Strong evidence supports the effi cacy of cognitive behavioral therapy for insomnia (CBTI). A signifi cant barrier to wide dissemination of CBTI is the lack of qualifi ed practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and fl exibility of the treatment protocol. We developed a case conceptualizationdriven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

Results suggest that pre- to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefits of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity.

Study Objectives: To evaluate whether depressive symptom severity leads to poorer response and perceived adherence to cognitive behavioral therapy for insomnia (CBTI) and to examine the impact of CBTI on well-being, depressive symptom severity, and suicidal ideation. Design: Pre-to posttreatment case replication series comparing low depression (LowDep) and high depression (HiDep) groups (based on a cutoff of 14 on the Beck Depression Inventory [BDI]). Participants: 127 men and 174 women referred for the treatment of insomnia. Interventions: Seven sessions of group CBTI. Measurements and Results: Improvement in the insomnia severity, perceived energy, productivity, self-esteem, other aspects of wellbeing, and overall treatment satisfaction did not differ between the HiDep and LowDep groups (p > 0.14). HiDep patients reported lower adherence to a fi xed rise time, restricting time in bed, and changing expectations about sleep (p < 0.05). HiDep participants experienced signifi cant reductions in BDI, after removing the sleep item. Levels of suicidal ideation dropped signifi cantly among patients with pretreatment elevations (p < 0.0001). Conclusion: Results suggest that pre-to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefi ts of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity. keywords: Insomnia, CBTI, nonpharmacological treatment, depression, suicide ideation Citation: Manber R; Bernert RA; Suh S; Nowakowski S; Siebern AT; Ong JC. Cbt for insomnia in patients with high and low depressive symptom severity: adherence and clinical outcomes. J Clin Sleep Med 2011;7(6):645-652. S C I E N T I F I C I N V E S T I g A T I O N SP atients who experience diffi culty initiating and maintaining sleep comorbid with a psychiatric disorder, most prominently depression, represent the largest subgroup of individuals with insomnia complaints.1 Cognitive behavioral therapy for insomnia (CBTI) is an effective, nonpharmacological treatment of primary insomnia. It is recognized as a fi rst-line treatment for insomnia by the National Institutes of Health (NIH) Consensus Statement 2 and the British Association of Psychopharmacology.3 Emerging data furthermore indicate that CBTI is an effective treatment for chronic insomnia comorbid with depression and that it also leads to signifi cant posttreatment improvements in depression. [4][5][6] CBTI is comprised of behavioral components (stimulus control instructions, sleep restriction therapy, relaxation training, and other stress management techniques), a cognitive component (restructuring cognitio...

Results suggest that a non-pharmacological intervention to improve sleep in older adults with MCI also improve cognitive functioning. Further exploration of the mechanisms underlying these improvements is warranted.