Home-Based Video CBT for Comorbid Geriatric Insomnia: A Pilot Study Using Secondary Data Analyses

Two recent studies showed that cognitive-behavioral treatment (CBT) is efficacious in treating insomnia in older adults with comorbid medical conditions. The authors extended these findings by comparing 12 older adults with comorbid insomnia who received a home-based video CBT program to the authors' previously published data on 24 participants who received classroom CBT or no treatment. All 36 participants were initially randomized within the same protocol, but the video arm was conducted 7 months after completion of the other two study arms. Compared to controls, the video CBT group demonstrated significant changes in five of eight self-report measures of sleep at posttreatment, including sleep latency, time awake after sleep onset, total time in bed, overall sleep quality, and dysfunctional beliefs and attitudes about sleep. Compared to controls, the video CBT group also had posttreatment improvements in daytime functioning, including mood, pain perception, social functioning, and energy-vitality. Although video CBT was not significantly different from classroom CBT on self-report measures, the attrition rate was higher (27% vs. 19%) and the number of participants who achieved clinically significant change was lower (50% vs. 73%). These preliminary findings suggest that delivering CBT in a home-based video format has the potential to serve as a first-line, cost-effective treatment for comorbid insomnia.     

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.     

Hypnotic taper with or without self-help treatment of insomnia: a randomized clinical trial

This study aimed to assess the efficacy of a minimal intervention focusing on hypnotic discontinuation and cognitive-behavioral treatment (CBT) for insomnia. Fifty-three adult chronic users of hypnotics were randomly assigned to an 8-week hypnotic taper program, used alone or combined with a self-help CBT. Weekly hypnotic use decreased in both conditions, from a nearly nightly use at baseline to less than once a week at posttreatment. Nightly dosage (in lorazepam equivalent) decreased from 1.67 mg to 0.12 mg. Participants who received CBT improved their sleep efficiency by 8%, whereas those who did not remained stable. Total wake time decreased by 52 min among CBT participants and increased by 13 min among those receiving the taper schedule alone. Total sleep time remained stable throughout withdrawal in both CBT and taper conditions. The present findings suggest that a systematic withdrawal schedule might be sufficient in helping chronic users stop their hypnotic medication. The addition of a self-help treatment focusing on insomnia, a readily available and cost-effective alternative to individual psychotherapy, produced greater sleep improvement.     

Management of Obstructive Sleep Apnea and Comorbid Insomnia: A Mixed-Methods Evaluation

The purpose of this study was to examine the process of care in an interdisciplinary sleep clinic for patients with obstructive sleep apnea (OSA) and comorbid insomnia. A mixed-methods approach was used to examine clinical and patient-centered measures for 34 patients who received positive-airway pressure for OSA or cognitive-behavior therapy for insomnia. The results revealed baseline-to-follow-up improvements on several self-reported sleep parameters and measures of daytime functioning. Qualitative analyses from patient interviews revealed three themes: conceptual distinctions about each sleep disorder, importance of treating both sleep disorders, and preferences with regard to the sequence of treatment. These findings indicate that patients with OSA and comorbid insomnia encounter unique challenges. A dimensional approach to assessment and treatment is proposed for future research.     

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.     

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.     

Treating insomnia in Swiss primary care practices: A survey study based on case vignettes

Guidelines recommend cognitive behavioural therapy for insomnia (CBT‐I) as first‐line treatment for chronic insomnia, but it is not clear how many primary care physicians (PCPs) in Switzerland prescribe this treatment. We created a survey that asked PCPs how they would treat chronic insomnia and how much they knew about CBT‐I. The survey included two case vignettes that described patients with chronic insomnia, one with and one without comorbid depression. PCPs also answered general questions about treating chronic insomnia and about CBT‐I and CBT‐I providers. Of the 820 Swiss PCPs we invited, 395 (48%) completed the survey (mean age 54 years; 70% male); 87% of PCPs prescribed sleep hygiene and 65% phytopharmaceuticals for the patient who had only chronic insomnia; 95% prescribed antidepressants for the patient who had comorbid depression. In each case, 20% of PCPs prescribed benzodiazepines or benzodiazepine receptor agonists, 8% prescribed CBT‐I, 68% said they knew little about CBT‐I, and 78% did not know a CBT‐I provider. In the clinical case vignettes, most PCPs treated chronic insomnia with phytopharmaceuticals and sleep hygiene despite their lack of efficacy, but PCPs rarely prescribed CBT‐I, felt they knew little about it, and usually knew no CBT‐I providers. PCPs need more information about the benefits of CBT‐I and local CBT‐I providers and dedicated initiatives to implement CBT‐I in order to reduce the number of patients who are prescribed ineffective or potentially harmful medications.     

