Cognitive processes mediate the effects of insomnia treatment: evidence from a randomized wait-list controlled trial

Clinical effectiveness of internet-based cognitive behavioral therapy for insomnia in routine secondary care: results of a randomized controlled trial

Introduction

Delivering cognitive behavioral therapy for insomnia over the internet bears the advantage of accessibility and uptake to many patients suffering from chronic insomnia. In the current study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy for insomnia (iCBT-I) in routine care.

Materials and methods

We conducted a two-arm non-blinded randomized controlled trial with care as usual (CAU) as a control condition. Participants were recruited in a specialized outpatient sleep medicine department. Both arms had access to other healthcare resources, and the intervention group had access to the iCBT-I program for 2 months. The primary outcome was insomnia severity, measured by the Insomnia Severity Index (ISI). Secondary outcomes were fatigue severity, daytime sleepiness, affective symptoms, dysfunctional beliefs and attitudes about sleep, sleep locus of control, sleep hygiene, sleep efficiency (SE), sleep onset latency, wake time after sleep onset (WASO), and total sleep time (TST). Linear mixed models for repeated measures were used to analyze the longitudinal data at baseline, post-treatment, and after 3 months of follow-up. The trial was registered at www.clinicaltrials.gov (NCT04300218 21.04.2020).

Results

The results showed a significant time*group interaction effect (p = 0.001) at post-treatment with between-group effect size (d = 0.51), indicating that the ISI decreased by a score of 3.8-fold in the iCBT-I group than in the CAU group. There was no significant difference in ISI between groups at follow-up. Regarding secondary outcomes, dysfunctional beliefs about sleep, SE, and WASO decreased significantly during treatment in the intervention group with between-group effect sizes d = 0.35, d = -0.51, and d = 0.47, respectively. At the follow-up, between-group effects on DBAS and SE remained significant: d = 0.36 and d = -0.63, respectively. For TST, we observed a significant time*group effect of d = -0.38 only after follow-up.

Conclusion

Our findings suggest that iCBT-I has a significant effect on insomnia severity at post-treatment compared to CAU. iCBT-I further improved dysfunctional beliefs about sleep and improved subjective sleep characteristics, such as SE, WASO, and TST during 3 months after treatment.

Clinical trial registration

www.clinicaltrials.gov, identifier (NCT04300218).

Prediction of insomnia severity based on early maladaptive schemas: a logistic regression analysis

BACKGROUND

In spite of the major role of early maladaptive schemas in vulnerability to various psychological disorders, studies about the relationship between early maladaptive schemas and insomnia disorder are scarce. Hence, the aim of the current study was to explore the contribution of early maladaptive schemas in insomnia severity by comparing a sample of patients with chronic insomnia and good sleepers.

METHODS

Patients with chronic insomnia and good sleepers were evaluated using Young Schema Questionnaire-Short Form (YSQ-SF), Depression Anxiety and Stress Scale (DASS-21), and Insomnia Severity Index (ISI).

RESULTS

The study enrolled 117 patients with chronic insomnia and 76 good sleepers. All early maladaptive schemas (EMSs) except for enmeshment showed significant correlations with insomnia severity. After controlling for depression/anxiety symptoms, logistic regression analysis showed that the EMSs including emotional deprivation, vulnerability to harm, and subjugation schemas were significantly associated with insomnia severity.

CONCLUSIONS

These preliminary findings suggest that EMSs may constitute a vulnerability factor for developing insomnia. Early maladaptive schemas may require attention in the existing treatments of insomnia.

Mechanisms of cognitive behavioural therapy for insomnia

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

Challenging beliefs for quality sleep: A systematic review of maladaptive sleep beliefs and treatment outcomes following cognitive behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is an empirically supported intervention for insomnia. Given the strong, consistent support of its efficacy, scholars have become increasingly interested in the behavioral and cognitive mechanisms targeted during CBT-I. The purpose of the systematic review was to synthesize findings from the literature regarding the associations among maladaptive sleep beliefs, a cognitive mechanism implicated in maintaining insomnia, and treatment outcomes following CBT-I. The systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies were included in the final sample of reviewed articles and a study quality assessment was performed for all studies included in the review. The results suggested that reductions in maladaptive sleep beliefs were associated with improved insomnia severity; however, reductions in maladaptive beliefs were not associated with changes in sleep efficiency or other sleep parameters. Moreover, in some cases, improved sleep parameters preceded reductions in maladaptive beliefs. Maladaptive sleep beliefs may be an important target for improving insomnia. Targeting maladaptive sleep beliefs may initiate a trickle-down process that limits the influence of other cognitive and behavioral processes maintaining insomnia. Additional investigation is needed to evaluate the directional relationship between improved insomnia symptoms and reduced maladaptive beliefs.

