acute insomnia. Method: Twenty-eight individuals with acute insomnia (i.e., meeting full DSM-5 criteria for insomnia disorder for less than three months) self-assigned to either a group or individual treatment arm. Treatment consisted of a single one-hour session accompanied by a self-help pamphlet. Subjects completed measures of insomnia severity, anxiety and depression pre-treatment and at one-month post-treatment. Additionally, daily sleep diaries were compared between pre-treatment and at the one-month follow up. Results: There were no significant between group differences in treatment outcome on any sleep or mood measures although those in the group treatment arm were less adherent than those who received individual treatment. Furthermore, the combined (group and individual treatment arms) pre-post test effect size on insomnia symptoms, using the Insomnia Severity Index, was large (d = 2.27). Discussion: It appears that group treatment is as efficacious as individual treatment within the context of a “one shot” intervention for individuals with acute insomnia. The results are discussed with a view to integrating one-shot CBT-I in Primary Care.

Self-referral to group cognitive behavioural therapy: Is it effective for treating chronic insomnia?

OBJECTIVES

To evaluate the effectiveness of a short (3 session) programme of group cognitive behavioural therapy (CBT) on insomnia, sleepiness and symptoms of anxiety and depression.

METHODS

Prospective observational study of group CBT with follow-up at 3 months. Participants were self-referred patients with chronic insomnia. Outcome measures were the insomnia severity scale (ISI), the Epworth sleepiness scale (ESS), depression (Pichot scale), and the number of anxiety symptoms.

RESULTS

Participation in CBT was offered to 489 patients of whom 474 completed the programme and 154 were followed up at 3 months. Significant improvements in insomnia were seen: ISI score (17.74-14.27, P<0.0001) after CBT and at follow-up (13.78, P<0.0001). At the end of CBT, 76% (59/78) with initial severe insomnia and 52% (132/255) with moderate insomnia were improved, maintained at 3 months in 71% (15/21) with severe insomnia and 56% (50/90) with moderate insomnia. Depression and anxiety symptoms were significantly improved: mean depression symptoms (4.15-3.35, P<0.0001) and anxiety symptoms (4.52-3.95, P<0.0001), maintained at 3 months with mean depression symptoms (3.17, P<0.0001) and mean anxiety symptoms (3.62, P<0.0001). Sleepiness increased between baseline and the end of the group (6.67-7.24, P=0.015) followed by a reduction at 3 months (7.19-6.34 at 3 months, P=0.001). Initial ISI score but neither sex nor age were predictive of outcome.

CONCLUSIONS

A short programme of CBT can improve sleep, depression and anxiety symptoms in self-referred patients suffering from chronic insomnia with good adherence and maximum benefit in patients with severe insomnia.

Sequential psychological and pharmacological therapies for comorbid and primary insomnia: study protocol for a randomized controlled trial

BACKGROUND

Chronic insomnia is a prevalent disorder associated with significant psychosocial, health, and economic impacts. Cognitive behavioral therapies (CBTs) and benzodiazepine receptor agonist (BzRA) medications are the most widely supported therapeutic approaches for insomnia management. However, few investigations have directly compared their relative and combined benefits, and even fewer have tested the benefits of sequential treatment for those who do not respond to initial insomnia therapy. Moreover, insomnia treatment studies have been limited by small, highly screened study samples, fixed-dose, and fixed-agent pharmacotherapy strategies that do not represent usual clinical practices. This study will address these limitations.

