Cognitive Behavioral Treatment For Insomnia Research Articles

Better sleep in psychiatric care - ADHD: a randomized controlled study of cognitive behavioral treatment for insomnia adapted for patients with ADHD

Better sleep in psychiatric care - ADHD: a randomized controlled study of cognitive behavioral treatment for insomnia adapted for patients with ADHD

Insomnia Guidelines—The European Update 2023

The last ten years have seen the development and publication of numerous national and international guidelines devoted to the diagnosis and treatment of insomnia. These include guidelines by the American College of Physicians (ACP), the American Academy of Sleep Medicine (AASM), the British Sleep Society (BSS), the German Sleep Society (GSS), and the European Sleep Research Society (ESRS). Though coming from very diverse authors and backgrounds, these guidelines by and large agree concerning the therapeutic recommendations: cognitive behavioral treatment of insomnia (CBT-I), a multicomponent psychotherapeutic intervention, is unequivocally recommended as a first-line treatment. In this report, we will focus on the most recent guideline update from the ESRS, which was published in November 2023. After suggesting a careful diagnostic procedure, CBT-I, both applied face to face (F2F) or digitally (dCBT-I), is again recommended as a first-line treatment based on the available evidence. Hypnotic medications like benzodiazepines (BZ), benzodiazepine receptor agonists (BZRA), sedating antidepressants, and others are approved for short-term-treatment of up to four weeks. Orexin receptor antagonists (i.e., daridorexant) and prolonged release melatonin are considered as options for longer-term treatment when carefully considering the advantages and disadvantages. Both light therapy and exercise regimens were viewed as promising; however, they still lack convincing evidence for the time being. Given the fact that not every patient responds satisfactorily or even remits following CBT-I or other treatment options, the research agenda calls for the development and evaluation of new therapeutic avenues and combination therapies.

Survey ofResources inBehavioral Sleep Medicine Across the Department ofDefense, Defense Health Agency.

Insomnia affects approximately 40% of active duty service members and adversely affects health, readiness, and safety. The VA/DoD Clinical Practice Guideline for the management of insomnia recommends cognitive-behavioral treatment of insomnia (CBTI) or its abbreviated version (brief behavioral treatment of insomnia [BBTI]) as the first-line insomnia treatment. The goal of this study was to assess CBTI/BBTI resources at MTFs, perceived facilitators and barriers for CBTI/BBTI, and gaps in these treatments across the Defense Health Agency. Between July and October 2022, we conducted an electronic survey of CBTI/BBTI resources across Contiguous United States and the District of Columbia (CONUS) and Outside Continental United States (OCONUS) MTFs. The survey was distributed to 154 military sleep health care providers from 32 MTFs, and a link to the survey was posted on two online military sleep medicine discussion forums. Fifteen providers from 12 MTFs volunteered to complete a 30-minute qualitative interview to explore their perception of barriers and facilitators of CBTI/BBTI at their facility. Fifty-two of 154 providers (33.8%) at 20 MTFs completed the survey. A majority of providers indicated that hypnotics remain the most common treatment for insomnia at their facility. Sixty-eight percent reported that CBTI/BBTI was available at their facility and estimated that less than 50% of the patients diagnosed with insomnia receive CBTI/BBTI. The main facilitators were dedicated, trained CBTI/BBTI providers and leadership support. Referrals to the off-post civilian network and self-help apps were not perceived as significant facilitators for augmenting insomnia care capabilities. The primary barriers to offering CBTI/BBTI were under-resourced clinics to meet the high volume of patients presenting with insomnia and scheduling and workflow limitations that impede repeated treatment appointments over the period prescribed by CBTI/BBTI protocols. Four primary themes emerged from qualitative interviews: (1) CBTI/BBTI groups can scale access to insomnia care, but patient engagement and clinical outcomes are perceived as inferior to individual treatment; (2) embedding trained providers in primary or behavioral health care could accelerate access, before escalation and referral to a sleep clinic; (3) few providers have the time to adhere to traditional CBTI protocols, and appointment scheduling often does not support weekly or bi-weekly treatment visits; and (4) the absence of quality and/or continuity of care measures dampens providers' enthusiasm for using external referral resources or self-help apps. Although there is a wide recognition that CBTI/BBTI is the first-line recommended insomnia treatment, the limited scalability of treatment protocols, clinical workflow limitations, and scarcity of trained CBTI/BBTI providers limit the implementation of the VA/DoD clinical guideline. Educating and engaging health care providers and leadership about CBTI, augmenting CBTI-dedicated resources, and adapting clinical workflows were identified as specific strategies needed to meet the current insomnia care needs of service members. Developing protocols for scaling the availability of CBTI expertise at diverse points of care, upstream from the sleep clinics, could accelerate access to care. Establishing standardized quality measures and processes across points of care, including for external providers and self-help apps, would enhance providers' confidence in the quality of insomnia care offered to service members.

