A Comparison of Rates of Residual Insomnia Symptoms Following Pharmacotherapy or Cognitive-Behavioral Therapy for Major Depressive Disorder

Carney, Colleen E.; Segal, Zindel V.; Edinger, Jack D.; Krystal, Andrew D.

doi:10.4088/jcp.v68n0211

Cited by 229 publications

(162 citation statements)

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“…Estimated concordance rates for depression are as high as 80% to 90% in untreated patients. 1,2 Even after achieving remission from depression, half of these patients still suffer from residual insomnia. 3 Moreover, persistent insomnia might be a risk factor for depression relapse.…”

Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

Change in Quality of Life after Brief Behavioral Therapy for Insomnia in Concurrent Depression: Analysis of the Effects of a Randomized Controlled Trial

Shimodera

Watanabe

Furukawa

et al. 2014

Journal of Clinical Sleep Medicine

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Study Objectives:The effi cacy of cognitive behavioral therapy for insomnia (CBT-I) has been suggested for insomnia concomitant with depression, but its impact on quality of life (QoL) has not been adequately evaluated. The study aimed to determine which aspects of QoL could be affected by CBT-I and how any changes in QoL were mediated by changes in insomnia and depression. Methods: We conducted a 4-week randomized controlled trial with 4-week follow-up in outpatient clinics in Japan. Thirtyseven patients with DSM-IV diagnosis of major depressive disorder concomitant with chronic insomnia were randomly assigned to the treatment-as-usual (TAU) alone arm or the TAU with brief behavioral therapy for insomnia (TAU plus psychotherapy) arm using modifi ed CBT-I consisting of 4 weekly individual sessions. We evaluated QoL using normbased scoring of the Short Form-36 at baseline and at 8 weeks. We also examined associations between QoL subscales and remission in insomnia or depression while controlling for baseline scores of the entire sample. Results:We tested group effects while controlling for baseline scores. TAU plus psychotherapy resulted in signifi cantly better scores on physical functioning (p = 0.006), social functioning (p = 0.002), and mental health (p = 0.041) subscales than TAU alone at 8 weeks. Patients with either remitted insomnia or depression showed higher QoL scores than non-remitted patients; scores approximated those within the normal range. Conclusions: For patients with insomnia in depression, adding CBT-I to TAU can produce substantive benefi ts in some aspects of QoL. Trial Registration: ClinicalTrials.gov Identifi er: NCT00610259, http://www.clinicaltrials.gov/ Keywords: Depressive disorder, sleep initiation and maintenance disorders, behavior therapy, quality of life Citation: Shimodera S; Watanabe N; Furukawa TA; Katsuki F; Fujita H; Sasaki M; Perlis ML. Change in quality of life after brief behavioral therapy for insomnia in concurrent depression: analysis of the effects of a randomized controlled trial.

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Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

Change in Quality of Life after Brief Behavioral Therapy for Insomnia in Concurrent Depression: Analysis of the Effects of a Randomized Controlled Trial

Shimodera

Watanabe

Furukawa

et al. 2014

Journal of Clinical Sleep Medicine

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“…At the provider level, our findings suggest the need to provide PCPs with education about the processes by which insomnia develops so they understand why, in many cases, treatment of a precipitating condition (eg, depression and PTSD) does not result in successful resolution of comorbid insomnia. 37,38 In addition, PCPs should be made aware of the updated insomnia diagnostic criteria (International Classification of Sleep Disorders, Third Edition and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) and encouraged to document insomnia in the medical record because an inaccurate accounting of insomnia limits our ability to estimate prevalence and deploy resources. At the systems level, our findings reveal the need for health care systems to disseminate practice standards that align with the existing empirical evidence and to explicitly state that CBT-I is the standard of care for treatment of insomnia.…”

