The effects of modafinil and cognitive behavior therapy on sleep continuity in patients with primary insomnia

BACKGROUND: Daytime fatigue, if not frank sleepiness, is a common symptom among patients with insomnia, one that is exacerbated during acute treatment with cognitive behavior therapy (CBT). The present study was undertaken to assess whether modafinil could be used to reduce daytime fatigue, sleepiness, or both in patients with primary insomnia and whether the pharmacologic augmentation of wakefulness might produce improved sleep by itself or in combination with CBT. METHODS: 30 subjects with primary insomnia were enrolled in this study and were randomly assigned to 1 of 3 treatment conditions: (1) placebo plus CBT, (2) 100 mg modafinil plus CBT, or (3) 100 mg modafinil plus a contact control (monitor-only condition). Subjects were continuously monitored with sleep diaries from study intake until study end (10 weeks) and were evaluated on a weekly basis for changes in sleepiness. RESULTS: The mean age of the group was 41.3 years (SD, 13.4), and 70.4% of subjects were women. All 3 groups exhibited mean sleep latency and wake after sleep-onset times that were more than 30 minutes in duration. The mean pretreatment sleep profiles did not significantly differ. Modafinil, when administered alone, did not significantly affect the patients' sleep profiles. A trend, however, was evident for improved sleep latency. Modafinil, as an adjunct to CBT, tended to (1) reduce daytime sleepiness as measured by the Epworth Sleepiness Scale and (2) enhance compliance with CBT. With respect to the latter, subjects in the modafinil plus CBT group more reliably adhered to the prescribed phase delay in bedtime than did the placebo plus CBT group. DISCUSSION: These data suggest that modafinil may be used to diminish the negative side effects of CBT (increased daytime sleepiness) and may increase subject compliance with therapy. Whether enhanced daytime function mediates the change in adherence and whether reduced sleepiness and enhanced compliance translate to less patient attrition in the clinical setting remain to be evaluated.     

Cognitive-behavioral treatment of insomnia secondary to chronic pain

Sixty participants with insomnia secondary to chronic pain were assigned randomly to either a cognitive-behavioral therapy (CBT) or a self-monitoring/waiting-list control condition. The therapy consisted of a multicomponent 7-week group intervention aimed at promoting good sleep habits, teaching relaxation skills, and changing negative thoughts about sleep. Treated participants were significantly more improved than control participants on self-report measures of sleep onset latency, wake time after sleep onset, sleep efficiency, and sleep quality, and they showed less motor activity in ambulatory recordings of nocturnal movement. At a 3-month follow-up assessment, treated participants showed good maintenance of most therapeutic gains. These results provide the 1st evidence from a randomized controlled trial that CBT is an effective treatment for insomnia that is secondary to chronically painful medical conditions.     

Psychological treatment for insomnia in the management of long-term hypnotic drug use: a pragmatic randomised controlled trial.

OBJECTIVE: To evaluate the clinical and cost impact of providing cognitive behaviour therapy (CBT) for insomnia (comprising sleep hygiene, stimulus control, relaxation and cognitive therapy components) to long-term hypnotic drug users in general practice. DESIGN: A pragmatic randomised controlled trial with two treatment arms (a CBT treated 'sleep clinic' group, and a 'no additional treatment' control group), with post-treatment assessments commencing at 3 and 6 months. SETTING: Twenty-three general practices in Sheffield, UK. PARTICIPANTS: Two hundred and nine serially referred patients aged 31-92 years with chronic sleep problems who had been using hypnotic drugs for at least 1 month (mean duration = 13.4 years). RESULTS: At 3- and 6-month follow-ups patients treated with CBT reported significant reductions in sleep latency, significant improvements in sleep efficiency, and significant reductions in the frequency of hypnotic drug use (all P<0.01). Among CBT treated patients SF-36 scores showed significant improvements in vitality at 3 months (P<0.01). Older age presented no barrier to successful treatment outcomes. The total cost of service provision was 154.40 per patient, with a mean incremental cost per quality-adjusted life-year of 3416 (at 6 months). However, there was evidence of longer term cost offsets owing to reductions in sleeping tablet use and reduced utilisation of primary care services. CONCLUSIONS: In routine general practice settings, psychological treatments for insomnia can improve sleep quality and reduce hypnotic consumption at a favourable cost among long-term hypnotic users with chronic sleep difficulties.     