[Does a short telemedicine-based CBT programme for insomnia lead to changes in dysfunctional beliefs about sleep?]

INTRODUCTION

The Morphee Sleep network runs a short group CBT programme. During the pandemic, the programme was administered by videoconference. The programme focuses on behavioral modification. The objective of our study was to evaluate whether the videoconference programme produced changes in dysfunctional beliefs about sleep and whether these changes were linked to improvements in insomnia.

METHODS

Observational study of 3×90minute sessions of group CBT by videoconference over one month delivered by experienced psychologists. The outcome measures : insomnia severity scale (ISI), dysfunctional beliefs and attitudes about sleep short version (DBAS 16), hospital anxiety and depression scale (subscales depression HADD and anxiety HADA), and epworth sleepiness scale (ESS) completed before session 1 and at the end of session 3. The effectiveness of the programme on insomnia was evaluated by the decrease in the ISI score : full response R+ (>7 points), partial response, R- (4 - 6 points) non response, NR (<3 points). The effect on dysfunctional beliefs and attitudes about sleep were measured by the decrease in the DBAS 16 with response CR (>9 points) and no response CNR (<9 points).

RESULTS

There were fifty-five participants, 64 % women with a mean age of 49.1±16.1 years. The DBAS 16 was reduced by 6.12±1.29 to 5.09±1.57 (P< 0.0001) with 67 % of participants showing a response CR. The ISI score reduced from 17.7±3.6 to 14.0±4.9 (P< 0.0001) with 49 % showing at least a partial response (R+ and R-). A significant correlation (0.327, P=0.015) between the CBT response and dysfunctional beliefs about sleep was observed with a significant reduction in the DBAS 16 between responders R+ and non-responders (R+ vs. NR 1.67±1.3 vs. 0.57±1.28 P=0.012). Seventy-nine of R+ showed improvements in the DBAS 16 vs. 69 % of R- and 61 % of non-responders NR.

CONCLUSION

A short group CBT programme by videoconference focused on behavioral modification can reduce dysfunctional beliefs about sleep.

Subjective versus objective sleep outcomes in older adults with and without uncoupled sleep following online cognitive behavioural therapy for insomnia

BACKGROUND

Uncoupled sleep is a phenomenon characterised by a disconnect between sleep pattern and sleep complaint. This study examined the impact of uncoupled sleep on dysfunctional sleep beliefs and objective and subjective sleep outcomes in community-dwelling older adults following digitally delivered Cognitive Behavioural Therapy for Insomnia (CBT-I) to assess how these groups respond to CBT-I.

METHODS

Objective sleep was measured using wrist actigraphy, subjective sleep quality via sleep diaries and the Pittsburgh Sleep Quality Index (PSQI). Dysfunctional sleep beliefs were assessed by the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16). All measurements were taken prior to and following a 4-week online CBT-I program. Linear mixed model and generalised linear mixed model analyses were conducted to examine objective and subjective sleep onset latency, total sleep time, wake after sleep onset and number of awakenings as well as PSQI and DBAS-16 scores, respectively.

RESULTS

Out of 80 enrolled participants, 62 participants (55 females, 89%; 16 complaining good sleepers, 26 complaining poor sleepers, 11 non-complaining good sleepers, and nine non-complaining poor sleepers) completed the study. CBT-I reduced dysfunctional sleep beliefs across all sleeper classifications. Objective and self-reported changes in sleep parameters were demonstrated in complaining poor sleepers without uncoupled sleep. Complaining good sleepers with uncoupled sleep only reported a decrease in the number of subjective sleep awakenings. There were no changes in sleep outcomes in non-complaining good and non-complaining poor sleepers.

