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

Insomnia and depression are highly co-morbid conditions that share a complex, bi-directional relationship. By reviewing the literature examining the links between insomnia and depression, it becomes apparent that insomnia symptoms need to be directly targeted alongside depression symptoms when co-morbidities exist for optimal outcomes. The most common treatment in Australia for co-morbid insomnia and depression is currently antidepressant medication. Because a large percentage of individuals given antidepressants fail to remit from their depression and insomnia symptoms, an effective adjunct treatment to antidepressants for co-morbid insomnia and depression is required. Cognitive behavioural therapy for insomnia (CBT-I) is an empirically validated treatment for insomnia, and is efficacious in improving insomnia that is co-morbid with depression. Recent evidence also suggests that CBT-I produces significant improvements in depression severity. The main aim of the thesis was therefore to develop a cost-effective CBT-I intervention that could be easily administered, distributed and implemented on a wide-scale basis, both on its own for insomnia, and primarily as an adjunct therapy for co-morbid insomnia and depression. A therapist manual of CBT-I, based on the latest empirical findings, was specifically developed to increase consistency and ease of treatment administration by therapists wanting to deliver CBT-I treatment. A resource booklet was also developed to give to all individuals undergoing CBT-I treatment, to ensure that they were provided with the latest information about sleep and how to reduce their insomnia severity. A randomised controlled trial was then developed to investigate the efficacy of this CBT-I intervention in individuals with co-morbid insomnia and depression whose symptoms have failed to remit through antidepressant treatment. Forty-one participants (aged 18-64 years) were randomized to receive four sessions of either CBT-I or sleep education (self-help therapy) over an 8-week period (one session every two weeks). Participants had been treated with antidepressants for at least six weeks prior to screening, but were otherwise healthy. The Insomnia Severity Index and the Beck Depression Inventory were assessed at baseline, following each session, and at 3-month follow-up. Secondary outcomes were sleep quality and duration (actigraphy and self-report), anxiety, fatigue, and daytime sleepiness. Results indicated that CBT-I, compared to sleep education, produced significantly reduced depression and insomnia severity, and improved anxiety, fatigue, sleep quality and sleep efficiency. It is the first randomised controlled trial of CBT-I for co-morbid insomnia and depression, with an active control treatment, to show significant reductions in both insomnia and depression severity at post-treatment and follow-up. Large effect sizes were found for both insomnia and depression at post-treatment, and these effect sizes increased further by three month follow-up. At follow-up, ten times more CBT-I participants were in remission from both insomnia and depression than sleep education participants. This demonstrates that CBT-I is an efficacious treatment for co-morbid insomnia and depression, and should be considered an important adjunct therapy in individuals whose symptoms have not remitted through antidepressant treatment. Following the positive results of the randomised controlled trial, the proposed mediators of CBT-I were examined to determine which aspects of the intervention had the largest influence on reductions in insomnia and depression severity at post-treatment and 3-month follow-up. Changes in time-in-bed, bedtime variability, rise-time variability, sleep hygiene practices, dysfunctional beliefs about sleep and stress levels were assessed as potential mediators. Post-treatment results indicated that the significantly reduced depression severity through CBT-I was primarily via reduced stress levels, improved sleep hygiene practices, and other therapeutic effects of CBT-I, whereas reduced insomnia severity was primarily via reduced dysfunctional beliefs about sleep. By follow-up, the significantly reduced depression severity in the CBT-I group was primarily via reduced stress levels and reduced dysfunctional beliefs about sleep, whereas reduced dysfunctional beliefs about sleep and other therapeutic effects of CBT-I explained the significantly reduced insomnia severity. These results indicate that reducing stress levels through CBT-I treatment is required for optimal depression outcomes, whereas reducing dysfunctional beliefs about sleep is essential for optimal insomnia outcomes. Improving sleeping practices behaviourally is important for initial depression improvements, but reducing dysfunctional beliefs about sleep becomes more important for longer-term remission of depression symptoms. Other non-factual therapeutic elements of CBT-I treatment appear to be important, and may lead to a greater willingness to engage in the CBT-I strategies, which can improve depression in the short-term and insomnia in the longer-term. These mediators of CBT-I treatment had not been specifically examined in individuals with co-morbid insomnia and depression before this study. Their identification suggests that relaxation and behavioural sleep interventions should be prioritized initially through CBT-I for co-morbid insomnia and depression, followed by cognitive interventions to target unhelpful beliefs about sleep. By increasing the efficiency of CBT-I, optimal treatment outcomes can be achieved for individuals with co-morbid insomnia and depression, and the risk of future relapse can be minimized.

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning. A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures. A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring. Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes. Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303. Tu AY, Crawford MR, Dawson SC, etal. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

BackgroundInsomnia is highly prevalent in patients with rheumatoid arthritis (RA) and may exacerbate symptoms and burdens, such as fatigue, depressive symptoms, and pain1. Cognitive behavioural therapy for insomnia (CBT-I) has...

Do symptoms of depression, anxiety or stress impair the effectiveness of cognitive behavioural therapy for insomnia? A chart-review of 455 patients with chronic insomnia

We previously presented results from a randomized controlled trial that examined the effects of antidepressant medication plus cognitive behavioral therapy for insomnia (CBT-I) among patients with major depressive disorder (MDD) and insomnia. The current secondary analysis aims to examine whether circadian preference moderated the reduction in depression and insomnia symptom severity during this trial. A total of 139 adult participants with MDD and insomnia disorder were treated with antidepressant medication and randomized to receive 7 sessions of CBT-I or a control therapy (CTRL). Circadian preference (eveningness) was measured using the Composite Scale of Morningness (CSM). Depression symptom severity was assessed using the Hamilton Depression Rating Scale (HDRS); insomnia symptom severity was assessed using the Insomnia Severity Inventory (ISI). The moderating role of circadian preference on changes in HRSD and ISI was assessed via latent growth models within the framework of structural equation modeling. Greater evening preference was associated with smaller reduction in HDRS (P = .03) from baseline to week 6 across treatment groups. The interaction between CSM and treatment group was also significant (P = .02), indicating that participants with greater evening preference in the CTRL group had significantly smaller HDRS reduction than those with greater evening preference in the CBT-I group. Circadian preference did not share significant associations with ISI (all P > .30). Individuals with MDD and insomnia who have an evening preference are at increased risk for poor response to pharmacological depression treatment augmented with either CBT-I or CTRL behavioral insomnia treatment. However, evening types have better depression outcomes when treated with CBT-I than with CTRL for insomnia.