A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults

The present study tested cognitive-behavioral therapy (CBT) for insomnia in older adults with osteoarthritis, coronary artery disease, or pulmonary disease. Ninety-two participants (mean age = 69 years) were randomly assigned to classroom CBT or stress management and wellness (SMW) training, which served as a placebo condition. Compared with SMW, CBT participants had larger improvements on 8 out of 10 self-report measures of sleep. The type of chronic disease had no impact on these outcomes. The hypothesis that CBT would improve daytime functioning more than SMW was only supported by a global rating measure. These results add to findings that challenge the dichotomy between primary and secondary insomnia and suggest that psychological factors are likely involved in insomnias that are presumed to be secondary to medical conditions.     

Attentional Bias in People With Acute Versus Persistent Insomnia Secondary to Cancer

This study investigated the role of attentional bias in the development of persistent insomnia. Two groups of people with cancer who developed sleep-onset problems 0-3 months and 12-18 months after diagnosis completed a computerized emotional Stroop task comprising cancer-related and sleep-related word cues and self-complete measures. Both groups demonstrated attentional bias for cancer-related words, but only the persistent insomnia group demonstrated attentional bias for sleep-related words. High levels of presleep cognitive arousal were evident in both groups despite lower levels of psychological distress in the persistent insomnia group. Results suggest that secondary, sleep-related mental preoccupation may inhibit recovery to normal sleep after stress-related acute sleep disturbance. Findings are discussed in relation to current models of insomnia.     

The effect of arousals during sleep onset on estimates of sleep onset latency

It is well established that insomniacs overestimate sleep-onset latency. Furthermore, there is evidence that brief arousals from sleep may occur more frequently in insomnia. This study examined the hypothesis that brief arousals from sleep influence the perception of sleep-onset latency. An average of four sleep onsets was obtained from each of 20 normal subjects on each of two nonconsecutive, counterbalanced, experimental nights. The experimental nights consisted of a control night (control condition) and a condition in which a moderate respiratory load was applied to increase the frequency of microarousals during sleep onset (mask condition). Subjective estimation of sleep-onset latency and indices of sleep quality were assessed by self-report inventory. Objective measures of sleep-onset latency and microarousals were assessed using polysomnography. Results showed that sleep-onset latency estimates were longer in the mask condition than in the control condition, an effect not reflected in objective sleep-stage scoring of sleep-onset latency. Furthermore, an increase in the frequency of brief arousals from sleep was detected in the mask condition, and this is a possible source for the sleep-onset latency increase perceived by the subjects. Findings are consistent with the concept of a physiological basis for sleep misperception in insomnia.     

Attentional bias in people with acute versus persistent insomnia secondary to cancer

This study investigated the role of attentional bias in the development of persistent insomnia. Two groups of people with cancer who developed sleep-onset problems 0-3 months and 12-18 months after diagnosis completed a computerized emotional Stroop task comprising cancer-related and sleep-related word cues and self-complete measures. Both groups demonstrated attentional bias for cancer-related words, but only the persistent insomnia group demonstrated attentional bias for sleep-related words. High levels of presleep cognitive arousal were evident in both groups despite lower levels of psychological distress in the persistent insomnia group. Results suggest that secondary, sleep-related mental preoccupation may inhibit recovery to normal sleep after stress-related acute sleep disturbance. Findings are discussed in relation to current models of insomnia.     