METHODS/DESIGN

This is a two-site randomized controlled trial, which will enroll 224 adults who meet the criteria for a chronic insomnia disorder with or without comorbid psychiatric disorders. Prospective participants will complete clinical assessments and polysomnography and then will be randomly assigned to first-stage therapy involving either behavioral therapy (BT) or zolpidem. Treatment outcomes will be assessed after 6 weeks, and treatment remitters will be followed for the next 12 months on maintenance therapy. Those not achieving remission will be offered randomization to a second, 6-week treatment, again involving either pharmacotherapy (zolpidem or trazodone) or psychological therapy (BT or cognitive therapy (CT)). All participants will be re-evaluated 12 weeks after the protocol initiation and at 3-, 6-, 9-, and 12-month follow-ups. Insomnia remission, defined categorically as a score < 8 on the Insomnia Severity Index, a patient-reported outcome, will serve as the primary endpoint for treatment comparisons. Secondary outcomes will include sleep parameters derived from daily sleep diaries and from polysomnography, subjective measures of fatigue, mood, quality of life, and functional impairments; and measures of adverse events; dropout rates; and treatment acceptability. Centrally trained therapists will administer therapies according to manualized, albeit flexible, treatment algorithms.

DISCUSSION

This clinical trial will provide new information about optimal treatment sequencing and will have direct implication for the development of clinical guidelines for managing chronic insomnia with and without comorbid psychiatric conditions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01651442 , Protocol version 4, 20 April 2011, registered 26 June 2012.

Chronotype and Improved Sleep Efficiency Independently Predict Depressive Symptom Reduction after Group Cognitive Behavioral Therapy for Insomnia

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve both sleep and depressive symptoms, but predictors of depression outcome following CBT-I have not been well examined. This study investigated how chronotype (i.e., morningness-eveningness trait) and changes in sleep efficiency (SE) were related to changes in depressive symptoms among recipients of CBT-I.

METHODS

Included were 419 adult insomnia outpatients from a sleep disorders clinic (43.20% males, age mean ± standard deviation = 48.14 ± 14.02). All participants completed the Composite Scale of Morningness and attended at least 4 sessions of a 6-session group CBT-I. SE was extracted from sleep diary; depressive symptoms were assessed using the Beck Depression Inventory (BDI) prior to (Baseline), and at the end (End) of intervention.

RESULTS

Multilevel structural equation modeling revealed that from Baseline to End, SE increased and BDI decreased significantly. Controlling for age, sex, BDI, and SE at Baseline, stronger evening chronotype and less improvement in SE significantly and uniquely predicted less reduction in BDI from Baseline to End. Chronotype did not predict improvement in SE.

CONCLUSIONS

In an insomnia outpatient sample, SE and depressive symptoms improved significantly after a CBT-I group intervention. All chronotypes benefited from sleep improvement, but those with greater eveningness and/or less sleep improvement experienced less reduction in depressive symptom severity. This suggests that evening preference and insomnia symptoms may have distinct relationships with mood, raising the possibility that the effect of CBT-I on depressive symptoms could be enhanced by assessing and addressing circadian factors.

Predictors of dropout from internet-based self-help cognitive behavioral therapy for insomnia

Dropout from self-help cognitive-behavioral therapy for insomnia (CBT-I) potentially diminishes therapeutic effect and poses clinical concern. We analyzed the characteristics of subjects who did not complete a 6-week internet-based CBT-I program. Receiver operator characteristics (ROC) analysis was used to identify potential variables and cutoff for predicting dropout among 207 participants with self-report insomnia 3 or more nights per week for at least 3 months randomly assigned to self-help CBT-I with telephone support (n = 103) and self-help CBT-I (n = 104). Seventy-two participants (34.4%) did not complete all 6 sessions, while 42 of the 72 (56.9%) dropped out prior to the fourth session. Significant predictors of non-completion are total sleep time (TST) ≥ 6.82 h, Hospital Anxiety and Depression Scale depression score ≥ 9 and Insomnia Severity Index score < 13 at baseline in this ranking order. Only TST ≥ 5.92 h predicts early dropout. Longer TST and less severe insomnia predict dropout in this study of self-help CBT-I, in contrast to shorter TST as a predictor in 2 studies of face-to-face CBT-I, while greater severity of depression predicts dropout in both this study and a study of face-to-face CBT-I. Strategies for minimizing dropout from internet-based CBT-I are discussed.

