Cognitive-Behavioral Therapy for Insomnia Co-Morbid with Hearing Impairment: A Randomized Controlled Trial

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.     

Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial

ObjectiveInsomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference.MethodsChronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose.ResultsCompared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability.ConclusionThe hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.     

Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients

Primary care is often the place where patients with depression and comorbid insomnia seek treatment. The experience of comorbid insomnia with depression can have a significant impact on the efficacy of other depression treatments and exacerbate depressive symptoms. Using the empirically based Cognitive-Behavioral Treatment for Insomnia (CBT-I) to target the comorbid experience of insomnia in patients with depression can help improve sleep and potentially modify some depressive symptoms. Additional rationale for such an approach includes that a positive therapeutic experience may enhance engagement with or adherence to other psychotherapeutic interventions. Although other brief CBT-I interventions have been developed for primary care, none of them were actually delivered to depressed patients or implemented in primary care. Therefore, this paper describes a brief CBT-I intervention that was designed to be delivered in 4 sessions lasting from 15 to 45 minutes each within a primary care setting to depressed veterans. A case study is provided along with sample materials used in this intervention. In addition, we share implementation tips based on our experiences and feedback from eight veterans who have completed the intervention to date. Overall, the intervention was generally well received and suggests that the intervention may be feasibly delivered in a primary care setting.     

Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: A pilot study

IntroductionChronic pain is difficult to treat and often precedes or exacerbates sleep disturbances such as insomnia. Insomnia, in turn, can amplify the pain experience. Both conditions are associated with inflammatory processes, which may be involved in the bi-directional relationship between pain and sleep. Cognitive behavioral therapy (CBT) for pain and CBT for insomnia are evidence based interventions for, respectively, chronic pain and insomnia. The study objectives were to determine the feasibility of combining CBT for pain and for insomnia and to assess the effects of the combined intervention and the stand alone interventions on pain, sleep, and mood outcomes compared to a control condition.MethodsTwenty-one adults with co-occurring chronic pain and chronic insomnia were randomized to either CBT for pain, CBT for insomnia, combined CBT for pain and insomnia, or a wait-list control condition.ResultsThe combined CBT intervention was feasible to deliver and produced significant improvements in sleep, disability from pain, depression and fatigue compared to the control condition. Overall, the combined intervention appeared to have a strong advantage over CBT for pain on most outcomes, modest advantage over both CBT for insomnia in reducing insomnia severity in chronic pain patients.DiscussionCBT for pain and CBT for insomnia may be combined with good results for patients with co-occurring chronic pain and insomnia.     

The Effects of Cognitive Behavioral Therapy for Insomnia on Multidimensional Perfectionism

Perfectionism is related to insomnia and objective markers of disturbed sleep. This study examined whether multidimensional perfectionism is related to dysfunctional beliefs about sleep, sleep-effort, pre-sleep arousal, and polysomnography-determined markers of sleep among individuals with insomnia. The effects of cognitive behavioral therapy for insomnia (CBT-I) on perfectionism was also examined. This was a secondary analysis of a randomized controlled trial on CBT-I. Forty-three insomnia patients were randomized to treatment (receiving CBT-I) or waitlist control groups. Sleep was recorded using polysomnography at baseline. Participants completed measures of perfectionism, dysfunctional beliefs about sleep, sleep-effort and pre-sleep arousal at baseline and posttreatment. Total perfectionism scores and doubts about action, concern over mistakes and personal standards were each significantly related to increased sleep effort, pre-sleep arousal and dysfunctional beliefs about sleep at baseline. Patients receiving treatment displayed increased total perfectionism scores posttreatment d = .49. In those receiving treatment, levels of organization d = .49 and parental expectations d = .47 were significantly increased posttreatment, relative to baseline. In line with the literature, our results confirm that perfectionism is related to insomnia. Here, insomnia was related to increased sleep effort, pre-sleep arousal and dysfunctional beliefs about sleep. The propensity to maintain a high standard of order and organization may be elevated following CBT-I, considering the treatment protocol expects patients to strictly adhere to a set of clearly defined rules. Levels of parental expectations may be increased following CBT-I since the patient-therapist-relationship may trigger implicit expectations in patients which are reminiscent of their relationship to their parents.     