CBT for late‐life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized‐controlled trial

Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under‐report sleep time and over‐report wake time at night. This study examined the impact and durability of cognitive‐behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One‐hundred and fifty‐nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive‐behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post‐treatment, 6‐months and 12‐months follow‐up. Sleep measures included objective (via wrist actigraphy) and subjective (via self‐report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive‐behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post‐treatment, 6‐months and 12‐months follow‐up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive‐behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive‐behavioural therapy for insomnia.     

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.     

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.     

Cognitive-behavioral treatment of late-life generalized anxiety disorder

This study addressed the efficacy of cognitive-behavioral therapy (CBT), relative to minimal contact control (MCC), in a sample of 85 older adults (age 60 years and over) with generalized anxiety disorder (GAD). All participants completed measures of primary outcome (worry and anxiety), coexistent symptoms (depressive symptoms and specific fears), and quality of life. Results of both completer and intent-to-treat analyses revealed significant improvement in worry, anxiety, depression, and quality of life following CBT relative to MCC. Forty-five percent of patients in CBT were classified as responders, relative to 8% in MCC. Most gains for patients in CBT were maintained or enhanced over 1-year follow-up. However, posttreatment scores for patients in CBT failed to indicate return to normative functioning.     

Subjective–objective sleep discrepancy among older adults: associations with insomnia diagnosis and insomnia treatment

Discrepancy between subjective and objective measures of sleep is associated with insomnia and increasing age. Cognitive behavioural therapy for insomnia improves sleep quality and decreases subjective–objective sleep discrepancy. This study describes differences between older adults with insomnia and controls in sleep discrepancy, and tests the hypothesis that reduced sleep discrepancy following cognitive behavioural therapy for insomnia correlates with the magnitude of symptom improvement reported by older adults with insomnia. Participants were 63 adults >60 years of age with insomnia, and 51 controls. At baseline, participants completed sleep diaries for 7 days while wearing wrist actigraphs. After receiving cognitive behavioural therapy for insomnia, insomnia patients repeated this sleep assessment. Sleep discrepancy variables were calculated by subtracting actigraphic sleep onset latency and wake after sleep onset from respective self‐reported estimates, pre‐ and post‐treatment. Mean level and night‐to‐night variability in sleep discrepancy were investigated. Baseline sleep discrepancies were compared between groups. Pre–post‐treatment changes in Insomnia Severity Index score and sleep discrepancy variables were investigated within older adults with insomnia. Sleep discrepancy was significantly greater and more variable across nights in older adults with insomnia than controls, P ≤ 0.001 for all. Treatment with cognitive behavioural therapy for insomnia was associated with significant reduction in the Insomnia Severity Index score that correlated with changes in mean level and night‐to‐night variability in wake after sleep onset discrepancy, P < 0.001 for all. Study of sleep discrepancy patterns may guide more targeted treatments for late‐life insomnia.     

Cognitive-behavioral therapy for insomnia improves attentional function in fibromyalgia syndrome: a pilot, randomized controlled trial

This pilot, randomized controlled trial analyzed the effects of a cognitive behavioral therapy (CBT, n = 20) for insomnia vs a sleep hygiene (SH, n = 20) program on the three attentional networks (alertness, orienting, and executive function) and other additional outcome measures (sleep, pain, depression, anxiety, and daily functioning) of fibromyalgia patients. The CBT group showed significant improvement in alertness (F(1, 28) = 11.84, p = .0018), executive functioning (F(1, 28) = 15.76, p = .00059), sleep quality ( F(1, 38) = 6.33, p = .016), and a trend to improvement in daily functioning (p > .06), as compared with the SH group. The improvement in executive functioning was significantly related to the changes in sleep (r = 0.40, p = .026). A CBT for insomnia represents a useful intervention in fibromyalgia patients not only regarding sleep disturbance but also attentional dysfunction and probably daily functioning.     