Digital CBTI hubs as a treatment augmentation strategy in military clinics: study protocol for a pragmatic randomized clinical trial

BackgroundChronic insomnia is the most prevalent sleep disorder among military service members, and it compromises readiness, performance, and physical and mental health. Cognitive behavioral treatment for insomnia (CBTI) is the standard of care for the treatment of insomnia recommended by the VA/DoD Clinical Practice Guideline, the American Academy of Sleep Medicine, and the American College of Physicians. CBTI is highly effective but has limited scalability. It is often unavailable in clinical settings where service members receive sleep care. Digital technologies offer unique opportunities to scale and broaden the geographic reach of CBTI services and support increased patient access and engagement in behavioral sleep care. This study aims to evaluate the impact and acceptability of digital CBTI hubs to augment military treatment facilities’ capabilities in behavioral sleep medicine.MethodsThis is a multi-site, non-inferiority randomized clinical trial designed to compare the effects of in-person (face-to-face or virtual) insomnia care as usual at three military sleep clinics versus CBTI delivered remotely and asynchronously through digital CBTI hubs. Digital CBTI hubs are led by licensed, certified clinicians who use NOCTEM’s® evidence-based clinical decision support platform COAST™ (Clinician Operated Assistive Sleep Technology). Changes in insomnia severity and daytime symptoms of depression and anxiety will be compared at baseline, at 6–8 weeks, and at 3-month follow-up. Patient satisfaction with insomnia care as usual versus digital CBTI hubs will also be examined. We hypothesize that digital CBTI hubs will be non-inferior to insomnia care as usual for improvements in insomnia and daytime symptoms as well as patient satisfaction with insomnia care.DiscussionDigital technology has a high potential to scale CBTI accessibility and delivery options required to meet the insomnia care needs of military service members. Digital CBTI hubs using COAST offer a novel approach to broaden service members’ access to CBTI and to serve as an augmentation strategy for existing sleep services at military treatment facilities. The pragmatic approach leveraging technology in this trial has the potential to rapidly inform clinical practice within the Defense Health Agency as well as other healthcare systems.Trial registrationClinicalTrials.gov NCT05490550. Registered on 14 July 2023.

0400 Examining the Effectiveness of Telehealth Delivered Cognitive Behavioral Treatment of Insomnia

Abstract Introduction Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be an effective tool in improving symptoms of insomnia, however access is limited. One option for increasing access is the use of telehealth. We conducted a randomized trial comparing CBT-I delivered in-person to over video telehealth and found that telehealth treatment was non-inferior on self-reported insomnia severity. The objective of this study was to extend this analysis to secondary outcomes of subjective and objective measures of sleep as further assessment of the efficacy of telehealth compared to in-person treatment. Methods Individuals with DSM-5 insomnia disorder (n=60) were randomized to telehealth CBT-I, in person CBT-I, or 8-week waitlist control, although this analysis only compared the CBT-I groups. CBT-I was delivered over 6-8 weekly sessions by video telehealth or in-person in an outpatient clinic. Follow-up assessment was at 2 weeks post-treatment. Both objective and subjective outcomes of sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time (TST) were collected via actigraphy and sleep diaries. Random effects mixed models were used to determine the effects of group, treatment, and their interaction. Results The mean change in SE, SOL, WASO, and TST for objective measures from baseline to follow-up was 0.43% and -17.7 minutes, -6.8 minutes, -31.0 minutes, respectively, for in person CBT-I and 0.01%, -15.1 minutes, -2.1 minutes, -9.5 minutes, respectively, for telehealth. For subjective measures, the mean change was 0.16% and -27.0 minutes, -22.7 minutes, 28.9 minutes, respectively, for in person CBT-I and 0.15%, -23.4 minutes, -23.4 minutes, 51.6 minutes respectively for telehealth. The differences between the CBT-I groups were not statistically significant, nor were there significant interaction effects. Conclusion In both objective and subjective measures of insomnia, there is no evidence that outcomes from telehealth delivery of CBT-I is worse than in person treatment. Subjective effects were much larger than objective effects for insomnia possibly indicating a discrepancy between how sleep and more particularly insomnia is perceived by oneself and measured in the lab. Support (if any) This research was supported by grant 167-SR-17XYZ from the American Sleep Medicine Foundation and a Doris Duke Charitable Foundation Clinical Scientist Development Award.