CONCLUSIONS

Online CBT-I was effective in improving the sleep outcomes of individuals who had both subjective and objective poor sleep. However, as the online CBT-I reduced dysfunctional sleep beliefs in all sleep groups, further examination of dysfunctional sleep beliefs and whether they mediate the outcomes of digital CBT-I in older adults will need to be conducted.

The dysfunctional beliefs and attitudes about sleep scale: Dimensions of the European Portuguese DBAS-30 and development of a new short version (DBAS–SF–16)

OBJECTIVES

The Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) is the most widely validated instrument for assessing sleep-related cognitions. This study aimed to examine the reliability of the DBAS-30 European Portuguese version, explore its dimensionality, and develop a new short version suitable for differentiating the presence/absence of insomnia.

METHODS

From 824 participants aged 18-85 years, the Insomnia Group (IG, n = 355, 261 females and 94 males) and Normal Sleepers Group (NSG, n = 292, 237 females, 54 males and 1 with no response) were constituted. Thirty-one patients with Obstructive Sleep Apnea Syndrome were also recruited. For the DBAS 16-items version, the ability to differentiate dysfunctional beliefs between people with and without insomnia was used as the main criterion for item retention.

RESULTS

DBAS-30 PT demonstrated good internal consistency and significantly discriminated IG from NSG. Based on a robust EFA (RDWLS), a three-dimensional structure was determined for IG (Ageing and Hopelessness, Sleep Expectations, and Consequences and Helplessness). DBAS-SF-16 presented as an internally-consistent measure with a reliable two-factor structure (Consequences and Helplessness, Medication and Hopelessness) and showed construct and known groups validity. ROC analysis demonstrated DBAS-SF-16's relevant clinical accuracy, and 4.3 provides the best cut-off score in detecting the level of dysfunctional beliefs associated with clinical insomnia.

CONCLUSIONS

A new and meaningful dimensionality of the DBAS-30 was found. DBAS-SF-16 showed to be a reliable, valid, and robust tool for evaluating dysfunctional beliefs about insomnia in clinical and non-clinical populations.

Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Prognostic and Treatment-Predictive Factors

Understanding which factors predict the outcome of internet-based cognitive behavioral therapy for insomnia (iCBT-I) may help to tailor this intervention to the patient's needs. We have conducted a secondary analysis of a randomized, controlled trial comparing a multicomponent iCBT-I (MCT) and an online sleep restriction therapy (SRT) for 83 chronic insomnia patients. The difference in the Insomnia Severity Index from pre- to post-treatment and from pre-treatment to follow-up at 6 months after treatment was the dependent variable. Prognostic and treatment-predictive factors assessed at baseline were analyzed with multiple linear regression. The shorter duration of insomnia, female gender, high health-related quality of life, and the higher total number of clicks had prognostic value for a better outcome. Other factors were found to be prognostic for outcome at the follow-up assessment: treatment with benzodiazepines, sleep quality, and personal significance of sleep problems. A high level of dysfunctional beliefs and attitudes about sleep (DBAS) was a moderator for better effects in the MCT at post-treatment assessment. Various prognostic factors (e.g., duration of insomnia, gender, or quality of life) may influence the success of treatment. The DBAS scale may be recommended to select patients for MCT rather than SRT.

The Role of Dysfunctional Sleep Beliefs in Mediating the Outcomes of Web-Based Cognitive Behavioral Therapy for Insomnia in Community-Dwelling Older Adults: Protocol for a Single-Group, Nonrandomized Trial

BACKGROUND

Sleeping well is an essential part of good health. Older adult populations report a high rate of sleep problems, with recent studies suggesting that cognitive processes as well as behavioral and hyperarousal-related mechanisms could be important factors in the development and maintenance of insomnia. Individuals who have an asynchronous or uncoupled sleep pattern and sleep appraisal-those who complain about their sleep but do not have poor sleep quality, and vice versa-might show differences in subjective sleep and sleep perceptions and other characteristics that could impact their treatment outcomes following cognitive behavioral therapy for insomnia (CBT-I).

