Characteristics of Patients with Subjective Sleep Problems after Cognitive Behavioral Therapy for Insomnia: Secondary Analyses of a Randomized Controlled Trial

Objective  Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia, but half of the patients do not reach remission. This study aimed to explore subjective remission by investigating the characteristics of patients who reported lingering sleep problems after CBT-I. Methods  Secondary analyses of a randomized controlled trial of group CBT-I in 72 primary care patients with insomnia disorder. Sociodemographic characteristics and outcomes (insomnia severity, sleep variables, hypnotics use, fatigue, depressive symptoms, and dysfunctional beliefs/attitudes), including baseline data and symptom change, were investigated in relation to patients' posttreatment response to the yes-or-no question "Would you say that you have sleep problems?" Results  A total of 56.9% of patients reported sleep problems after CBT-I. At baseline, they had worse depressive symptoms (14.9 (SD 7.5) vs. 10.2 (SD 5.9), p  = 0.006) and more awakenings (2.6 (SD 1.5) vs. 1.8 (SD 1.3), p  = 0.034) than those in subjective remission from sleep problems. Patients in the non-remission and remission groups showed similar improvements in sleep, fatigue, and depressive symptoms, but patients in the non-remission group had improved less in insomnia severity, dysfunctional beliefs/attitudes about sleep, and hypnotic use. In patients with more pronounced depressive symptoms before CBT-I, change in depressive symptoms during treatment partially explained subjective remission from sleep problems. Discussion  More severe depressive symptoms prior to CBT-I and less improvements in depressive symptoms during treatment predicted remaining subjective sleep problems after treatment. These findings highlight the importance of assessing depressive symptoms in primary care patients with insomnia, as patients with pronounced depressive symptoms may need tailored treatment.

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.

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.

Potential mechanisms of the fatigue-reducing effect of cognitive-behavioral therapy in cancer survivors: Three randomized controlled trials

OBJECTIVE

Fatigue is a common symptom among cancer survivors that can be successfully treated with cognitive-behavioral therapy (CBT). Insights into the working mechanisms of CBT are currently limited. The aim of this study was to investigate whether improvements in targeted cognitive-behavioral variables and reduced depressive symptoms mediate the fatigue-reducing effect of CBT.

METHODS

We pooled data from three randomized controlled trials that tested the efficacy of CBT to reduce severe fatigue. In all three trials, fatigue severity (checklist individual strength) decreased significantly following CBT. Assessments were conducted pre-treatment and 6 months later. Classical mediation analysis testing a pre-specified model was conducted and its results compared to those of causal discovery, an explorative data-driven approach testing all possible causal associations and retaining the most likely model.

RESULTS

Data from 250 cancer survivors (n = 129 CBT, n = 121 waitlist) were analyzed. Classical mediation analysis suggests that increased self-efficacy and decreased fatigue catastrophizing, focusing on symptoms, perceived problems with activity and depressive symptoms mediate the reduction of fatigue brought by CBT. Conversely, causal discovery and post-hoc analyses indicate that fatigue acts as mediator, not outcome, of changes in cognitions, sleep disturbance and depressive symptoms.

CONCLUSIONS

Cognitions, sleep disturbance and depressive symptoms improve during CBT. When assessed pre- and post-treatment, fatigue acts as a mediator, not outcome, of these improvements. It seems likely that the working mechanism of CBT is not a one-way causal effect but a dynamic reciprocal process. Trials integrating intermittent assessments are needed to shed light on these mechanisms and inform optimization of CBT.

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.

Does cognitive behaviour therapy for insomnia reduce repetitive negative thinking and sleep-related worry beliefs? A systematic review and meta-analysis

Repetitive negative thinking (RNT), i.e., worry, rumination, and transdiagnostic repetitive thinking, is thought to exacerbate and perpetuate insomnia in cognitive models. Moreover, RNT is a longitudinal precursor of depression and anxiety, which are often co-present alongside insomnia. Whilst accumulating evidence supports the efficacy of cognitive behavioural therapy for insomnia (CBT-I) in reducing depression and anxiety symptoms, the literature on the effects of CBT-I on RNT has never been systematically appraised. Importantly, preliminary evidence suggests that reduction of RNT following CBT-I may be associated with reduction of depression and anxiety. Therefore, we aimed to conduct a systematic review and meta-analysis on the effects of CBT-I on RNT. Seven databases were searched, and 15 randomised controlled trials were included. Results showed moderate-to-large effects of CBT-I on worry (Hedge's g range: -0.41 to g = -0.71) but small and non-reliable effects on rumination (g = -0.13). No clear evidence was found for an association between post-treatment reduction in RNT and post-treatment reduction in depression and anxiety. Although the literature is small and still developing, CBT-I seems to have a stronger impact on sleep-related versus general measures of RNT. We discuss a research agenda aimed at advancing the study of RNT in CBT-I trials.

Changes in dysfunctional beliefs about sleep after cognitive behavioral therapy for insomnia: A systematic literature review and meta-analysis

Cognitive behavioral therapy for insomnia (CBT-I) is the preferred treatment for chronic insomnia and sleep-related cognitions are one target of treatment. There has been little systematic investigation of how sleep-related cognitions are being assessed in CBT-I trials and no meta-analysis of the impact of CBT-I on dysfunctional beliefs about sleep, a core cognitive component of treatment. Academic Search Complete, Medline, CINAHL and PsychInfo from 1990 to 2018 were searched to identify randomized controlled trials of CBT-I in adults (≥18 years) reporting some measure of sleep-related cognitions. Sixteen randomized controlled trials were identified comparing 1134 CBT-I and 830 control subjects. The Dysfunctional Beliefs and Attitudes about Sleep Scale was utilized almost exclusively to assess sleep-related cognitions in these trials. Hedge's g at 95% confidence interval (CI) was calculated to assess CBT-I effect size at post-treatment compared to controls. CBT-I significantly reduced dysfunctional beliefs about sleep (g = -0.90, 95% CI -1.19, -0.62) at post-treatment. Three trials contributed data to estimate effect size for long-term effects (g = -1.04, 95% CI -2.07, -0.02) with follow up time ranging from 3 to 18 mo. We concluded that cognitive behavioral therapy for insomnia has moderate to large effects on dysfunctional beliefs about sleep.

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.