0720 Depression and pain are barriers to benzodiazepine and z-drug deprescribing

Abstract Introduction Clinical guidelines recommend avoiding benzodiazepines and z-drugs (BZRAs) in older adults due to an increased risk of adverse outcomes (e.g., falls) in this population. Efforts to reduce BZRA use among older adults are growing, yet long-term BZRA deprescribing among patients with insomnia is challenging. We examined whether clinical conditions commonly comorbid with insomnia (i.e., depression, pain, nightmares, and anxiety) are barriers to BZRA deprescribing. Methods In an ongoing multi-site trial comparing two BZRA deprescribing programs (both include cognitive behavioral treatments for insomnia), participants aged >=55 years with chronic BZRA use for insomnia (N=165, mean age 68.7, sd 7.9) completed baseline Patient Health Questionnaire-9 (PHQ9), Brief Pain Inventory (BPI), Disturbing Dreams and Nightmare Severity Index (DDNSI), and Generalized Anxiety Disorder-7 (GAD-7). Deprescribing outcomes (discontinuation, dose, and frequency of use over 7-days) were assessed 1 week and 6 months after completing the deprescribing program. Using logistic and linear regression models, we assessed whether depression, pain severity, nightmare severity, and anxiety were predictors of BZRA deprescribing outcomes, controlling for site, gender, and age. Results Among participants assessed 1 week (n=133) and 6 months (n=106) after intervention, 77% and 66% discontinued their BZRA use, respectively. Worse PHQ-9 was associated with reduced odds of discontinuation (OR 0.88, 95% CI 0.79-0.99, p=.027) at 6 months, but not frequency of use or dose at follow up. Pain severity predicted more frequent use (b=0.26, p=.02) and higher dose (b=0.94, p=.016) but not discontinuation at 6 months. DDNSI (p values >=.068) and GAD-7 (p values >= 0.15) were not significant predictors of discontinuation, frequency, or dose at follow-up. Conclusion More severe depression at baseline is a predictor of BZRA deprescribing failure long-term. Pain is also a barrier to BZRA reduction efforts. Programs aimed at reducing and discontinuing BZRAs used for insomnia should consider interventions that not only address underlying insomnia, but also depression and pain. Support (if any) NIA R01AG057929; VA IIR 17-234

Longitudinal profiles of sleep during residential PTSD treatment

We investigated longitudinal profiles of objectively measured sleep periods (SP) over the course of residential treatment for posttraumatic stress disorder (PTSD) in a cohort of U.S. male veterans. Participants (N = 190) slept on mattress-actigraphy systems in a Veterans Affairs (VA) residential PTSD program. The final sample included 4078 sleep periods. Latent class mixed model analyses were used to identify between-subject profiles in sleep period durations, controlling for daily medication intake, over the first fifty days of residency. Logistic regression was used to determine the association of pre-treatment characteristics with identified profiles. Three longitudinal profiles of sleep period characterized most of the sample: ‘stable’ (56%), ‘decreasing’ (35%), and ‘increasing’ (8%). Less severe pre-treatment PTSD avoidance symptoms predicted membership in the 'decreasing' class and increased depression symptoms were predictive of membership in the 'increasing' class. Nearly half of the sample reported a summary change of 1 h or more over the course of the initial 50-nights in the program. Future work is needed to identify how these profiles might drive inpatient treatment decisions regarding the provision of adjunctive sleep-focused treatment such as cognitive-behavioral treatment for insomnia or hypnotic medications.

