CBT for Insomnia in Patients with High and Low Depressive Symptom Severity: Adherence and Clinical Outcomes

Abstract

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...

Sleep Related Cognitions in Individuals with Symptoms of Insomnia and Depression

“…This finding supports past work indicating that rumination and worry are discrete constructs, 27 that rumination differentiates good and poor sleepers, 26 and that it contributes to sleep quality 47 ; but, it is also consistent with Manber and colleagues' 22 suggestion that the efficacy of CBTI may be enhanced among individuals with comorbid insomnia and depression by paying greater attention to cognitive factors. Specifically, intervention for insomnia symptoms in the context of meaningful depression may be improved by targeting rumination related to daytime symptoms of insomnia.…”

“…Although a recent trial showed that group cognitive behavioral therapy for insomnia (CBTI) worked equally well at reducing insomnia among those treatment completers with high and low depression severity, insomnia severity remained higher among those with greater depression severity throughout treatment. 22 Thus, questions remain as to how to enhance interventions to more effectively reduce insomnia severity in patients with depression.…”

“…Previous work in this area has largely focused on dysfunctional sleep related beliefs (i.e., unhelpful thought patterns focused on consequences of insomnia, worry/ helplessness about insomnia, sleep expectations, and medication) and worry (i.e., concerns about future consequences and associated with anxiety). Specifically within the context of insomnia co-morbid with depression, Manber and colleagues 22 noted differences in a cognitive treatment component relevant to sleep between those with high and low depression severity, specifically that those with greater depression severity had lower adherence to changing expectations about sleep. Thus, treatment-related changes in sleep-focused cognitions may be moderated by depression severity.…”

Chronotype and Improved Sleep Efficiency Independently Predict Depressive Symptom Reduction after Group Cognitive Behavioral Therapy for Insomnia

“…For example, CBT-I has been shown to reduce depressive symptom severity and to have other benefi ts, such as better perceived energy levels, productivity, and self-esteem. 3,4 Several studies identifi ed predictors of improvements in insomnia following CBT-I. 5,6 However, to the best of our knowledge, factors associated with the effects of CBT-I on depressive symptom severity have not been examined.…”

Sleep Disturbance and Suicide Risk in the Elderly

“…Improvements in sleep quality have been shown to significantly reduce anxiety, depression, and suicidal ideation [25][26][27][28]. In 2013, the US Veterans Affairs Department of Defense included sleep disturbances in their practice guidelines for those at risk of suicide [29].…”