Treating Acute Insomnia: A Randomized Controlled Trial of a "Single-Shot" of Cognitive Behavioral Therapy for Insomnia

STUDY OBJECTIVES

Despite considerable evidence supporting cognitive behavioral therapy for insomnia (CBT-I) for chronic insomnia, it remains untested within the context of acute insomnia. This study examined the efficacy of a single session of CBT-I, with an accompanying self-help pamphlet, for individuals with acute insomnia.

DESIGN

A pragmatic parallel group randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Forty adults (mean age 32.9 ± 13.72 y) with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defined insomnia disorder, except a self-reported duration of less than 3 mo (i.e., acute insomnia), who reported no previous exposure to CBT-I and were not currently taking medication for sleep.

INTERVENTIONS

A single 60- to 70-min session of CBT-I (n = 20), with an accompanying self-help pamphlet, or wait list control group (n = 20). All subjects were offered a full individual course of CBT-I on completion of the study, regardless of group allocation.

MEASUREMENTS AND RESULTS

Subjects completed sleep diaries and the Insomnia Severity Index (ISI) pretreatment and 1 mo following treatment. There were no between-group differences on baseline ISI scores or subjective sleep continuity. The intervention group reported significantly lower ISI scores than controls (t(38) 2.24, P < 0.05) at follow-up. Further, using proposed ISI scores for identifying insomnia caseness (i.e., ≥ 10), 60% of those in the CBT-I group had remitted by 1 mo compared to 15% of those in the control group.

CONCLUSIONS

This single session of cognitive behavioral therapy for insomnia (CBT-I) is sufficiently efficacious for a significant proportion of those with acute insomnia. The results are discussed in terms of integrating this brief form of CBT-I into the "stepped care" model of insomnia.

TRIAL REGISTRATION

Testing the efficacy of an early intervention for acute insomnia (SRCTN05891695) http://www.controlled-trials.com/ISRCTN05891695.

Psychiatric comorbidity and aspects of cognitive coping negatively predict outcome in cognitive behavioral treatment of psychophysiological insomnia

Cognitive behavioral treatment is the gold standard treatment for insomnia, although a substantial group does not respond. We examined possible predictors for treatment outcome in psychophysiological insomniacs, with a focus on the presence of clearly defined psychiatric comorbidity. This was a longitudinal uncontrolled case series study comprising 60 patients with chronic psychophysiological insomnia consecutively referred to a tertiary sleep medicine center, to receive cognitive behavioral treatment for insomnia (CBT-I). Remission of insomnia was defined as a posttreatment Insomnia Severity Index score below 8. As an alternative outcome, we used a clinically relevant decrease on the Insomnia Severity Index (drop of > 7 points). Personality, coping, and social support questionnaires were assessed before the start of the treatment and were compared between treatment responders and nonresponders. To examine whether these variables were predictive for negative treatment outcome, logistic regression analyses were applied. Treatment nonresponders had a significantly higher prevalence of psychiatric comorbidity. Logistic regression analyses showed that the presence of psychiatric comorbidity was strongly predictive for negative treatment outcome (odds ratios: 20.6 and 10.3 for the 2 outcome definitions). Additionally, higher scores on the cognitive coping strategy called "refocus on planning" were associated with worse CBT-I outcome. Current psychiatric comorbidity is strongly predictive for negative treatment outcome. The presence of a psychiatric disorder must therefore be one of the leading arguments in the choice of treatment modalities that are being proposed to patients with insomnia.

Decision tree analysis of genetic risk for clinically heterogeneous Alzheimer's disease

BACKGROUND

Heritability of Alzheimer's disease (AD) is estimated at 74% and genetic contributors have been widely sought. The ε4 allele of apolipoprotein E (APOE) remains the strongest common risk factor for AD, with numerous other common variants contributing only modest risk for disease. Variability in clinical presentation of AD, which is typically amnestic (AmnAD) but can less commonly involve visuospatial, language and/or dysexecutive syndromes (atypical or AtAD), further complicates genetic analyses. Taking a multi-locus approach may increase the ability to identify individuals at highest risk for any AD syndrome. In this study, we sought to develop and investigate the utility of a multi-variant genetic risk assessment on a cohort of phenotypically heterogeneous patients with sporadic AD clinical diagnoses.