Behavioral Activation as an Adjunct Treatment to CBT-I.

Behavioral activation (BA) has long been long understood to be a particularly effective treatment for depression. Elements of BA are also to be found in components of insomnia treatment such as sleep restriction, stimulus control, and the setting of a morning routine. Although little research exists that examines the independent contribution of BA to the treatment of insomnia, it is reasonable to apportion some of the effect of cognitive-behavioral treatment of insomnia (CBT-I) to the implementation of BA whether that implementation is simply incidental to standard practice or more extensively deployed.

Internet delivered, non-inferiority, two-arm, assessor-blinded intervention comparing mindfulness-based stress reduction and cognitive-behavioral treatment for insomnia: a protocol study for a randomized controlled trial for nursing staff with insomnia

BackgroundInsomnia and poor sleep quality are highly prevalent conditions related to coronavirus disease 2019 (COVID-19) complications among clinical nurses. Although cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment, CBT-I suffers from several major drawbacks. This study investigates whether the application of the internet-delivered mindfulness-based stress reduction (iMBSR) intervention will produce effects that are non-inferior to the internet-delivered CBT-I (iCBT-I) intervention in reducing the severity of insomnia in clinical nurses with insomnia at the end of the study.MethodsThis study protocol presents an internet-delivered, parallel-groups, assessor-blinded, two-arm, non-inferiority randomized controlled trial. The primary outcome is sleep quality, assessed by the Insomnia Severity Index. Secondary outcomes include depression, dysfunctional beliefs, five facets of mindfulness, and client satisfaction.ConclusionIt is expected that this study may address several gaps in the literature. The non-inferiority study design is a novel approach to evaluating whether a standardized, complementary treatment (i.e., MBSR) is as practical as a gold standard treatment rather than its potential benefits. This approach may lead to expanded evidence-based practice and improve patient access to effective treatments.Trial registrationTrial registration number: ISRCTN36198096. Registered on 24th May 2022.

Decreased Transition Rate From Situational Insomnia to Chronic Insomnia by One-Week Internet Cognitive Behavioral Treatments for Insomnia During the COVID-19 Pandemic.

PurposeThe purpose of the study was to determine the long-term effects of one-week self-guided internet cognitive behavioral treatments for insomnia (CBTI) on situational insomnia during the COVID-19 pandemic.Patients and MethodsThe participants with situational insomnia (n = 194) were recruited from March 2020 to April 2020 in Guangzhou, China. The insomnia severity index (ISI), pre-sleep arousal scale (PSAS), and hospital anxiety and depression scale (HADS) were evaluated at baseline and a one-week internet CBTI program was delivered to all individuals. The participants were divided into the complete treatment group (the participants completed all seven modules of the CBTI course, n = 75), and the incomplete treatment group (the participants completed 0–6 modules of the CBTI course, n = 119). A total of 135 participants completed the post-intervention assessments. At 3 months follow-up, a total of 117 participants (complete treatment group: n = 51; incomplete treatment group: n = 66) completed the assessments of the ISI, PSAS and HADS. The transition rate from situational insomnia to chronic insomnia (duration of insomnia ≥ 3 months and ISI ≥ 8) was calculated in the two groups. Linear mixed effect model was used to investigate the effect of group (between the two groups), time (baseline vs. follow-up), and interaction (group x time) on various questionnaire score.ResultsThe transition rate from situational insomnia to chronic insomnia was significantly lower in the complete treatment group compared to the incomplete treatment group (27.5%, 14/51 vs. 48.5%, 32/66, p = 0.023). There were significant differences in group effect (p = 0.032), time effect (p = 0.000) and group × time effect (p = 0.048) between the two groups in the ISI total score. The ISI total scores decreased in both groups during follow-up compared to their baseline values, with a greater magnitude of decrease in the complete treatment group. There were no significant group x time effects between the two groups in the PSAS-total score, PSAS-somatic, PSAS-cognitive score, HADS total score, HADS anxiety score or HADS depression score.ConclusionOur results suggested that one-week self-guided internet CBTI prevented the development of chronic insomnia from situational insomnia during the COVID-19 pandemic.

