Treatment of Insomnia within an Interdisciplinary Pain Rehabilitation Program: A Randomized Trial

Background/ObjectivePrior research indicates interdisciplinary pain rehabilitation program (IPRP) usual care (UC) does not sufficiently address sleep problems among individuals with comorbid chronic pain and clinical levels of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based insomnia intervention. The current study investigates the translation of CBT-I into an IPRP.MethodIn this single-site, prospective, randomized controlled pilot study, insomnia and pain-related outcomes were examined for adults participating in a 10-week IPRP (N = 79) who were allocated to a 4-session group-based CBT-I (IPRP+CBT-I) or usual care (IPRP-UC) condition.ResultsPatients in the IPRP+CBT-I group showed improvements in insomnia symptoms at the end compared to the beginning of the CBT-I group; however, there were no IPRP outcome differences relative to the IPRP-UC condition. Both groups reported statistically significant reductions in insomnia, pain severity, pain-related life interference, and depressed mood. Fewer than one-third of participants reported clinically meaningful reductions in insomnia symptoms following IPRP participation.ConclusionsFurther efforts are needed to address sleep problems in pain rehabilitation settings.     

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.     

Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression

Insomnia and depression are two of the most common mental health problems that negatively impact older adults. The burden associated with these highly comorbid conditions requires an innovative approach to treatment. There have been significant advancements in the field of cognitive behaviour therapy for insomnia (CBT-I) over recent years. CBT-I has evolved from targeting homogenous insomnia samples to now showing promising results for comorbid insomnia. CBT-I is not only effective at treating comorbid insomnia, but can also have a positive impact on depression severity. Despite these important clinical developments, limited research has explored whether modifying CBT-I programmes to specifically target comorbid depression could improve outcomes for older populations. This paper reviews recent literature and provides therapeutic recommendations to advance CBT-I for older adults with comorbid insomnia and depression.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Cognitive-Behavioral Therapy for Insomnia in Older Adults

Sleep is disturbed by a range of factors across the lifespan. However, older adults experiencing disruptions in their sleep are often simultaneously contending with a range of comorbid medical and psychiatric conditions that compound the biological changes in sleep that commonly occur with age. Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard, nonpharmacological intervention for sleep disturbances, and is a cost-effective treatment approach that can occur in either individual or group format. It has also been shown effective in older adults with medical, psychiatric, and cognitive comorbid disorders. This review highlights the success of CBT-I with older adults, as well as studies that illustrate the use of alternative delivery methods and treatment modifications for complex clinical presentations.     

Cognitive behavioral therapy and acceptance and commitment therapy for insomnia: Exploring the potential benefit of psychological flexibility and self-compassion combined with behavioral strategies

Chronic insomnia is a prevalent sleep disorder with serious consequences on wellbeing and health that largely extend into daily functioning. Cognitive-Behavioral Therapy for Insomnia (CBT-I), an efficacious intervention for insomnia with solid empirical support, is the recommended first-line treatment. Given the complexity of factors and mechanisms involved in its aetiology and maintenance, advances in treatment protocols and modules are important. We will review the current knowledge on insomnia and examine how advancements in behavioral sleep medicine and third-wave therapies may apply to treatment. Specifically, we will outline how a treatment protocol based on Acceptance and Commitment Therapy (ACT), adapted to include insomnia-specific behavioral strategies and with an explicit focus on self-compassion, could be a potentially effective treatment. We believe that broadening treatment focus to target hyperarousal, metacognitions, dysfunctional though control strategies and provide self-compassion training may benefit treatment outcomes, increase sleep quality, reduce daytime symptoms, and improve quality of life.     

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.     

An Investigation of the Rate and Predictors of Initiating and Attending Group Cognitive Behavioral Therapy for Insomnia After Referral

Although group Cognitive Behavioral Therapy for Insomnia (CBT-I) is an efficacious and well-studied treatment, relatively less is known about its clinical effectiveness in community outpatient settings. Prior research has suggested that dropout from CBT-I may be high in treatment settings vs. clinical trials. The current study therefore investigated the rates and predictors of initiating and attending CBT-I group within an outpatient psychiatry clinic. Participants were 75 consecutive outpatients presenting for treatment at a specialty sleep and anxiety clinic who completed an evaluation and were referred to CBT-I group. Participants completed self-report measures at initial evaluation, and their attendance throughout treatment was tracked. The majority of patients attended ≥1 session, with a mean of 3/5 sessions completed for initiators. Those with poorer global sleep quality and longer sleep onset latency were less likely to attend group and attended fewer sessions. Those with more severe anxiety and depression were less likely to initiate attendance and attended fewer sessions. The majority of patients referred to CBT-I initiated group and attended at least half of the sessions. Further, demographics do not seem to impact these rates. Unfortunately, those with the most severe symptoms, and thus in most need for treatment, are least likely to initiate and attend. This may be due to comorbid anxiety or depression symptoms. Future research should replicate these findings, as well as explore how to encourage those most in need of treatment to initiate and attend CBT-I.     