Cognitive behavioral therapy for insomnia (CBT-I) is a well-known, effective treatment for primary insomnia. However, the majority of sleeping problems occur in the presence of another medical or psychiatric disorder. Depression and general anxiety disorder (with a main feature of excessive generalized worrying) are disorders that frequently co-occur with insomnia. The purpose of this study is to evaluate whether depressive symptom severity or worrying influences the subjective effectiveness of CBT-I. Patients with a complaint of insomnia received CBT-I. At the beginning of the therapy, patients completed a sleep evaluation list, the Beck Depression Inventory (BDI-II-NL, N = 92), and the Penn State Worry Questionnaire (PSWQ, N = 119). Based on the BDI and the PSWQ, the sample was divided into different groups: patients with low versus high depression scores, low worriers versus high worriers, and patients without depressive symptoms who were also classified as low worriers and patients with depressive symptoms who were also classified as high worriers. The sleep evaluation list was completed directly after the treatment and 6 months later. Sleep evaluation scores, subjective total sleep time, subjective sleep onset latency, and subjective wake after sleep onset all changed in a positive way after CBT-I and remained that way over the next 6 months for all patients. These positive effects of CBT-I did not differ between the subgroups. Results suggest that CBT-I improves subjective sleep experiences, regardless of depressive symptom severity or worrying.

Effects of subjective-objective sleep discrepancy on the response to cognitive behavior therapy for insomnia

Treatment-related changes in insomnia, anticipatory pleasure, and depression symptoms: A proof-of-concept study with cancer survivors

Relationships Among Pain, Depressed Mood, and Global Status in Fibromyalgia Patients: Post Hoc Analyses of a Randomized, Placebo-Controlled Trial of Milnacipran

Cognitive behavioral therapy for insomnia (CBT-I) is a first-line therapy for insomnia disorders. We assessed changes in discrepancies between subjective and objective sleep measures and correlations between discrepancy changes and clinical insomnia severity for CBT-I in patients with primary insomnia METHODS: Fifty-two outpatients (mean age, 60.3years; 26 women) with primary insomnia were treated by individual CBT-I (50min, maximum six sessions, once every 1-2weeks). One week before and after CBT-I, patients recorded a sleep log and wore an actigraphy device. Subjective and objective time in bed (TIB), total sleep time (TST), sleep-onset latency (SOL), wake time after sleep onset (WASO), and sleep efficiency (SE) were evaluated by averaging 1-week records. Relative values of sleep discrepancy in TIB, TST, SOL, WASO, and SE were calculated for estimating effects of CBT-I. The therapeutic effects were also evaluated using psychological scales before and after CBT-I. Subjective and objective discrepancies in sleep measures decreased by 36, 25, and 37min in TST, SOL, and WASO, respectively, and 7% in SE (all P < 0.001) after CBT-I. Seven patients transitioned from underestimating SE before CBT-I to overestimating SE after CBT-I. Although CBT-I improved relative values of discrepancy in WASO and SE, alongside ISI, the improvement in insomnia severity only correlated with SOL discrepancy. CBT-I may reduce the discrepancy between subjective and objective sleep measures in patients with primary insomnia. However, a greater therapeutic effect of CBT-I was observed in reducing the ISI, which was slightly influenced by improvements in sleep discrepancies.

Brain-derived neurotrophic factor levels and depression during methamphetamine withdrawal

Apport de la pleine conscience dans les thérapies cognitives et comportementales de l’insomnie

BackgroundInsomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown.ObjectiveThis open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS).MethodsA total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi.ResultsAverage baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005).ConclusionsOur study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health.International Registered Report Identifier (IRRID)RR2-10.2196/11324

The authors evaluated the effects of brief group cognitive behavioral therapy for insomnia (G-CBT-I) in outpatients with psychophysiological insomnia (PPI). This brief G-CBT-I was designed to yield results in a shorter period of time, because its strategy was intended to lower the dropout rate and enhance the cost performance. And also, it was intended to be easy to make use of CBT-I for both therapists and patients. This process consists of four components and only two sessions weekly, and a total therapy time is approximately 3 h. Thirty-three participants (including 17 women) with PPI received G-CBT-I therapy. The short-term outcome (4 weeks after G-CBT-I) was measured using sleep logs, actigraphy, the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J), and the Japanese version of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-J). The long-term outcome was evaluated by checking medical records at 6 months after G-CBT-I. At 4 weeks after G-CBT-I, subjective sleep onset latency decreased by 32.1%, and objective sleep efficiency increased to approximately 90%. The dissociation between subjective and objective evaluations of sleep decreased. The total score of the PSQI-J and the scores on the DBAS-J (“consequences of insomnia”, “control and predictability of sleep”, and “sleep-promoting practice”) were decreased. At the long-term follow-up, the amount of hypnotics needed by each participant decreased by 0.6 mg (1 being equivalent to 1 mg of flunitrazepam) (33% reduction). These findings suggested that patients with PPI could derive significant benefit from brief G-CBT-I therapy.

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.