认知行为与安眠药物治疗慢性失眠症临床效果对比分析

目的：比较认知行为、安眠药物和安慰剂治疗慢性失眠症的临床效果。方法：48名慢性失眠症男女患者自愿受试者，随机分成4组，分别接受认知行为、安眠药物、安眠药物和认知行为结合、安慰剂治疗。记录患者在治疗前后的主观和客观（夜间多导睡眠图，简称PSG）指标。结果：治疗开始后第8天，药物组和结合组的主观记录睡眠潜伏期分别为20分钟和27分钟，睡眠效率80％和82％，睡眠总时间分别为381分钟和356分钟，睡眠状况显著改善，效果好于认知行为组。经8周疗程治疗结束时，认知行为组上述睡眠3项指标好于治疗前，安慰剂组与治疗前无显著差异。治疗结束8个月时，认知行为组PSG记录睡眠潜伏期26分钟，睡眠效率84％，睡眠总时间378分钟，睡眠状态好于药物组和结合组，后两组较治疗刚结束时睡眠指标变差，药物组睡眠又恢复到治疗前的水平。结论：药物对睡眠改善起效快，短期效果好，认知行为治疗对睡眠改善有主观和客观（PSG记录）证明的长期效果，对与患者失眠相关的睡眠心理状态也有改善。安眠药物与认知行为结合治疗远期效果不如单纯认知行为治疗。     

Cognitive behavioral treatment in clinically referred chronic insomniacs: group versus individual treatment

In this study, we compared the effect of group and cognitive behavioral treatment (CBT) in clinically referred patients with chronic insomnia. The participants were 32 individually treated primary insomniacs and 74 individuals with either primary or secondary insomnia treated in a group (5-7 patients per group). The primary outcome measures were subjective sleep, quality of life (QOL), and psychological well-being. CBT produced significant changes in sleep onset latency, total sleep time, sleep efficiency, and wake after sleep onset. For total sleep time and sleep efficiency, the improvements were maintained at follow-up as well. In the questionnaires, significant improvements from treatment were seen for the Sickness Impact Profile, Sleep Evaluation Form, and Dysfunctional Beliefs and Attitudes About Sleep. All these improvements remained significant at follow-up. We conclude that CBT for insomnia is effective for both individual and group treatment. Improvements were seen in subjective sleep parameters, QOL, attitudes about sleep, and sleep evaluation in general, both posttreatment and at follow-up.     

Cognitive Behavioral Treatment in Clinically Referred Chronic Insomniacs: Group Versus Individual Treatment

In this study, we compared the effect of group and cognitive behavioral treatment (CBT) in clinically referred patients with chronic insomnia. The participants were 32 individually treated primary insomniacs and 74 individuals with either primary or secondary insomnia treated in a group (5–7 patients per group). The primary outcome measures were subjective sleep, quality of life (QOL), and psychological well-being. CBT produced significant changes in sleep onset latency, total sleep time, sleep efficiency, and wake after sleep onset. For total sleep time and sleep efficiency, the improvements were maintained at follow-up as well. In the questionnaires, significant improvements from treatment were seen for the Sickness Impact Profile, Sleep Evaluation Form, and Dysfunctional Beliefs and Attitudes About Sleep. All these improvements remained significant at follow-up. We conclude that CBT for insomnia is effective for both individual and group treatment. Improvements were seen in subjective sleep parameters, QOL, attitudes about sleep, and sleep evaluation in general, both posttreatment and at follow-up.     

Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice

STUDY OBJECTIVES: Persistent insomnia, although very common in general practice, often proves problematic to manage. This study investigates the clinical effectiveness and the feasibility of applying cognitive behavior therapy (CBT) methods for insomnia in primary care. DESIGN: Pragmatic randomized controlled trial of CBT versus treatment as usual. SETTING: General medical practice. PARTICIPANTS: Two hundred one adults (mean age, 54 years) randomly assigned to receive CBT (n = 107; 72 women) or treatment as usual (n = 94; 65 women). INTERVENTION: CBT comprised 5 sessions delivered in small groups by primary care nurses. Treatment as usual comprised usual care from general practitioners. MEASUREMENTS AND RESULTS: Assessments were completed at baseline, after treatment, and at 6-month follow-up visits. Sleep outcomes were appraised by sleep diary, actigraphy, and clinical endpoint. CBT was associated with improvements in self-reported sleep latency, wakefulness after sleep onset, and sleep efficiency. Improvements were partly sustained at follow-up. Effect sizes were moderate for the index variable of sleep efficiency. Participants receiving treatment as usual did not improve. Actigraphically estimated sleep improved modestly after CBT, relative to no change in treatment as usual. CBT was also associated with significant positive changes in mental health and energy/vitality. Comorbid physical and mental health difficulties did not impair sleep improvement following CBT. CONCLUSION: This study suggests that trained and supervised nurses can effectively deliver CBT for insomnia in routine general medical practice. Treatment response to small-group service delivery was encouraging, although effect sizes were smaller than those obtained in efficacy studies. Further research is required to consider the possibility that CBT could become the treatment of first choice for persistent insomnia in primary healthcare.     

Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004)

BACKGROUND: Recognition that psychological and behavioral factors play an important role in insomnia has led to increased interest in therapies targeting these factors. A review paper published in 1999 summarized the evidence regarding the efficacy of psychological and behavioral treatments for persistent insomnia. The present review provides an update of the evidence published since the original paper. As with the original paper, this review was conducted by a task force commissioned by the American Academy of Sleep Medicine in order to update its practice parameters on psychological and behavioral therapies for insomnia. METHODS: A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients) published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline searches. Each study was systematically reviewed with a standard coding sheet and the following information was extracted: Study design, sample (number of participants, age, gender), diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings. Criteria for inclusion of a study were as follows: (a) the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment condition was psychological or behavioral in content, (c) the study design was a randomized controlled trial, a nonrandomized group design, a clinical case series or a single subject experimental design with a minimum of 10 subjects, and (d) the study included at least 1 of the following as dependent variables: sleep onset latency, number and/or duration of awakenings, total sleep time, sleep efficiency, or sleep quality. RESULTS: Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders. Nine studies documented the benefits of insomnia treatment in older adults or for facilitating discontinuation of medication among chronic hypnotic users. Sleep improvements achieved with treatment were well sustained over time; however, with the exception of reduced psychological symptoms/ distress, there was limited evidence that improved sleep led to clinically meaningful changes in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria for empirically-supported psychological treatments for insomnia: Stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior therapy. DISCUSSION: These updated findings provide additional evidence in support of the original review's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia. Nonetheless, further research is needed to develop therapies that would optimize outcomes and reduce morbidity, as would studies of treatment mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also needed to validate those therapies when implemented in clinical settings (primary care), by non-sleep specialists. There is also a need to disseminate more effectively the available evidence in support of psychological and behavioral interventions to health-care practitioners working on the front line.     

Sleep-related attentional bias in patients with primary insomnia compared with sleep experts and healthy controls

Sleep-related attentional bias has been proposed to be an important factor in the development and maintenance of primary insomnia. In this study, a newly introduced mixed modality (visual auditory) task and an emotional Stroop task were used to investigate attentional processes in patients with primary insomnia, sleep experts and healthy controls (n = 20 per group). The sleep expert group served as second control group to control for effects of frequency of concept usage (FOCU). The results of the emotional Stroop task showed a sleep-related attentional bias in the insomnia group in comparison with the expert group. However, no significant differences were detected in the other group comparisons and in the mixed modality task. The difference between insomnia patients and sleep experts in the emotional Stroop task indicates that FOCU is not the underlying process of sleep-related attentional bias. Insomnia patients seem to be more emotionally, cognitively or procedurally affected by sleep-related stimuli than sleep experts. The findings suggest that a desensitization of sleep-related stimuli might be used therapeutically, thus extending the current cognitive behavioral treatments for primary insomnia.     

认知行为疗法对失眠症患者睡眠和生活质量的影响

目的探讨认知行为疗法对失眠症患者睡眠质量和生活质量的影响。方法39例失眠症患者随机分成研究组和对照组，研究组给予安眠药物与认知行为疗法治疗，对照组单纯药物治疗。匹兹堡睡眠质量指数（PSQI）评价睡眠质量，总体幸福感量表（GWB）评价生活质量。结果匹兹堡睡眠质量（PSQJ）总分、睡眠质量、入睡时间、睡眠时间、睡眠效率、睡眠障碍、催眠药物使用、日间功能因子分．以及总体幸福感（GWB）总分治疗前后均有显著性差异（P〈0．05）；在第三周末，研究组PSQI及GWB总分均优于对照组。结论认知行为疗法对失眠症患者有良好的疗效，同时提高患者生活质量。     