Adapting Brief CBT-I for Depressed Adolescents: A Case Illustration of the Sleeping Better Program

Disturbed sleep is a common symptom of depression in adolescents, but this symptom is not often targeted in psychological therapies for depression. Although the causal relationship between sleep and depression is unclear, there is increasing evidence that in adults, Cognitive Behavioral Therapy for Insomnia (CBT-I) improves sleep problems and reduces symptoms of depression; however, there has been little investigation of using this approach with adolescents. This article describes the adaptation of brief CBT-I for adolescents with depression. A single case study is reported to illustrate the use of the Sleeping Better program. Adaptations for adolescents include increased emphasis on engagement of the young person and the inclusion of parents in treatment. The treatment program was acceptable to the adolescent and parent, and treatment outcome, as indicated by sleep diaries and standardized measures of depression and anxiety, was positive. Further evaluation of the Sleeping Better program is needed to establish if it is an effective low-intensity intervention for sleep problems in adolescents who have depression or anxiety.     

Is amenorrhea a clinically useful criterion for the diagnosis of anorexia nervosa?

Aim of the study was to evaluate the clinical characteristics and the treatment outcome of underweight patients with eating disorder (ED) not otherwise specified without amenorrhea (EDNOS-WA), compared with classical anorexia nervosa (AN) cases. Seventy-three consecutive female patients (57 AN, and 16 EDNOS-WA) were evaluated before and after a 20-week cognitive behaviour inpatient treatment (CBT-I). Assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Temperament and Character Inventory (TCI). At logistic regression analysis, amenorrhea was only predicted by baseline BMI and intense exercise, not by psychopathological variables. Response to CBT-I was good and similar between groups, without differences in the dropout rate or time-to-dropout. Our data lend support to the hypothesis that the criterion “amenorrhea” is of no clinical utility in the diagnosis and treatment of AN and could be removed in the forthcoming DSM-V proposal.     

The Effects of Transdiagnostic Group CBT for Anxiety on Insomnia Symptoms

Insomnia is a common feature among individuals with anxiety disorders. Studies of cognitive behavioral therapy (CBT) for anxiety report moderate effects on concomitant insomnia symptoms, but further research is still needed especially toward understanding how CBT for anxiety renders beneficial effects on insomnia. The current study examined changes in insomnia symptoms reported by 51 Veterans who participated in a group-based transdiagnostic CBT for anxiety intervention. In addition, insomnia symptoms were examined in relation to symptoms of general distress (GD), anhedonic depression (AD), and anxious arousal (AA) pre- to post-treatment. Results revealed a small, though statistically significant (p < .05) beneficial effect on insomnia symptoms. When changes in GD, AD, and AA were simultaneously examined in relation to changes in insomnia, change in AA was the only significant predictor of insomnia symptoms. The current study highlights the role of AA in the relationship between anxiety disorders and insomnia and demonstrates that reductions in insomnia during transdiagnostic CBT for anxiety can be largely attributed to changes in AA.     

Correlates of general quality of life are different in patients with primary insomnia as compared to patients with insomnia and psychiatric comorbidity

Chronic insomnia is known to have a negative influence on quality of life (QOL). To date, most studies on chronic insomnia have focused on health-related aspects of QOL. General QOL, which is a different construct, has not been studied in detail. Moreover, it is not known which factors are associated with general QOL in insomnia, and whether the presence of mental disorders, a condition known as comorbid insomnia, affects these variables. The present study focused on identifying sleep and psychosocial variables that might be associated with general QOL in primary and comorbid insomnia. Personality traits, coping variables, anxiety and depressive symptoms, fatigue and subjective sleep variables were assessed in 218 consecutive well-characterized patients with primary and comorbid insomnia, referred to a third line centre for sleep medicine. In primary insomnia, higher extraversion and lower discrepancies in social support were associated with higher QOL. Surprisingly, insomnia severity was not significantly associated with QOL in this group. However, lower fatigue, which can be seen as an important daytime consequence of insomnia was correlated with higher QOL in patients with primary insomnia. In both insomnia groups, low anxiety and depressive symptoms and low fatigue were associated with higher general QOL. In contrast with the primary insomnia group, lower insomnia severity was correlated with higher QOL in patients with comorbid insomnia. These results stress the importance of assessing and treating daytime fatigue in insomnia. In primary insomnia, improving social support might be an important treatment goal. Furthermore, this study supports the concept that treatment of insomnia should not be neglected in patients with comorbid insomnia. Indeed, both insomnia and indices of psychiatric disease are strongly associated with general QOL in this condition.     

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.