OBJECTIVE

The purpose of this protocol is to describe the rationale and methods for a nonrandomized, single-arm trial assessing objective and subjective sleep quality in community-dwelling older adults aged 60-80 years with synchronous sleep patterns and sleep appraisal compared to those in older adults with asynchronous sleep patterns and sleep appraisal. The trial will further examine the role of cognitive, behavioral, and hyperarousal processes in mediating the treatment outcomes of web-based CBT-I.

METHODS

This trial aims to recruit a sample of 60 participants, who will be assigned to 1 of 4 sleep groups based on their sleep pattern and sleep appraisal status: complaining good sleepers, complaining poor sleepers, noncomplaining good sleepers, and noncomplaining poor sleepers, respectively. The trial will be completed in 2 phases: phase 1 will assess objective sleep (measured via wrist actigraphy) and subjective (self-reported) sleep. Phase 2 will investigate the impact of a web-based CBT-I program on the sleep outcomes of individuals with uncoupled sleep compared to that of individuals without uncoupled sleep, as well as the mediators of CBT-I.

RESULTS

Recruitment began in March 2020, and the last participants were recruited by March 2021. A total of 65 participants completed phases 1 and 2. Data analysis for phase 1 was finished in December 2021, and data analysis for phase 2 was finalized in July 2022. The results for phase 1 were submitted for publication in March 2022, and those for phase 2 will be submitted by the end of December 2022.

CONCLUSIONS

This trial will provide guidance on factors that contribute to the variability of sleep in older adults and their sleep outcomes following CBT-I. The outcomes of this study could be valuable for future research attempting to tailor CBT-I to individual needs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001509156; https://tinyurl.com/69hhdu2w.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32705.

Cognitive and psychological factors associated with severe insomnia in Brazilian women: a cross-sectional study

Insomnia is the most prevalent sleep disorder in women. Sociodemographic, cognitive, and psychological factors may contribute to its severity. This study evaluated factors associated with severe insomnia in women with insomnia complaints. We evaluated 530 women aged 18-59 (mean = 40.5, SD = 10.2), who experienced insomnia complaints, using self-report instruments. Severe insomnia was defined as a score above 21 on the Insomnia Severity Index. Age, marital status, educational level, depression and anxiety, psychological inflexibility, and beliefs about sleep were assessed as potential factors associated with severe insomnia. Simple and multivariate analyses were conducted using binary logistic regression. Low education level (odds ratio; OR = 1.85 [1.27-2.69]), depression (OR = 2.17 [1.27-3.81]), psychological inflexibility (OR = 1.05 [1.02-1.08]), and dysfunctional beliefs about sleep (OR = 1.04 [1.02-1.06]) were factors associated with severe insomnia scores in the multiple logistic regression model. These findings are important from a public health perspective, because behavioral strategies designed to treat insomnia with a focus on cognitive and psychological factors are low-cost treatments and may help improve sleep quality in women, which also influences mental health.

Randomized controlled trial of cognitive refocusing versus stimulus control treatment for college insomnia: feasibility of a brief, electronic-based, and peer-led approach

OBJECTIVE

Performance of Cognitive Refocusing Treatment for Insomnia (CRT-I) relative to stimulus control treatment (SCT) remains unknown among college students. This pilot trial compared single-session, electronic-based, peer-led CRT-I to SCT, and as well as awareness-based (AC) and no-treatment (NTC) controls.

PARTICIPANTS

College students (N = 82; Mage=18.59 [SD = 0.78]; 58% female; 61% White; 16% Hispanic) with insomnia symptoms were randomly assigned to CRT-I (n = 12), SCT (n = 14), and AC (n = 14) conditions, or non-randomly recruited to NTC (n = 42).

METHODS

All participants completed baseline and one-month follow-up surveys, and reported daily task enactment (except NTC).

RESULTS

Feasibility ratings were comparable across conditions. Within-group treatment effects revealed greater improvements in (a) insomnia symptom severity among CRT-I (d = 1.13) and SCT (d = 1.66) groups relative to AC (d = 0.90) and (b) pre-sleep cognitive arousal among CRT-I (d = 0.94) and SCT (d = 1.42) groups relative to AC (d = 0.75).

