Insomnia as a mediating therapeutic target for depressive symptoms: A sub-analysis of participant data from two large randomized controlled trials of a digital sleep intervention.

Alasdair L Henry,Christopher B Miller,Michelle L Davis,Jenna R Carl,Donna L Littlewood,Richard Emsley,Colin A Espie,Daniel Freeman,Jennifer C Kanady,Annemarie I Luik,Bryony Sheaves,Simon D Kyle,Kate E A Saunders

doi:10.1111/jsr.13140

Abstract

SummaryInsomnia predicts the onset of depression, commonly co‐presents with depression and often persists following depression remission. However, these conditions can be challenging to treat concurrently using depression‐specific therapies. Cognitive behavioural therapy for insomnia may be an appropriate treatment to improve both insomnia and depressive symptoms. We examined the effects of a fully‐automated digital cognitive behavioural therapy intervention for insomnia (Sleepio) on insomnia and depressive symptoms, and the mediating role of sleep improvement on depressive symptoms in participants from two randomized controlled trials of digital cognitive behavioural therapy for insomnia. We also explored potential moderators of intervention effects. All participants met criteria for probable insomnia disorder and had clinically significant depressive symptomatology (PHQ‐9 ≥ 10; n = 3,352). Individuals allocated to treatment in both trials were provided access to digital cognitive behavioural therapy. Digital cognitive behavioural therapy significantly improved insomnia (p < .001; g = 0.76) and depressive symptoms (p < .001; g = 0.48) at post‐intervention (weeks 8–10), and increased the odds (OR = 2.9; 95% CI = 2.34, 3.65) of clinically significant improvement in depressive symptoms (PHQ‐9 < 10). Improvements in insomnia symptoms at mid‐intervention mediated 87% of the effects on depressive symptoms at post‐intervention. No variables moderated effectiveness outcomes, suggesting generalizability of these findings. Our results suggest that effects of digital cognitive behavioural therapy for insomnia extend to depressive symptoms in those with clinically significant depressive symptomatology. Insomnia may, therefore, be an important therapeutic target to assist management of depressive symptoms.

Highlights

Depression is a common disorder that is estimated to affect 9%–20% of adults (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012)
Insomnia is a promising therapeutic target in depressive disorders because sleep disturbance is a typically co-morbid characteristic; and because insomnia symptoms often persist with otherwise effective treatment of depression (Nutt, Wilson, & Paterson, 2008)
Cognitive behavioural therapy (CBT) for insomnia is an effective intervention for insomnia and co-morbid depressive symptoms (Gebara et al, 2018)

Summary

Introduction

Depression is a common disorder that is estimated to affect 9%–20% of adults (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Cognitive behavioural therapy (CBT) for insomnia is an effective intervention for insomnia and co-morbid depressive symptoms (Gebara et al, 2018). The evolution of digital CBT formats (web/mobile) address accessibility challenges around managing insomnia (Luik, Kyle, & Espie, 2017). Both guided (Blom et al, 2015; van der Zweerde, Van Straten, Effting, Kyle, & Lancee, 2019) and fully-automated digital CBT (Christensen et al, 2016; Luik, Bostock, et al, 2017) for insomnia demonstrate similar effects on depressive symptoms as in-person CBT for insomnia. Data from trials of fully-automated digital CBT provide an opportunity to test this hypothesized relationship between sleep and subsequent depressive symptom improvement in large sample sizes

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Discussion

Conclusion