METHODS

We genotyped 75 variants in our cohort and, using a two-staged study design, we developed a 17-marker AD risk score in a Discovery cohort (n = 59 cases, n = 133 controls) then assessed its utility in a second Validation cohort (n = 126 cases, n = 150 controls). We also performed a data-driven decision tree analysis to identify genetic and/or demographic criteria that are most useful for accurately differentiating all AD cases from controls.

RESULTS

We confirmed APOE ε4 as a strong risk factor for AD. A 17-marker risk panel predicted AD significantly better than APOE genotype alone (P < 0.00001) in the Discovery cohort, but not in the Validation cohort. In decision tree analyses, we found that APOE best differentiated cases from controls only in AmnAD but not AtAD. In AtAD, HFE SNP rs1799945 was the strongest predictor of disease; variation in HFE has previously been implicated in AD risk in non-ε4 carriers.

CONCLUSIONS

Our study suggests that APOE ε4 remains the best predictor of broad AD risk when compared to multiple other genetic factors with modest effects, that phenotypic heterogeneity in broad AD can complicate simple polygenic risk modeling, and supports the association between HFE and AD risk in individuals without APOE ε4.

The insomnia patient perspective, a narrative review

Insomnia is a common sleep disorder associated with substantial direct and indirect costs, yet there is a strong propensity among patients to self-medicate which often delays professional help. Understanding the process which underpins the initiation, engagement and adherence to insomnia treatment(s) is a vital step for understanding this phenomenon. The current paper explores how the patient perspective has been conceptualized in the research literature and its implications for insomnia treatment and health care delivery. A literature search was conducted using Embase, Medline and PsycINFO databases. Articles have been thematically organized into patient correlates of health behaviors, patient experiences and treatment attitudes. Deferral of professional help among insomnia patients is partially related to barriers embedded in the health care system and patient health beliefs.

Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea

OBJECTIVES

Our study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4 years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms.

METHODS

Our population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1 years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2 years apart (baseline, time 1, and time 2).

RESULTS

Among individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors.

CONCLUSIONS

In particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

Adherence to cognitive behavioral therapy for insomnia: a systematic review

Chronic insomnia is a significant public health problem worldwide, and insomnia has considerable personal and social costs associated with serious health conditions, greater healthcare utilization, work absenteeism, and motor-vehicle accidents. Cognitive behavioral therapy for insomnia (CBTI) is an efficacious treatment, yet attrition and suboptimal adherence may diminish its impact. Despite the increasing use of CBTI, surprisingly little attention has been devoted to understanding the role of adherence. This review describes a comprehensive literature search of adherence to CBTI. The search revealed 15 studies that evaluated adherence to CBTI in adults using valid and reliable measures of sleep, and measure of adherence other than study withdrawals. The primary purposes of this review were to 1) synthesize current study characteristics, methodology, adherence rates, contributing factors, and impact on outcomes, 2) discuss measurement issues, and 3) identify future practice and research directions that may lead to improved outcomes. Strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the role of adherence as a factor and outcome of CBTI success. The importance of standardized adherence and outcome measures is discussed. In light of the importance of adherence to behavior change, this systematic review may better inform future intervention efforts.

Adherence to cognitive behavioral therapy for insomnia (CBTI) among women following primary breast cancer treatment: a pilot study

Cognitive behavioral therapy for insomnia (CBTI) has proven efficacy, yet 32%-89% of patients fail to consistently follow recommendations. This pilot study examines adherence to CBTI in breast cancer survivors with insomnia. There was a significant decline in adherence to prescribed rise time, and total time in bed, but no change in adherence to prescribed bedtime during six weekly sessions. Factors associated with higher adherence included lower fatigue and higher baseline motivation. Higher adherence was associated with worse subjective sleep quality at the beginning of CBTI and fewer nocturnal awakenings at the end of treatment. Results provide preliminary evidence supporting the impact of adherence on sleep outcomes such as fewer nocturnal awakenings. Attention to adherence as part of CBTI may yield greater sleep improvements.

