Cognitive processes mediate the effects of insomnia treatment: evidence from a randomized wait-list controlled trial

Abstract

Introduction: Both guided online and individual face-to-face cognitive behavioral therapy for insomnia (CBT-I) are effective in improving insomnia symptoms and sleep efficiency. Little is known about the underlying mechanisms generating this effect. The present study tests the assumption that pre-sleep arousal, sleep-related worry and dysfunctional beliefs about sleep are mediators in the effect of cognitive behavioral treatment for insomnia. Methods: A secondary analysis was performed on data previously collected from a randomized controlled trial (N ¼ 90). In this trial, participants were randomized to either a face-to-face CBT-I condition, an internet-delivered CBT-I condition, or a wait-list group. This article reports on the efficacy of these interventions on pre-sleep arousal, sleep-related worry, and dysfunctional beliefs. Furthermore, we investigated whether these measures mediated the treatment effect on insomnia severity and sleep efficiency. Results: Both treatment modalities were efficacious for these cognitive measures; however, face-to-face treatment showed superiority over the online treatment. All three cognitive measures mediated the effect on insomnia severity. Sleep-related worry and pre-sleep arousal mediated the effect on sleep efficiency, but dysfunctional beliefs did not. Conclusion: Overall, these results point toward the importance of cognitive processes in the treatment of insomnia, implying that psychological treatments for insomnia may best be guided by (also) targeting these cognitive processes.

Digital Delivery of Cognitive Behavioral Therapy for Insomnia

“…Several cognitive processes have been hypothesized to mediate insomnia improvement. In the past 5 years, the evidence for a role of dysfunctional beliefs about sleep as a mediating factor in the improvement of insomnia after dCBT has grown substantially [ 30 , 51 , 58 ]. Additionally, knowledge, locus of control, sleep-related worry, and pre-sleep arousal have been suggested to mediate improvement in sleep [ 51 , 58 ].…”

“…This can also further improve treatment and reduce attrition. Although several studies have increased our understanding [ 30 , 47 , 51 , 52 •, 55 , 58 , 75 , 76 ], we still have a limited understanding of why people drop out and why some do not respond. This is also true for in-person CBT; we still do not know why a third of patients do not respond to CBT for insomnia [ 84 ].…”

Effectiveness and Cost-Effectiveness of Internet-Based Cognitive Behavioral Therapy for Insomnia in Clinical Settings

“…Even that low level is achieved under specific conditions, which are modular structure of the program, updating once a week, lasting for 10 weeks, including interaction with the system, a counselor, and peers (42). Studies of adherence and dropout from iCBT-I and CBT-I programs identify lower socioeconomic status, longer baseline total sleep time (TST), lower insomnia severity, and higher levels of depression and anxiety as predictors of dropout (43)(44)(45). These results may indicate that some participants who dropped out of insomnia treatment have lower demand for insomnia treatment and need more specific treatment of the comorbid disorder (depression and or anxiety).…”

Cognitive arousal mediates the relationship between perceived ostracism and sleep quality but it is not moderated by experiential avoidance

“…Further research needs to be conducted to explore the mechanism of experiential avoidance in the context of sleep, given a focus in some studies on increasing psychological flexibility and acceptance in chronic pain patients concerning their sleep difficulties (Daly‐Eichenhardt et al, 2016; McCracken et al, 2011), and college students with depressive symptoms (Peltz et al, 2020), as the present data suggests that interventions designed to reduce cognitive arousal prior to sleep might be most promising. Indeed, it is perhaps unsurprising that cognitive behavioural therapy (e.g., CBT‐i for insomnia) is consistently regarded in the literature as the gold‐standard nonpharmocological treatment for sleep difficulties (Koffel, Koffel, & Gehrman, 2015; Murtagh & Greenwood, 1995; Van Straten et al, 2018), with particular focus on intervention techniques such as cognitive restructuring designed to target processes such as presleep cognitive arousal (Bélanger et al, 2005; Lancee et al, 2019). Through a specific focus on process‐based therapy (Hofmann & Hayes, 2019), future researchers can more systematically identify the key mechanisms that mediate sleep difficulties to serve as targets for therapeutic intervention in either CBT‐ or ACT‐based treatment packages.…”