Combining mindfulness meditation with cognitive-behavior therapy for insomnia: a treatment-development study

This treatment-development study is a Stage I evaluation of an intervention that combines mindfulness meditation with cognitive-behavior therapy for insomnia (CBT-I). Thirty adults who met research diagnostic criteria for Psychophysiological Insomnia (Edinger et al., 2004) participated in a 6-week, multi-component group intervention using mindfulness meditation, sleep restriction, stimulus control, sleep education, and sleep hygiene. Sleep diaries and self-reported pre-sleep arousal were assessed weekly while secondary measures of insomnia severity, arousal, mindfulness skills, and daytime functioning were assessed at pre-treatment and post-treatment. Data collected on recruitment, retention, compliance, and satisfaction indicate that the treatment protocol is feasible to deliver and is acceptable for individuals seeking treatment for insomnia. The overall patterns of change with treatment demonstrated statistically and clinically significant improvements in several nighttime symptoms of insomnia as well as statistically significant reductions in pre-sleep arousal, sleep effort, and dysfunctional sleep-related cognitions. In addition, a significant correlation was found between the number of meditation sessions and changes on a trait measure of arousal. Together, the findings indicate that mindfulness meditation can be combined with CBT-I and this integrated intervention is associated with reductions in both sleep and sleep-related arousal. Further testing of this intervention using randomized controlled trials is warranted to evaluate the efficacy of the intervention for this population and the specific effects of each component on sleep and both psychological and physiological arousal.     

Changes in Subjective-Objective Sleep Discrepancy Following Inpatient Cognitive Behavior Therapy for Insomnia

Discrepancy between objective and subjective sleep parameters is a frequent symptom in persons suffering from insomnia. Since it has an impairing effect on daytime well-being and neglects possible positive objective improvements, it would be useful if it was treated. Apart from hypnotics, cognitive behavior therapy (CBT-I) is the therapy of choice for chronic forms of insomnia. However, there is limited information about whether CBT-I can also improve subjective-objective sleep discrepancy. We investigated a large sample of patients showing chronic forms of insomnia regarding their subjective-objective sleep discrepancy pre and post CBT-I. Objective sleep data were obtained from 3 nights (2 baseline nights and 1 night after therapy) using polysomnography in our sleep laboratory. All 92 patients participated in a 14-day inpatient program with CBT-I including psychoeducation about subjective-objective sleep discrepancy. Repeated measures analyses showed an improvement in subjective-objective sleep discrepancy parameters after CBT-I. Those parameters were also correlated with perceived quality of sleep. We conclude that CBT-I is a useful tool to improve subjective-objective sleep discrepancy in patients showing chronic forms of insomnia.     

A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility,Acceptability, and Potential Efficacy

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28–55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = −0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = −1.1, p = .001), sleep onset latency (d = −0.6, p = .021), global sleep quality (d = −0.9, p = .002), and depression symptoms (d = −0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.     

Predictors of treatment attendance and adherence to treatment recommendations among individuals receiving Cognitive Behavioral Therapy for Insomnia

ABSTRACT

Insomnia disorders affect up to 10% of adults and are associated with other health problems and poor quality of life. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment; however, its effectiveness is hindered by poor attendance and adherence to treatment recommendations. The present study sought to identify predictors of attendance and adherence in CBT-I. Participants were 108 adults with insomnia disorder. Participants were primarily female (71.3%), middle aged (mean age = 50.5), and Caucasian (92.6%). Demographic variables, physical health problems, Beck Anxiety Inventory, Center for Epidemiologic Studies Depression-Revised scale, and Insomnia Severity Index were used to predict attending three or more sessions and adherence to consistent bedtime and waketime. Higher age was associated with better attendance and less deviation in bed and wake times. Anxiety and depression symptoms were associated with less attendance, and depression was also associated with more deviation in waketimes. To promote better attendance and adherence in treatment, depression or anxiety symptoms should be addressed before or during CBT-I. Identifying and tailoring CBT-I treatments toward the needs of different age groups may also improve attendance and adherence.     

Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: A randomized trial

Internet-delivered treatment is effective for insomnia, but little is known about the beneficial effects of support. The aim of the current study was to investigate the additional effects of low-intensity support to an internet-delivered treatment for insomnia. Two hundred and sixty-two participants were randomized to an internet-delivered intervention for insomnia with (n = 129) or without support (n = 133). All participants received an internet-delivered cognitive behavioral treatment for insomnia. In addition, the participants in the support condition received weekly emails. Assessments were at baseline, post-treatment, and 6-month follow-up. Both groups effectively ameliorated insomnia complaints. Adding support led to significantly higher effects on most sleep measures (d = 0.3–0.5; p < 0.05), self-reported insomnia severity (d = 0.4; p < 0.001), anxiety, and depressive symptoms (d = 0.4; p < 0.01). At the 6-month follow-up, these effects remained significant for sleep efficiency, sleep onset latency, insomnia symptoms, and depressive symptoms (d = 0.3–0.5; p < 0.05). Providing support significantly enhances the benefits of internet-delivered treatment for insomnia on several variables. It appears that motivational feedback increases the effect of the intervention and encourages more participants to complete the intervention, which in turn improves its effectiveness.     

Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care

Although past work has shown that alcohol use co-occurs with anxiety/depression among Latinos, little work has examined the variables that qualify such associations. The present investigation sought to address whether pain severity (i.e. pain intensity and/or pain-related disability, respectively) moderated relations between hazardous drinking and depressive/anxious arousal symptoms among an economically disadvantaged Latino sample recruited from a primary care medical setting. Participants included 253 adult Latinos (M_age = 38.5 years, SD = 10.8; 86.6% female) who attended a community-based primary care clinic. There was a significant interaction of hazardous drinking with pain intensity in relation to depressive symptoms and significant interactions of hazardous drinking and pain-related disability in relation to depressive and anxious arousal symptoms. Hazardous drinking was associated with more severe depressive/anxious arousal symptoms only when pain intensity/disability was high. This is the first study to demonstrate the moderating role of pain intensity and disability in associations between hazardous drinking and anxiety/depression among Latinos in a primary care medical setting.     

Special Considerations in the Adaptation of Cognitive Behavioral Therapy for Insomnia With Active-Duty U.S. Army Personnel

Insomnia is highly prevalent among active-duty military service members. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a well-established and effective treatment; however, research and treatment recommendations have primarily focused on civilian or veteran populations. A multitude of military-specific factors directly impact service members’ sleep and the subsequent treatment recommendations. This article provides treatment considerations for the use of CBT-I with active-duty U.S. Army personnel. First, an overview of the theoretical model of insomnia, including military-specific predisposing, precipitating, and perpetuating factors, is presented, followed by a review of common comorbid conditions among service members with insomnia. Finally, discussion focuses on considerations and strategies for implementing components of CBT-I with service members, managing sleep during deployments, and adjusting sleep to accommodate overnight duties. Additional training resources and supplemental video examples (with actors) are provided.     

Multimedia Field Test: Digitalizing Better Sleep Using the Sleepio Program

The promise of online cognitive behavioral therapy for insomnia (CBT-I) and other sleep-related problems as an alternative to traditional face-to-face treatment rests upon the accessibility, ease-of-use, and effectiveness of these approaches. Here we provide a review of Sleepio, a digitalized, state-of-the-art CBT-I program for adults, informed by our personal experience with the program, available research, and information provided at the Sleepio website. The 6-week treatment program can be completed flexibly via web-based or mobile platform. Initial assessment of individual goals and baseline sleep patterns is used to build a personalized account comprised of four sections: Sleep Diary, Case File, Library, and Community. Sleepio uses evidence-based principles and practices, engaging content, and an easy-to-follow format. Unique features of the program including synchronization with compatible sleep tracking devices, multiple built-in user supports, and a 14-day money-back guarantee. Both statistical and clinically meaningful sleep improvements have been found in a large randomized controlled trial. Overall, Sleepio represents a model program for online CBT-I delivery.     