A Randomized Controlled Trial Comparing Neurofeedback and Cognitive-Behavioral Therapy for Insomnia Patients: Pilot Study.

Insomnia is a common disease that negatively affects patients both mentally and physically. While insomnia disorder is mainly characterized by hyperarousal, a few studies that have directly intervened with cortical arousal. This study was conducted to investigate the effect of a neurofeedback protocol for reducing cortical arousal on insomnia compared to cognitive-behavioral treatment for insomnia (CBT-I). Seventeen adults with insomnia, free of other psychiatric illnesses, were randomly assigned to neurofeedback or CBT-I. All participants completed questionnaires on insomnia [Insomnia Severity Index (ISI)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and dysfunctional cognition [Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16)]. The neurofeedback group showed decreases in beta waves and increases in theta and alpha waves in various areas of the electroencephalogram (EEG), indicating lowered cortical arousal. The ISI and PSQI scores were significantly decreased, and sleep efficiency and sleep satisfaction were increased compared to the pre-treatment scores in both groups. DBAS scores decreased only in the CBT-I group (NF p = 0.173; CBT-I p = 0.012). This study confirmed that neurofeedback training could alleviate the symptoms of insomnia by reducing cortical hyperarousal in patients, despite the limited effect in reducing cognitive dysfunction compared to CBT-I.

Improvement of Insomnia Symptoms following a Single 4-Hour CBT-I Workshop

ABSTRACT Study Objectives : Cognitive behavioral treatment for insomnia (CBT-I) is the first line of treatment for insomnia. However, the expanded use of CBT-I is limited by the number of specialty-trained clinicians in addition to the duration and cost of individual treatment sessions. One viable option is a single-session educational group format delivered by a trained health educator. Methods : In a preliminary, single group pretest-posttest design, the effectiveness of group CBT-I delivered to community dwelling individuals with self-reported insomnia symptoms was evaluated. Participants completed the Insomnia Severity Index (ISI) and provided information on sleep aid use, prior to and 1-month post attendance of a single 4-hour CBT-I workshop. Results : Participants (N = 45) were 54 ± 16 years and 71% female. ISI scores significantly improved from baseline (20.09 ± 4.1) to 1-month follow-up (11.89 ±5.7; t = 10.1, p < .001) with an average change of 8.2 ± 5.4 points. Frequency of sleep aid use significantly dropped (χ2 = 105.7, p = .017). Eighty percent of participants reported sleeping better or much better at follow-up. Twenty percent of participants met criteria for remission of insomnia and 35.6% of participants had ISI change scores meeting criteria for a Minimally Important Difference associated with improvements in fatigue, work productivity, and health related quality of life. Conclusions : These preliminary data suggest that a single 4-hour CBT-I workshop delivered by a health educator can significantly improve insomnia symptoms, improve subjective sleep quality, and reduce sleep aid use among community dwelling adults with and without co-morbidities within 1-month.

Prediction of good sleep with physical activity and light exposure: a preliminary study.

Cognitive behavioral treatment for insomnia is performed under the premise that feedback provided by evaluation of sleep diaries written by patients will result in good sleep. The sleep diary is essential for behavior therapy and sleep hygiene education. However, limitations include subjectivity and laborious input. We aimed to develop an artificial intelligence sleep prediction model and to find factors associated with good sleep using a wrist-worn actigraphy device. We enrolled 109 participants who reported having no sleep disturbances. We developed a sleep prediction model using 733 days of actigraphy data of physical activity and light exposure. Twenty-four sleep prediction models were developed based on different data sources (actigraphy alone, sleep diary alone, or combined data), different durations of data (1 or 2 days), and different analysis methods (extreme gradient boosting, convolutional neural network, long short-term memory, logistic regression analysis). The outcome measure of "good sleep" was defined as ≥ 90% sleep efficiency. Actigraphy model performance was comparable to sleep diary model performance. Two-day models generally performed better than 1-day models. Among all models, the 2-day, combined (actigraphy and sleep diary), extreme gradient boosting model had the best performance for predicting good sleep (accuracy = 0.69, area under the curve = 0.70). The findings suggested that it is possible to develop automated sleep models with good predictive performance. Further research including patients with insomnia is needed for clinical application. Park KM, Lee SE, Lee C, etal. Prediction of good sleep with physical activity and light exposure: a preliminary study. J Clin Sleep Med. 2022;18(5):1375-1383.