Presleep cognitions and attributions in sleep-onset insomnia

This research examined the role of cognitive factors (attributions about the causes of sleep difficulties and presleep cognitive activity) in sleep-onset insomnia. Thirty-four subjects, including 13 mild to extreme insomniacs, were interviewed and then spent 5 consecutive nights in a sleep laboratory. In a multiple regression paradigm predictor measures included attribution ratings of sleep difficulty, perceived control of presleep cognitions, presleep cognitive content, and affect associated with presleep cognitions. Criterion measures included laboratory measured objectives and subjective sleep-onset latency, a score presenting the difference between objective and subjective laboratory measures of sleep-onset latency, interview-measured subjective sleep-onset latency, and degree of overall concern and presleep concern about initiating sleep. The results of multiple regression analyses suggested that the content of presleep cognitions and the attributions of sleep difficulties were significantly associated with several subjective measures of sleep-onset latency or concern with initiating sleep. None of the predictor measures was significantly associated with objectively measured sleep-onset latency. Implications for cognitive theories of sleep-onset insomnia and for the psychophysiologic-subjective dimension of insomnia are discussed.The authors would like to express their appreciation for the assistance provided by Wade Horn, Linda Gannon, Paula Heiser, Sarah Dickson, Kathy Kyndberg, A. E. Adams, IV, and Bill Hoffman.     

Relation Between Adherence and Outcome in the Group Treatment of Insomnia

This study evaluated adherence to group cognitive behavioral treatment in 50 adults with chronic insomnia. Adherence was measured using questionnaire data, consistency of sleep scheduling, and % of sessions attended. Results showed that therapists' rated 48% of participants as "very much" to "extremely" adherent. Using stepwise regression, only therapist-rated adherence explained a significant amount of variance in post-treatment outcome. Therapist-rated adherence predicted post-treatment ratings of sleep-related impairment, dysfunctional beliefs about sleep, and overall sleep quality (but not actual sleep duration or efficiency). Using a multivariate analysis of variance (MANOVA) procedure, results revealed that a diagnosis of dysthymia, based on a structured clinical interview, was associated with reduced adherence and less improvement in sleep-onset latency and sleep efficiency, but that scores on a dimensional measure of depression were not associated with either adherence or outcome. Implications of these findings are that the practice of treatment techniques is related to an improved perception of sleep and more healthy and appropriate beliefs about the causes of poor sleep. Therapists should continue to pay close attention to the adherence behavior of those with insomnia, particularly if they are depressed.     

Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial

SUBJECT OBJECTIVE: To determine the optimal number of therapist-guided Cognitive-Behavioral Insomnia Therapy (CBT) sessions required for treating primary sleep-maintenance insomnia. DESIGN AND SETTING: Randomized, parallel-group, clinical trial at a single academic medical center. Outpatient treatment lasted 8 weeks with final follow-up conducted at 6 months. PARTICIPANTS: 86 adults (43 women; mean age 55.4 +/- 9.7 years) with primary sleep-maintenance insomnia (nightly mean wake time after sleep onset [WASO] = 93.4 +/- 44.5 minutes). INTERVENTIONS: One (week 1), 2 (weeks 1 and 5), 4 (biweekly), or 8 (weekly) individual CBT sessions scheduled over an 8-week treatment phase, compared with an 8-week no-treatment waiting period (WL). MEASUREMENT: Sleep diary and actigraphy measures of total sleep time, onset latency, WASO, total wake time, and sleep efficiency, as well as questionnaire measures of global insomnia symptoms, sleep related self-efficacy, and mood. RESULTS: Statistical tests of subjective/objective sleep measures favored the 1- and 4-session CBT doses over the other CBT doses and WL control. However, comparisons of pretreatment data with data acquired at the 6-month follow-up showed only the 4-session group showed significant long-term improvements in objective wake time and sleep efficiency measures. Additionally, 58.3% of the patients receiving 4 CBT sessions met criteria for clinically significant improvement by the end of treatment compared to 43.8% of those receiving 1 CBT session, 22.2% of those provided 2 sessions, 35.3% of those receiving 8 sessions, and 9.1% of those in the control condition. CONCLUSION: Findings suggest that 4 individual, biweekly sessions represents the optimal dosing for the CBT intervention tested. Additional dose-response studies are warranted to test CBT models that contain additional treatment components or are delivered via group therapy.     