Insomnia Symptoms,Nightmares, and Suicide Risk: Duration of Sleep Disturbance Matters

Duration of insomnia symptoms or nightmares was investigated to see if it was related to suicide risk independent of current insomnia symptoms, nightmares, anxiety symptoms, depressive symptoms, and posttraumatic symptoms. The cross‐sectional study involved analyses of survey responses from undergraduate students who endorsed either insomnia symptoms (n = 660) or nightmares (n = 312). Both insomnia symptom and nightmare duration were significantly associated with suicide risk independent of current insomnia symptoms or nightmares, respectively. Relations were also significant after controlling for anxiety symptoms, depressive symptoms, and posttraumatic symptoms. Results suggest that duration of sleep disturbance is relevant when assessing suicide risk.     

Internet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context

Background and Objectives: Anxiety and insomnia can be treated with internet-delivered Cognitive Behavioral Therapy (iCBT). iCBT may be well-suited to students who are known to be poor help-seekers and suffer these symptoms. iCBT can offer easy access to treatment and increase service availability. The aim of this study was to evaluate the efficacy of anxiety and insomnia iCBT programs in students. Design: A randomized, controlled study. Methods: Students were randomly allocated to intervention (“Anxiety Relief”: n?=?43; “Insomnia Relief”: n?=?48; control: n?=?47). Interventions lasted six weeks. Outcome measures were the State-Trait Anxiety Inventory and the Pittsburgh Sleep Quality Index. Results: Significant within-group reductions in anxiety (t(31)?=?2.00, p?=?.03) with moderate between-groups (compared to control) effect size (d?=?.64) and increases in sleep quality (t(31)?=?3.46, p?=?.002) with a moderate between-groups effect size (d?=?.55) were found for completers of the anxiety program from pre- to post-intervention. Significant within-group increases in sleep quality were found for completers of the insomnia program from pre- to post-intervention (t(35)?=?4.28, p?>?.001) with a moderate between-groups effect size (d?=?.51). Conclusions: Findings support the use of iCBT for anxiety and insomnia in students, and indicate that further research is needed.     

A Clinical Intervention in Chronic Pain and Insomnia with a Combined Model of Treatment: A Test of Concept

Co-occurring chronic pain and insomnia are common in a clinical setting. Cognitive–behavioral theoretical (CBT) frameworks exist for both conditions independently. The purpose of this study was to address the problem of co-occurring chronic pain and insomnia with an integrated CBT model based on empirical support. One-hundred eleven individuals (age range 21–65 years) meeting the general criteria for chronic pain and insomnia were included in this study. Participants completed a demographic form, the Dysfunctional Beliefs and Attitudes about Sleep—16-item version, Insomnia Severity Index, Sleep Hygiene Index, Sleep Associated Monitoring Index, Pain Catastrophizing Scale, Pain Disability Questionnaire, Modified Somatic Perceptions Questionnaire, Hospital Anxiety and Depression Scale, and Multidimensional Scale of Perceived Social Support. Significant positive bivariate relationships were observed for pain catastrophizing (PC) and dysfunctional beliefs and attitudes about sleep (DBAS), as well as somatic awareness and sleep-associated monitoring. Two backward stepwise regression models were utilized to determine a model for predicting insomnia severity and pain disability respectively using a combination of sleep and pain-associated measures. Insomnia severity was predicted by DBAS, PC, and somatic awareness. Pain disability was predicted by PC, DBAS, depression, and social support. Maladaptive thought patterns related to pain and insomnia and associated features appear to have a synergistic effect on both insomnia severity and pain disability and support a combined cognitive–behavioral model.     