Cannabis use as a moderator of cognitive behavioral therapy for insomnia.

Cannabis use is common among young adults and has been proposed as a potential treatment for insomnia. However, controlled studies examining the impact of cannabis use on insomnia symptoms are rare. This secondary analysis of published trial data tested cannabis use during cognitive behavioral treatment for insomnia (CBT-I) as a moderator of treatment efficacy. Young adults (ages 18-30 years) who reported past-month binge drinking (4/5+ drinks for women/men) and met diagnostic criteria for insomnia disorder were randomized to CBT-I (n = 28) or sleep hygiene (n = 28) groups. Interaction effects were tested using multilevel models. Outcomes included insomnia severity, actigraphy-assessed sleep efficiency, diary-assessed sleep quality, drinking quantity, and alcohol-related consequences. Twenty-six participants (46%; 12 in the sleep hygiene group and 14 in the CBT-I group) reported using cannabis during the treatment phase of the study, on an average of 23% of treatment days (range, 3%-100%). Relative to those who did not use cannabis, participants who used cannabis during treatment reported heavier drinking and more frequent cigarette use. Approximately 1 in 4 cannabis users (27%) reported using cannabis to help with sleep; however, cannabis users and nonusers did not differ in the use of alcohol as a sleep aid. Controlling for sex, race, drinking quantity, cigarette use, symptoms of depression, and symptoms of anxiety, use of cannabis during treatment did not moderate CBT-I effects on insomnia severity (b, -.002; p = .99) or other outcomes (all p > .20). CBT-I is effective in reducing insomnia symptoms among young adult drinkers with insomnia, regardless of cannabis use. Registry: ClinicalTrials.gov; Name: The Insomnia Treatment and Problems (iTAP) Study; URL: https://clinicaltrials.gov/ct2/show/NCT03627832; Identifier: NCT03627832. Miller MB, Carpenter RW, Freeman LK, Curtis AF, Yurasek AM, McCrae CS. Cannabis use as a moderator of cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2022;18(4):1047-1054.

Using Telehealth to Deliver Family-Based Cognitive Behavioral Treatment of Insomnia in a School-Aged Child With Autism Spectrum Disorder.

Chronic insomnia (>3 months) is common in children with autism. Cognitive behavioral treatment for insomnia in children (CBT-CI) holds promise for improving sleep and daytime functioning in school-aged children with autism and their parents, but typical delivery involving multiple in-person office visits limits accessibility. This case study describes telehealth delivery of CBT-CI (teleCBT-CI) with a 7-year 4-month-old biracial boy with autism spectrum disorder (ASD) and insomnia and his parents. He and his mother wore actigraphs and completed electronic sleep diaries for 2 weeks, and his mother completed the Aberrant Behavior Checklist at pre/post/1-month follow-up. He and both of his parents completed eight telehealth treatment sessions. TeleCBT-CI improved the boy's sleep (objective, subjective) and decreased irritability, lethargy, stereotypy, and hyperactivity. This case study shows that teleCBT-CI is feasible and can improve child sleep and functioning.

Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study.