CONCLUSIONS

Brief, electronic-based, peer-led CRT-I and SCT interventions appear feasible and potentially efficacious for college insomnia.

How Does E-mail-Delivered Cognitive Behavioral Therapy Work for Young Adults (18-28 Years) with Insomnia? Mediators of Changes in Insomnia, Depression, Anxiety, and Stress

This study examined whether cognitive behavioral therapy (CBT) for insomnia (CBT-I) improved insomnia severity, by changing sleep-related mediating factors. It also examined whether an improvement in insomnia led to enhanced mental health. This study was a secondary analysis of a randomized controlled trial of e-mail-delivered CBT-I for young adults with insomnia. The participants were randomized to either CBT-I or self-monitoring. The mental health-related measures were depression, anxiety, and stress. The sleep-related mediating factors were sleep hygiene practices, dysfunctional beliefs, sleep reactivity, and pre-sleep arousal. A total of 41 participants, who completed all the sessions (71% females; mean age 19.71 ± 1.98 years), were included in the analysis. The hierarchical multiple regression analysis showed that 53% of the variance in the improvements in insomnia severity was explained by the treatment group (β = −0.53; ΔR2 = 0.25; p < 0.01) and the changes in sleep reactivity (β = 0.39; ΔR2 = 0.28; p < 0.05). Moreover, the mediation analysis showed that the reductions in depression and stress were explained by the changes in insomnia severity; however, anxiety symptoms were not reduced. CBT-I for young adults suggested that sleep reactivity is a significant mediator that reduces insomnia severity, and that the alleviation and prevention of depression and stress would occur with the improvement in insomnia.

A virtual reality-based mind–body approach to downregulate psychophysiological arousal in adolescent insomnia

Objective

In this study, we describe the rationale, supported by preliminary data, for a novel, digital, immersive virtual reality (VR)-based mind–body approach, designed to reduce bedtime arousal in adolescents with insomnia.

Methods

Fifty-two high-school students (16–20 years; 32 female) with ( N = 18) and without ( N = 34) DSM-5 insomnia symptoms engaged with 20 min of immersive VR-guided meditation and paced breathing (0.1 Hz) ( intervention condition) and 20 min of quiet activity ( control condition), right before bedtime, on two separate evenings.

Results

The intervention resulted in acute autonomic and cortical modulation ( p < 0.05), leading to reduced physiological arousal (↓heart rate, ↓cortisol) compared with the control condition, with similar effects in adolescents with and without insomnia. No significant changes were detected for cognitive arousal levels. During the intervention, all participants were able to achieve the targeted 0.1 Hz breathing rate, and the majority experienced no discomfort associated with the VR exposure. However, 30–40% of the participants experienced some trouble slowing down their breathing.

Conclusions

The study provides supporting preliminary evidence for the mechanism behind a novel VR-based digital approach, designed to regulate psychophysiological arousal levels by acting on neurocognitive and autonomic pathways. Further studies (e.g. randomized clinical trials) are needed to evaluate the isolated and synergistic effects of its components (e.g. VR vs. VR + paced breathing), and its efficacy, acceptance, and feasibility in alleviating insomnia symptoms in adolescents.

Can an E-Mail-Delivered CBT for Insomnia Validated in the West Be Effective in the East? A Randomized Controlled Trial

This study examined the effects of an e-mail-delivered cognitive behavioral therapy for insomnia (CBT-I), validated in Western countries, on insomnia severity, anxiety, and depression in young adults with insomnia in Eastern countries, particularly Japan. This prospective parallel-group randomized clinical trial included college students with Insomnia Severity Index (ISI) scores of ten or higher. Participants were recruited via advertising on a university campus and randomized to an e-mail-delivered CBT-I (REFRESH) or self-monitoring (SM) with sleep diaries group. The primary outcomes were insomnia severity, anxiety, and depression; secondary outcomes were sleep hygiene practices, dysfunctional beliefs, sleep reactivity, and pre-sleep arousal. All measurements were assessed before and after the intervention. A total of 48 participants (mean (SD) age, 19.56 (1.86) years; 67% female) were randomized and included in the analysis. The results of the intent-to-treat analysis showed a significant interaction effect for insomnia severity, anxiety, depression, sleep hygiene practice, and pre-sleep arousal. Compared with the SM group, the REFRESH group was more effective in reducing insomnia severity (Hedges’ g = 1.50), anxiety (g = 0.97), and depression (g = 0.61) post-intervention. These findings suggest that an e-mail-delivered CBT-I may be an effective treatment for young adults with elevated insomnia symptoms living in Japan.