Sleep America: managing the crisis of adult chronic insomnia and associated conditions

INTRODUCTION

Chronic insomnia, a public health crisis affecting 10-15% of the U.S. population and costing billions of dollars annually, typically presents with one or more comorbid psychiatric or organic conditions. Historical classification of chronic insomnia as "secondary" to a presenting comorbid condition has resulted in under-recognition and under-treatment of both the insomnia and comorbid condition(s). Though critical in any model of comorbid disease management, chronic insomnia receives little, if any, public policy attention.

METHOD

We conducted a systematic review of recent empirical studies, review papers, books, government documents, press releases, advertisements, and articles pertaining to the classification, epidemiology, treatment, and physiology of sleep, insomnia, and comorbid conditions. Data were located primarily through MEDLINE, PsycINFO, SCOPUS, and PUBMED databases.

OBJECTIVE AND RESULTS

Our goal was to provide an overview of the systems for classifying insomnia and available epidemiological data, and to review theoretical models regarding the etiology and maintaining factors of chronic insomnia along with research on the complex, bidirectional associations between chronic insomnia and various affective (and other) conditions.

CONCLUSIONS

After thorough review of the literature, we propose several public policy measures as an initial step in managing chronic insomnia in the United States. These include introducing a nation-wide multi-modal educational and awareness campaign titled "Sleep America;" increasing the availability and demand for behavioral sleep medicine - the initially preferred treatment approach; and increasing the use of monitoring and enforcement activities by regulatory authorities to curtail false and misleading claims by sponsors of supplements or treatments for insomnia. Through the adoption of such measures, we hope to galvanize a national interest in healthy sleep and the evidence-based treatment of chronic insomnia.

CBT for insomnia in patients with high and low depressive symptom severity: adherence and clinical outcomes

STUDY OBJECTIVES

To evaluate whether depressive symptom severity leads to poorer response and perceived adherence to cognitive behavioral therapy for insomnia (CBTI) and to examine the impact of CBTI on well-being, depressive symptom severity, and suicidal ideation.

DESIGN

Pre- to posttreatment case replication series comparing low depression (LowDep) and high depression (HiDep) groups (based on a cutoff of 14 on the Beck Depression Inventory [BDI]).

PARTICIPANTS

127 men and 174 women referred for the treatment of insomnia.

INTERVENTIONS

Seven sessions of group CBTI.

MEASUREMENTS AND RESULTS

Improvement in the insomnia severity, perceived energy, productivity, self-esteem, other aspects of wellbeing, and overall treatment satisfaction did not differ between the HiDep and LowDep groups (p > 0.14). HiDep patients reported lower adherence to a fixed rise time, restricting time in bed, and changing expectations about sleep (p < 0.05). HiDep participants experienced significant reductions in BDI, after removing the sleep item. Levels of suicidal ideation dropped significantly among patients with pretreatment elevations (p < 0.0001).

CONCLUSION

Results suggest that pre- to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefits of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity.

Cognitions and Insomnia Subgroups

PURPOSE

This study explored cognitive predictors of multiple symptoms of insomnia (difficulty with sleep initiation, maintenance, and early morning awakenings) among a sample of individuals seeking cognitive-behavior therapy for insomnia.

METHODS

Participants consisted of 146 clinical patients with insomnia of which 67 (45.89%) were classified as Single Symptoms subgroup and 79 (54.11%) as Combined subgroup. A receiver operating curve (ROC) analysis was conducted to identify predictors of Combined versus Single Symptom subgroups. The set of predictor variables included demographics, sleep-related cognitions, circadian preferences, depression symptoms, and self-report sleep parameters with insomnia subgroups (Combined versus Single Symptom only) as the dependent variable.