To examine whether cognitive behavioral treatments for insomnia (CBT-I) and pain (CBT-P) lead to neural activation changes in response to pain in fibromyalgia. Thirty-two patients with fibromyalgia (mean age = 55.9, standard deviation = 12.2) underwent an experimental pain protocol during functional magnetic resonance imaging and completed 14-day diaries assessing total wake time, total sleep time, and pain intensity before and after CBT-I, CBT-P, or waitlist control. Random effects analysis of covariance identified regions with significant group (CBT-I, CBT-P, waitlist control) by time (baseline, post-treatment) interactions in blood oxygen level-dependent response to pain. Linear regressions using residualized change scores examined how changes in total wake time, total sleep time, and pain intensity were related to activation (blood oxygen level-dependent) changes. Twelve regions exhibited small to moderate effects with significant interactions Ps < .00; right hemisphere: inferior frontal, middle occipital, and superior temporal gyri, insula, lentiform nucleus; left hemisphere: angular, superior temporal, midfrontal, inferior occipital, midtemporal, and inferior frontal gyri. Blood oxygen level-dependent response to pain decreased in 8 regions following CBT-I, and in 3 regions following CBT-P (CBT-I effects > CBT-P). Blood oxygen level-dependent response also increased in 3 regions following CBT-P and in 6 regions following waitlist control. Improved total wake time and/or total sleep time, not pain intensity, predicted decreased blood oxygen level-dependence in 7 regions (Ps < .05), accounting for 18%-47% of the variance. CBT-I prompted greater decreases in neural activation in response to pain across more regions associated with pain and sleep processing than CBT-P. Reported sleep improvements may underlie those decreases. Future research examining the longer-term impact of CBT-I and improved sleep on central pain and sleep mechanisms is warranted. Registry: ClinicalTrials.gov; Title: Sleep and Pain Interventions in Fibromyalgia (SPIN); Identifier: NCT02001077; URL: https://clinicaltrials.gov/ct2/show/NCT02001077. McCrae CS, Craggs JG, Curtis AF, etal. Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study. J Clin Sleep Med. 2022;18(1):203-215.

Effect of trazodone versus cognitive-behavioural treatment on high- and slow-frequency activity during non-rapid eye movement sleep in chronic insomnia: A pilot, randomized clinical trial.

Trazodone and cognitive-behavioural treatment for insomnia (CBT-I) are widely used to treat patients with chronic insomnia. Although both treatments improve sleep continuity, no study has compared their comparative effectiveness in modifying spectral electroencephalographic (EEG) activity during sleep in humans. In this study, participants included 19 men and women with chronic insomnia who were randomized to either trazodone (n=8) or CBT-I (n=11) treatment for 3months. We examined delta (0.39-3.91Hz), theta (4.30-7.81Hz), alpha (8.20-11.72Hz), sigma (12.11-14.84Hz), beta (15.23-35.16Hz) and gamma (35.55-49.61Hz) relative power during non-rapid eye movement (NREM) sleep at pre-treatment, 3-month post-treatment and 6-month follow-up. This study was registered in Clinical Trials (NCT01348542). We found trazodone but not CBT-I significantly decreased sigma (p=.041, d=0.88; time×group p=.009) and beta (p=.005, d=1.41; time×group p=.016) power during NREM sleep at post-treatment. Compared to CBT-I, trazodone increased delta (p=.018) and decreased sigma (p=.013) and beta (p=.023) power during NREM sleep at post-treatment. At follow-up, we did not observe significant changes in relative EEG power during NREM sleep in either the CBT-I or trazodone group compared to pre-treatment. Compared to CBT-I, trazodone decreased alpha (p=.039) and sigma (p=.009) power during NREM sleep at follow-up. In conclusion, trazodone, but not CBT-I, decreased fast-frequency EEG activity during NREM sleep. Compared to CBT-I, trazodone appears to have a stronger impact on cortical and physiological hyperarousal in patients with chronic insomnia.

One-Week Self-Guided Internet Cognitive Behavioral Treatments for Insomnia in Adults With Situational Insomnia During the COVID-19 Outbreak.

Objective: In the current global home confinement due to COVID-19, most individuals are facing unprecedented stress which can induce situational insomnia. We explored the efficacy of self-guided online cognitive behavioral treatment for insomnia (CBTI) on situational insomnia during the COVID-19 outbreak.Methods: Participants were recruited from March to April in 2020 in Guangzhou, China. A 1-week Internet CBTI intervention was performed for all individuals with situational insomnia. The Pre-sleep Arousal Scale (PSAS), Insomnia Severity Index (ISI), and Hospital Anxiety and Depression Scale (HADS) were measured before and after the intervention and compared between individuals who completed the intervention and those who did not.Results: One hundred and ninety-four individuals with situational insomnia were included. For PSAS score, significant group effects were found on total score (p = 0.003), somatic score (p = 0.014), and cognitive score (p = 0.009). Time effect was significant on total score (p = 0.004) and cognitive score (p < 0.001). There was a significant group × time effect of the somatic score (p = 0.025). For ISI total score, there were significant time effect (p < 0.001) and group × time effect (p = 0.024). For the HADS score, a significant group effect was found on the anxiety score (p = 0.045). The HADS had significant time effects for anxiety and depressive symptoms (all p < 0.001).Conclusion: Our study suggests good efficacy of CBTI on situational insomnia during COVID-19 for adults in the community, as well as on pre-sleep somatic hyperarousal symptom. The CBTI intervention is not applied to improve pre-sleep cognitive hyperarousal, depression, and anxiety symptoms.