An investigation and replication of sleep-related cognitions, acceptance and behaviours as predictors of short- and long-term outcome in cognitive behavioural therapy for insomnia

The objectives were to investigate the potential for sleep-related behaviours, acceptance and cognitions to predict outcome (insomnia severity) of cognitive behavioural therapy for insomnia (CBT-I). Baseline and outcome data from four randomised controlled trials (n = 276) were used. Predictors were the Dysfunctional Beliefs and Attitudes about Sleep-10 (DBAS-10), Sleep-Related Behaviours Questionnaire (SRBQ), and Sleep Problems Acceptance Questionnaire (SPAQ), and empirically derived factors from a factor analysis combining all items at baseline (n = 835). Baseline values were used to predict post-treatment outcome, and pre-post changes in the predictors were used to predict follow-up outcomes after 3-6 months, 1 year, or 3-10 years, measured both as insomnia severity and as better or worse long-term sleep patterns. A majority (29 of 52) of predictions of insomnia severity were significant, but when controlling for insomnia severity, only two (DBAS-10 at short-term and SRBQ at mid-term follow-up) of the 12 predictions using established scales, and three of the 40 predictions using empirically derived factors, remained significant. The strongest predictor of a long-term, stable sleep pattern was insomnia severity reduction during treatment. Using all available predictors in an overfitted model, 21.2% of short- and 58.9% of long-term outcomes could be predicted. We conclude that although the explored constructs may have important roles in CBT-I, the present study does not support that the DBAS-10, SRBQ, SPAQ, or factors derived from them, would be unique predictors of outcome.

Intraindividual variability in sleep schedule: effects of an internet-based cognitive-behavioral therapy for insomnia program and its relation with symptom remission

STUDY OBJECTIVES

Sleep schedule consistency is fundamental to cognitive-behavioral therapy for insomnia (CBT-I), although there is limited evidence suggesting whether it predicts treatment response. This analysis tested whether: (1) an Internet-based CBT-I program affects intraindividual variability (IIV) in sleep schedule and (2) sleep schedule IIV predicts insomnia symptom remission.

METHODS

This secondary analysis compares participants (N = 303) randomized to an Internet-based CBT-I program (SHUTi-Sleep Healthy Using the Internet) or Internet-based patient education (PE). Participants reported daily bedtimes and rising times on 10 online sleep diaries collected over 2 weeks at baseline and 9-week post-intervention assessment. Participants completed the Insomnia Severity Index (ISI) at post-assessment and 6-month follow-up; symptom remission was defined by ISI < 8. Mixed effects location scale modeling was used to examine the effect of SHUTi on bedtime and rising time IIV; a novel two-staged analysis examined the effect of bedtime and rising time IIV on insomnia symptom remission.

RESULTS

At post-assessment, SHUTi participants reported about 30% less bedtime and 32% less rising time variability compared to PE (ps < 0.03). Bedtime and rising time IIV was not independently associated with likelihood of insomnia symptom remission at the subsequent time point (ps > 0.18), nor did sleep schedule IIV moderate treatment response (ps > 0.12).

CONCLUSIONS

Findings demonstrate that an Internet-delivered CBT-I program can effectively increase users' sleep schedule consistency relative to an educational control. This consistency, however, was not related to treatment outcome when defined by insomnia symptom remission, suggesting that enforcing rigid sleep schedules for patients may not be necessary for treatment success.

CLINICAL TRIAL REGISTRATION

NCT00328250.