Prevalence and social and health correlates of insomnia symptoms among middle-and older-age persons in rural South Africa

This study investigated the prevalence and social and health correlates of insomnia symptoms among middle-and older-adults in rural South Africa. We analysed baseline survey data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH community in South Africa (HAALSI) (N = 5 059; females = 53.6%; largely African Shangaan/Tsonga-speaking). In all, 8.0% of the adults had three insomnia symptoms, 8.9% of participants had difficulty initiating sleep, 13.6% had difficulty in sleep maintenance, and 6.5% had poor sleep quality. In adjusted logistic regression, lower education, perceived unsafe neighbourhood, poorer self-rated health status, vision difficulty, pain, depressive symptoms, and posttraumatic stress disorder (PTSD) symptoms increased the odds of having insomnia symptoms. Insomnia symptoms are common in middle-and older-age adults in rural South Africa, and various risk factors were identified. This can help in improving insomnia prevention treatment in this population.     

Who is a candidate for cognitive-behavioral therapy for insomnia?

Chronic insomnia impacts 1 in 10 adults and is linked to accidents, decreased quality of life, diminished work productivity, and increased long-term risk for medical and psychiatric diseases such as diabetes and depression. Recent National Institutes of Health consensus statements and the American Academy of Sleep Medicine's Practice Parameters recommend that cognitive-behavioral therapy for insomnia (CBT-I) be considered the 1st line treatment for chronic primary insomnia. Growing research also supports the extension of CBT-I for patients with persistent insomnia occurring within the context of medical and psychiatric comorbidity. In the emerging field of behavioral sleep medicine, there has yet to be a consensus point of view about who is an appropriate candidate for CBT-I and how this determination is made. This report briefly summarizes these issues, including a discussion of potential contraindications, and provides a schematic decision-to-treat algorithm.     

Evaluation of the effectiveness of mindfulness-based cognitive therapy to treat chronic insomnia

IntroductionAs having positive effects on reducing distress and symptoms associated with different mental and physical disorders, many studies have focused on mindfulness-based cognitive therapy.ObjectiveIt is suggested that mindfulness-based cognitive therapy (MBCT) could help reducing insomnia by focusing on certain cognitive factors associated to insomnia.MethodA pre-experimental, pre-test protocol with a post-test and three month follow-up was used to measure the effect of a group intervention of eight sessions and 12 participants.ResultsThe intervention had a positive effect on participants’ subjective evaluation regarding their sleep and the gains were maintained after three months. However, after the intervention, no significant effect was found on the objective measures of sleep. Two factors associated to the maintenance of insomnia, such as dysfunctional beliefs and attitudes about sleep and mental control strategies were improved following treatment and these improvements were maintained during the follow-up.ConclusionThe results of this study suggest that mindfulness-based cognitive therapy might be an interesting addition in the treatment of insomnia, given that it focuses on certain cognitive factors that contribute to the maintenance of insomnia.     

Exploring the associations shared by mood,pain-related attention and pain outcomes related to sleep disturbance in a chronic pain sample

Objective: Sleep disturbance in chronic pain is common, occurring in two-thirds of patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and poor sleep can exaggerate pain intensity. This may have an impact on both depressive symptoms and attention to pain. This study aims to evaluate the relationship between chronic pain and sleep, and the role of mood and attention.

Methods: Chronic pain patients, recruited from a secondary care outpatient clinic, completed self-report measures of pain, sleep, depressive symptoms and attention to pain. Hierarchical regression and structural equation modelling were used to explore the relationships between these measures. Participants (n = 221) were aged between 20 and 84 (mean = 52) years.

Results: The majority of participants were found to be ‘poor sleepers’ (86%) with increased pain severity, depressive symptoms and attention to pain. Both analytical approaches indicated that sleep disturbance is indirectly associated with increased pain severity Instead the relationship shared by sleep disturbance and pain severity was further associated with depressive symptoms and attention to pain.

Conclusions: Our results indicate that sleep disturbance may contribute to clinical pain severity indirectly though changes in mood and attention. Prospective studies exploring lagged associations between these constructs could have critical information relevant to the treatment of chronic pain.