Randomized trial of telehealth delivery of cognitive-behavioral treatment for insomnia vs. in-person treatment in veterans with PTSD

• Insomnia is common in veterans with PTSD. • Cognitive behavioral treatment for insomnia can effectively treat insomnia in this population. • Cognitive behavioral treatment can be delivered via telemedicine without losing clinical effectiveness. Insomnia is prevalent in veterans with PTSD but often goes untreated. Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment but many patients do not have access to this intervention. Clinical video telehealth provides a means of increasing access to care but there is a need to understand the effectiveness of care delivered using this modality. Randomized non-inferiority trial comparing group CBT-I delivered between VA clinics over video telehealth to in-person treatment. 116 Veterans with PTSD received CBT-I over six weeks in a group format at a VA healthcare facility. The Insomnia Severity Index (ISI) was the primary outcome measure. Secondary outcomes included measures of sleep, PTSD severity and quality of life. The non-inferiority margin was defined as a difference in ISI change scores between groups ≥1.67 points. The mean(SD) improvement in the ISI was 6.48 (0.90) points for in-person treatment and 4.45 (0.98) points for telehealth treatment in intent-to-treat analyses. In both intent-to-treat and per-protocol analyses, the difference between these change scores of 2.03 had a confidence interval that included the non-inferiority margin of 1.67, supporting the hypothesis of non-inferiority. On secondary outcomes, there were significant improvements after treatment only in sleep quality and no between-group differences. The eligibility criteria were intentionally broad, so there were several potential confounding factors. Drop-out was also considerable, with only 54.3% of subjects in the in-person group and 46.9% in the telehealth group completing treatment. Delivery of group CBT-I by clinical video telehealth to veterans with PTSD is non-inferior to in-person treatment, although overall efficacy of treatment was modest. Telehealth technology can increase access to care without sacrificing clinical gains.

Protocol for the impact of CBT for insomnia on pain symptoms and central sensitisation in fibromyalgia: a randomised controlled trial.

IntroductionApproximately 50% of individuals with fibromyalgia (a chronic widespread pain condition) have comorbid insomnia. Treatment for these comorbid cases typically target pain, but growing research supports direct interventions for insomnia (eg, cognitive behavioural treatment for insomnia (CBT-I)) in these patients. Previous research suggests sustained hyperarousal mediated by a neural central sensitisation mechanism may underlie insomnia and chronic pain symptoms in fibromyalgia. We hypothesise CBT-I will improve insomnia symptoms, improve clinical pain and reduce central sensitisation. The trial will be the first to evaluate the short-term and long-term neural mechanisms underlying insomnia and pain improvements in fibromyalgia. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target pain mechanisms, perhaps reversing chronic pain or preventing it.Methods and analysisFemale participants (n=130) 18 years of age and older with comorbid fibromyalgia (with pain severity of at least 50/100) and insomnia will be recruited from the University of Missouri in Columbia, Missouri, and surrounding areas. Participants will be randomised to 8 weeks (plus 4 bimonthly booster sessions) of CBT-I or a sleep hygiene control group (SH). Participants will be assessed at baseline, post-treatment, 6 and 12 months follow-ups. The following assessments will be completed: 2 weeks of daily diaries measuring sleep and pain, daily actigraphy, insomnia severity index, pain-related disability, single night of polysomnography recording, arousal (heart rate variability, cognitive affective arousal), structural and functional MRI to examine pain-related neural activity and plasticity and mood (depression, anxiety).Ethics and disseminationEthics approval was obtained in July 2018 from the University of Missouri. All data are expected to be collected by 2022. Full trial results are planned to be published by 2024. Secondary analyses of baseline data will be subsequently published.Trial registration number NCT03744156.