RESULTS

The ROC analysis identified two significant predictors: Self Efficacy Scale (SES) < 23 and a 3-item subscale of the Glasgow Content of Thoughts Inventory (GCTI) assessing "thoughts about the environment" with scores ≥ 5. Post-hoc comparisons revealed that individuals with combined symptoms who had SES score < 23 had significantly longer sleep onset latency (SOL) and more number of nights with SOL>30 minutes, poorer sleep quality, higher insomnia severity, less morningness tendency, higher depression symptom severity, and more anxiety about anxiety and about sleep compared to individuals with SES score ≥ 23.

CONCLUSIONS

These findings indicate that low self-efficacy and increased thoughts about the environment are associated with having multiple symptoms of insomnia. Further research should examine the specific role of self-efficacy and thought content in the etiology of individuals who suffer from multiple symptoms of insomnia.

Acupuncture and reflexology for insomnia: a feasibility study

OBJECTIVE

To assess the feasibility of patient recruitment and retention, logistics of intervention and outcome measure sensitivity for a study designed to investigate the use of acupuncture and reflexology for the management of insomnia.

DESIGN

Feasibility study for a randomised controlled trial.

SETTING

University of Ulster Clinic.

PATIENTS

Thirteen participants with sleep disturbances.

INTERVENTIONS

Participants were randomised to receive one of three treatments, either: acupuncture (n = 5), reflexology (n = 4) or music therapy (n = 4). These treatments were administered six times over a 3-week period.

MAIN OUTCOME MEASURES

The Pittsburgh Sleep Quality Index (PSQI) and Short Form 36 version 2 (SF-36v2) were recorded at baseline, post-treatment and follow-up. Each participant also completed a Sleep Diary.

RESULTS

Ten participants completed treatment. In the acupuncture and reflexology groups, a clinically relevant improvement in two out of three participants was observed on the PSQI following treatment. Music therapy produced no clinically important improvements. This study has demonstrated the feasibility of conducting an RCT on the effect of acupuncture and reflexology in primary insomnia using PSQI as the primary outcome measure. Modifications for a more rigorous study design have been discussed. Results from such a study would address the lack of high-quality evidence for the effectiveness of such therapies.

Cognitive behavioral therapy for sleep disorders

More than 70 million people in the United States experience primary insomnia (PI) at some point in their life, resulting in an estimated $65 billion in health care costs and lost productivity. PI is therefore one of the most common health care problems in the United States. To mollify the negative effects of PI, scholars have sought to evaluate and improve treatments of this costly health care problem. A breadth of research has demonstrated that cognitive behavioral therapy (CBT) is an effective intervention for PI. The goal of this article is to provide an overview of CBT for PI, including evidence regarding treatment efficacy, effectiveness, and practitioner considerations.

Minimizing attrition bias: a longitudinal study of depressive symptoms in an elderly cohort

BACKGROUND

Attrition from mortality is common in longitudinal studies of the elderly. Ignoring the resulting non-response or missing data can bias study results.

METHODS

1260 elderly participants underwent biennial follow-up assessments over 10 years. Many missed one or more assessments over this period. We compared three statistical models to evaluate the impact of missing data on an analysis of depressive symptoms over time. The first analytic model (generalized mixed model) treated non-response as data missing at random. The other two models used shared parameter methods; each had different specifications for dropout but both jointly modeled both outcome and dropout through a common random effect.

RESULTS

The presence of depressive symptoms was associated with being female, having less education, functional impairment, using more prescription drugs, and taking antidepressant drugs. In all three models, the same variables were significantly associated with depression and in the same direction. However, the strength of the associations differed widely between the generalized mixed model and the shared parameter models. Although the two shared parameter models had different assumptions about the dropout process, they yielded similar estimates for the outcome. One model fitted the data better, and the other was computationally faster.

CONCLUSIONS

Dropout does not occur randomly in longitudinal studies of the elderly. Thus, simply ignoring it can yield biased results. Shared parameter models are a powerful, flexible, and easily implemented tool for analyzing longitudinal data while minimizing bias due to nonrandom attrition.