How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change

Insomnia is prevalent and debilitating, comprising sustained difficulties initiating or maintaining sleep. Cognitive-behavioural therapy for insomnia (CBT-I) is a multicomponent intervention recommended as the first-line treatment, but the mediators of change remain unclear. This systematic review and meta-analysis aimed to synthesise and evaluate the evidence for potential mediators of CBT-I. Searches were performed for studies published until February 2021, reporting on mediation analyses with CBT-I. Seventeen unique samples of adults with insomnia (20 studies, N = 3125) were included. Two-stage structural equation modelling was applied to the available data, where 7 studies examined the cognitive mediator, 'dysfunctional beliefs about sleep', 5 studies examined a hyperarousal mediator, and 3 studies examined the behavioural mediator, 'time in bed'. There was evidence in support of changes in dysfunctional beliefs as a cognitive mediator of insomnia symptom improvement following CBT-I. There was more limited evidence in support of changes in hyperarousal-related mediators, and no significant effect of time in bed as a mediator. Numerous studies recorded diary-based measures of potential behavioural mediators, but analyses of these variables were not typically conducted. The most serious limitation of the evidence base is that the temporal precedence of mediator changes cannot be established. Future studies should consider: i) using mid-treatment measurements of mediator changes; ii) reporting on mediator psychometric properties; and iii) explicitly stating analyses as pre-specified or exploratory.

Cognitive arousal mediates the relationship between perceived ostracism and sleep quality but it is not moderated by experiential avoidance

Previous research suggests that longer-term perceived ostracism is related to poor sleep quality. In this study, we investigated the mediating effect of cognitive arousal on the perceived ostracism-sleep quality relationship. We also investigated whether experiential avoidance was a moderator of the cognitive arousal-sleep quality relationship. Participants (N = 251) were recruited through online research portals to take part in an online survey. A path analysis was used to test a moderated mediation effect between variables. It was found that cognitive arousal mediated the perceived ostracism-sleep quality relationship; however, experiential avoidance was not a significant moderator. These findings suggest that further research needs to be conducted to elucidate the mechanism of experiential avoidance to account for when it may impact sleep quality. Moreover, treatment interventions targeted at reducing cognitive arousal (e.g., cognitive behavioural therapy) prior to sleep are likely to bear some fruit.

Effectiveness and Cost-Effectiveness of Internet-Based Cognitive Behavioral Therapy for Insomnia in Clinical Settings

BACKGROUND

Internet-delivered cognitive-behavior treatment for insomnia (iCBT-I) has the potential to fill the gap created by the discrepancy between insomnia cases and number of trained professionals. Although the effectiveness of this method was proven in multiple studies conducted in research settings, its feasibility in routine care is still unclear. Predictors, mediators, and moderators of treatment effect remain uncertain since previous studies often give contradictory results. The present study aims to investigate clinical effectiveness and cost-effectiveness of an internet-based CBT-I program Sleepsy in comparison with care as usual (CAU) among patients with CI recruited from clinical settings. Baseline data will be further analyzed to find predictors of treatment outcome.

METHODS/DESIGN

The proposed study is a parallel-group randomized controlled trial comparing CAU plus iCBT-I with CAU in a clinical setting. One hundred ten participants will be referred from the medical doctors in Moscow. Both groups will have access to CAU, which corresponds to the treatment prescribed by the referring doctor. Patients of the first group will additionally get access to the iCBT-I program with the opportunity to contact a specialist (guidance on request) in a secured environment. The primary outcome is insomnia severity change from pre- to post-treatment. Secondary outcomes include change of subjective sleep characteristics, life quality, fatigue, daytime sleepiness, comorbid affective disorders, dysfunctional beliefs about sleep, sleep hygiene, healthcare consumption, productivity losses, and longer term outcomes at 3 months follow-up. Predictor analysis will include baseline scores of the aforementioned outcomes along with treatment expectancies and personality traits.

DISCUSSION

The proposed study is one of the first studies evaluating whether iCBT-I also works in routine care. We expect that recruitment of the participants let us determine the target group more precisely and exclude health problems interfering with treatment. Using CAU as control condition may result in a loss of power to detect a meaningful difference. Nevertheless, this approach is reasonable since it reconstructs the clinical situation faced by practicing doctors.