A comparison of actigraphy and polysomnography in older adults treated for chronic primary insomnia

STUDY OBJECTIVES: The present study explores the accuracy and clinical utility of actigraphy compared with polysomnography in older adults treated for chronic primary insomnia. DESIGN: Polysomnographic and actigraphic data were collected before and after treatment. SETTING: A university-based outpatient clinic for adults and elderly. PARTICIPANTS: Thirty-four participants with chronic primary insomnia. Mean age was 60.5 years. INTERVENTIONS: Participants received either a manualized treatment package based on cognitive-behavior therapy and sleep management or hypnotic-drug treatment (7.5 mg zopiclone) for 6 weeks (these findings are reported elsewhere). MEASUREMENTS AND RESULTS: Although the sensitivity of actigraphy to detect sleep was very high (95.2%), actigraphy performed poorly in detecting wakefulness (specificity: 36.3%), yielding on an overall level of accuracy of 83.1%. However, the level of actigraphy accuracy was dependent upon polysomnography-registered sleep efficiency. Actigraphy underestimated total wake time and sleep-onset latency and consequently overestimated total sleep time and sleep efficiency. Compared with polysomnography, actigraphy captured only part of the treatment effects on total wake time and sleep-onset latency and failed to detect significant changes in sleep efficiency. CONCLUSIONS: The present findings suggest that the clinical utility of actigraphy is still suboptimal in older adults treated for chronic primary insomnia and should, hence, be used in this clinical setting with the concurrent use of supplementary assessment methods.     

Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia

STUDY OBJECTIVES: To determine the long-term efficacy of eszopiclone in patients with chronic insomnia. DESIGN: Randomized, double-blind, multicenter, placebo-controlled. SETTING: Out-patient, with monthly visits. PATIENTS: Aged 21 to 69 years meeting DSM IV criteria for primary insomnia and reporting less than 6.5 hours of sleep per night, and/or a sleep latency of more than 30 minutes each night for at least 1 month before screening. INTERVENTIONS: Eszopiclone 3 mg (n = 593) or placebo (n = 195), nightly for 6 months MEASUREMENTS AND RESULTS: Efficacy was evaluated weekly using an interactive voice-response system. Endpoints included sleep latency; total sleep time; number of awakenings; wake time after sleep onset; quality of sleep; and next-day ratings of ability to function, daytime alertness, and sense of physical well-being. At the first week and each month for the study duration, eszopiclone produced significant and sustained improvements in sleep latency, wake time after sleep onset, number of awakenings, number of nights awakened per week, total sleep time, and quality of sleep compared with placebo (P < or = 0.003). Monthly ratings of next-day function, alertness, and sense of physical well-being were also significantly better with the use of eszopiclone than with placebo (P < or = 0.002). There was no evidence of tolerance, and the most common adverse events were unpleasant taste and headache. CONCLUSIONS: Throughout 6 months, eszopiclone improved all of the components of insomnia as defined by DSM-IV, including patient ratings of daytime function. This placebo-controlled study of eszopiclone provides compelling evidence that long-term pharmacologic treatment of insomnia is efficacious.     

Relation between adherence and outcome in the group treatment of insomnia

This study evaluated adherence to group cognitive behavioral treatment in 50 adults with chronic insomnia. Adherence was measured using questionnaire data, consistency of sleep scheduling, and % of sessions attended. Results showed that therapists' rated 48% of participants as “very much” to “extremely” adherent. Using stepwise regression, only therapist-rated adherence explained a significant amount of variance in post-treatment outcome. Therapist-rated adherence predicted post-treatment ratings of sleep-related impairment, dysfunctional beliefs about sleep, and overall sleep quality (but not actual sleep duration or efficiency). Using a multivariate analysis of variance (MANOVA) procedure, results revealed that a diagnosis of dysthymia, based on a structured clinical interview, was associated with reduced adherence and less improvement in sleep-onset latency and sleep efficiency, but that scores on a dimensional measure of depression were not associated with either adherence or outcome. Implications of these findings are that the practice of treatment techniques is related to an improved perception of sleep and more healthy and appropriate beliefs about the causes of poor sleep. Therapists should continue to pay close attention to the adherence behavior of those with insomnia, particularly if they are depressed.