Section: 9mentioning

confidence: 99%

Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment

Ulmer

Bosworth

Beckham

et al. 2017

Journal of Clinical Sleep Medicine

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Study Objectives: Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that: sleep hygiene and pharmacotherapy are the primary treatments offered; PCPs tend to focus on perceived causes of insomnia rather than the insomnia itself; and neither patients nor providers are satisfied with insomnia treatment options. Although insomnia complaints are typically first reported to primary care providers, little research has focused on perspectives regarding insomnia treatment among PCPs working in the largest integrated health care system in the United States-the Veterans Affairs (VA) health care system. This study was conducted to examine VA PCP perceptions of the availability of insomnia treatments, identify specific strategies offered by PCPs, and examine perceptions regarding the importance of treating insomnia and the role of comorbid conditions. Methods: A survey was conducted within the VA health care system. Primary care providers completed surveys electronically. Results: A high percentage of veterans (modal response = 20% to 39%) seen in VA primary care settings report an insomnia complaint to their provider. Almost half of respondents do not consistently document insomnia in the medical record (46% endorsed "sometimes," "rarely," or "never"). PCPs routinely advise sleep hygiene recommendations for insomnia (ie, avoid stimulants before bedtime [84.3%], and keep the bedroom environment quiet and dark and comfortable [68.6%]) and many are uncertain if cognitive behavioral therapy for insomnia is available at their facility (43.1%). Conclusions: Findings point to the need for systems-level changes within health care systems, including the adoption of evidence-based clinical practice standards for insomnia and PCP education about the processes that maintain insomnia. Commentary: A commentary on this article appears in this issue on page 937.

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“…However, those MDD patients who present with clinically significant insomnia complaints comprise a particularly challenging group to treat. For many such patients, insomnia represents a long-standing and problematic condition that can: (1) predate the onset of MDD, 6,7 (2) increase the risk of suicide, 8,9 (3) show a suboptimal response to traditional depression treatment, 10,11 (4) remain after successful depression treatment, 12,13 and (5) increase risk for MDD relapse (e.g., Nierenberg et al 14 ). Perhaps because the insomnia of MDD patients traditionally has been viewed as an MDD symptom rather than a comorbid disorder, the sleep-specific treatment needs of MDD patients have been largely ignored until recently.…”

Section: Introductionmentioning

confidence: 99%

Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial

Carney

Edinger

Kuchibhatla

et al. 2017

Sleep

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153

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Study Objective: To compare cognitive behavioral therapy for insomnia (CBT-I) + antidepressant medication (AD) against treatments that target solely depression or solely insomnia. Design: A blinded, randomized split-plot experimental study. Setting: Two urban academic clinical centers. Participants: 107 participants (68% female, mean age 42 ± 11) with major depressive disorder and insomnia. Interventions: Randomization was to one of three groups: antidepressant (AD; escitalopram) + CBT-I (4 sessions), CBT-I + placebo pill, or AD + 4-session sleep hygiene control (SH). Measurements and Results: Subjective sleep was assessed via 2 weeks of daily sleep diaries (use of medication was covaried in all analyses); although there were no statistically significant group differences detected, all groups improved from baseline to posttreatment on subjective sleep efficiency (SE) and total wake time (TWT) and the effect sizes were large. Objective sleep was assessed via overnight polysomnographic monitoring at baseline and posttreatment; analyses revealed both CBT groups improved on TWT (p = .03), but the AD + SH group worsened. There was no statistically significant effect for PSG SE (p = .07). There was a between groups medium effect observed for the AD + SH and CBT + placebo group differences on diary TWT and both PSG variables. All groups improved significantly from baseline to posttreatment on the Hamilton Rating Scale for Depression (HAMD-17); the groups did not differ. Conclusions: Although all groups self-reported sleeping better after treatment, only the CBT-I groups improved on objective sleep, and AD + SH's sleep worsened. This suggests that we should be treating sleep in those with depression with an effective insomnia treatment and relying on self-report obscures sleep worsening effects. All groups improved on depression, even a group with absolutely no depression-focused treatment component (CBT-I + placebo). The depression effect in CBT-I only group has been reported in other studies, suggesting that we should further investigate the antidepressant properties of CBT-I.

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A Comparison of Rates of Residual Insomnia Symptoms Following Pharmacotherapy or Cognitive-Behavioral Therapy for Major Depressive Disorder

Cited by 229 publications

References 0 publications

Change in Quality of Life after Brief Behavioral Therapy for Insomnia in Concurrent Depression: Analysis of the Effects of a Randomized Controlled Trial

Change in Quality of Life after Brief Behavioral Therapy for Insomnia in Concurrent Depression: Analysis of the Effects of a Randomized Controlled Trial

Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment

Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial

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