Efficacy of a Self-Help Web-Based Recovery Training in Improving Sleep in Workers: Randomized Controlled Trial in the General Working Population

BACKGROUND

Sleep complaints are among the most prevalent health concerns, especially among workers, which may lead to adverse effects on health and work. Internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) offers the opportunity to deliver effective solutions on a large scale. The efficacy of iCBT-I for clinical samples has been demonstrated in recent meta-analyses, and there is evidence that iCBT-I is effective in the working population with severe sleep complaints. However, to date, there is limited evidence from randomized controlled trials that iCBT-I could also be an effective tool for universal prevention among the general working population regardless of symptom severity. Although increasing evidence suggests that negatively toned cognitive activity may be a key factor for the development and maintenance of insomnia, little is known about how iCBT-I improves sleep by reducing presleep cognitive activity.

OBJECTIVE

This study aimed to examine the efficacy of a self-help internet-delivered recovery training, based on principles of iCBT-I tailored to the work-life domain, among the general working population. General and work-related cognitive activities were investigated as potential mediators of the intervention's effect.

METHODS

A sample of 177 workers were randomized to receive either the iCBT-I (n=88) or controls (n=89). The intervention is a Web-based training consisting of six 1-week modules. As the training was self-help, participants received nothing but technical support via email. Web-based self-report assessments were scheduled at baseline, at 8 weeks, and at 6 months following randomization. The primary outcome was insomnia severity. Secondary outcomes included measures of mental health and work-related health and cognitive activity. In an exploratory analysis, general and work-related cognitive activities, measured as worry and work-related rumination, were investigated as mediators.

RESULTS

Analysis of the linear mixed effects model showed that, relative to controls, participants who received iCBT-I reported significantly lower insomnia severity scores at postintervention (between-group mean difference -4.36; 95% CI -5.59 to - 3.03; Cohen d=0.97) and at 6-month follow-up (between-group difference: -3.64; 95% CI -4.89 to -2.39; Cohen d=0.86). The overall test of group-by-time interaction was significant (P<.001). Significant differences, with small-to-large effect sizes, were also detected for cognitive activity and for mental and work-related health, but not for absenteeism. Mediation analysis demonstrated that work-related rumination (indirect effect: a₁b₁=-0.80; SE=0.34; 95% boot CI -1.59 to -0.25) and worry (indirect effect: a₂b₂=-0.37; SE=0.19; 95% boot CI -0.85 to -0.09) mediate the intervention's effect on sleep.

CONCLUSIONS

A self-help Web-based recovery training, grounded in the principles of iCBT-I, can be effective in the general working population, both short and long term. Work-related rumination may be a particularly crucial mediator of the intervention's effect, suggesting that tailoring interventions to the workplace, including components to reduce the work-related cognitive activity, might be important when designing recovery interventions for workers.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00007142; https://www.drks.de/DRKS00007142.

Internet-Delivered Cognitive Behavioral Therapy for Insomnia: Tailoring Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Insomnia

Chronic insomnia is preferably treated with cognitive behavioral therapy for insomnia (CBTI), but many insomnia sufferers receive medication instead, likely because of high costs, lack of knowledge about optimal insomnia treatment among physicians, and lack of CBTI-trained professionals in mental health care. A possible solution is to offer CBTI through the Internet: I-CBTI. I-CBTI is generally acceptable to patients and greatly improves insomnia symptoms. We review the state of knowledge around I-CBTI and its effects. CBTI's effectiveness is influenced by treatment characteristics and patient-specific factors. We review potential factors that help identify which patients may benefit from I-CBTI.

Digital Delivery of Cognitive Behavioral Therapy for Insomnia

PURPOSE OF REVIEW

Digital cognitive behavioral therapy (dCBT) has been available for over a decade. We reviewed the evidence that accumulated over the past 5 years and discuss the implications for introducing dCBT into standard healthcare.

RECENT FINDINGS

Studies have consistently supported the use of dCBT to treat insomnia. Evidence is now demonstrating large short-term effects and smaller long-term effects up to 1.5 years after treatment across populations with various co-occurring health problems. The effects also extend into a range of psychological well-being factors. Mediators and moderators have been studied to understand mechanisms and create new opportunities to enhance effectiveness and reduce dropout. Incorporating personalized guidance in dCBT may further enhance effectiveness. The evidence for dCBT for insomnia is strong and suggests that dCBT is ready for application in standard healthcare. Further research, digital innovation, and development of effective implementation methods are required to ensure dCBT fulfills its potential.