A classroom mind/body wellness intervention for older adults with chronic illness: comparing immediate and 1-year benefits

The authors tested the efficacy of a mind/body wellness intervention for older adults with chronic illness. They randomly assigned 243 physician-referred patients from an urban HMO to a classroom intervention or a wait-list control group. The intervention provided instruction on mind/body relationships; relaxation training; cognitive restructuring; problem-solving; communication; and behavioral treatment for insomnia, nutrition, and exercise. At posttreatment, the intervention group had significant decreases in self-reported sleep difficulties, pain, anxiety, and depression symptoms compared with controls. The intervention also led to a significant decrease in "chance" and "powerful others" health locus of control beliefs. At 1-year follow-up, the intervention group maintained benefits in sleep and health locus of control and also reported a significant increase in health behaviors compared with controls. Pain, anxiety, and depression benefits were not maintained. This type of classroom intervention appears to have some lasting effects on health behaviors and beliefs.     

Case-control study of subjective and objective differences in sleep patterns in older adults with insomnia symptoms

Older adults have high prevalence rates of insomnia symptoms, yet it is unclear if these insomnia symptoms are associated with objective impairments in sleep. We hypothesized that insomnia complaints in older adults would be associated with objective differences in sleep compared with those without insomnia complaints. To test this hypothesis, we conducted a cross‐sectional study in which older adults with insomnia complaints (cases, n = 100) were compared with older adults without insomnia complaints (controls, n = 100) using dual‐night in‐lab nocturnal polysomnography, study questionnaires and 7 days of at‐home actigraphy and sleep diaries. Cases were noted to have reduced objective total sleep time compared with controls (25.8 ± 8.56 min, P = 0.003). This was largely due to increased wakefulness after sleep onset, and not increased sleep latency. When participants with sleep‐related breathing disorder or periodic limb movement disorder were excluded, the polysomnography total sleep time difference became even larger. Cases also had reduced slow‐wave sleep (5.10 ± 1.38 min versus 10.57 ± 2.29 min, effect size −0.29, P = 0.04). When comparing self‐reported sleep latency and sleep efficiency with objective polysomnographic findings, cases demonstrated low, but statistically significant correlations, while no such correlations were observed in controls. Cases tended to underestimate their sleep efficiency by 1.6% (±18.4%), while controls overestimated their sleep efficiency by 12.4% (±14.5%). In conclusion, we noted that older adults with insomnia complaints have significant differences in several objective sleep findings relative to controls, suggesting that insomnia complaints in older adults are associated with objective impairments in sleep.     

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.     

Self-help treatment for insomnia: bibliotherapy with and without professional guidance.

Fifty-four adults with primary insomnia were randomly assigned to a self-help treatment (cognitive-behavioral bibliotherapy [BT]), BT with weekly phone consultations, or a waiting-list control (WL) group. Treated participants were mailed 6 treatment booklets at the rate of 1 booklet per week; 1/2 of them also received minimal professional guidance through a 15-min weekly phone consultation. The WL group members continued to monitor their sleep during this period. Participants in both treatment conditions improved significantly on the main outcome variables (total wake time and sleep efficiency) at posttreatment, whereas WL participants remained unchanged. The addition of weekly phone calls slightly enhanced improvements at posttreatment. However, both treatment conditions were comparable at follow-up. These results suggest that BT, with or without minimal professional guidance, is an effective approach for treating primary insomnia.     

Clinical Significance and Predictors of Treatment Response to Cognitive-Behavior Therapy for Insomnia Secondary to Chronic Pain

We examined individual responses to cognitive-behavior therapy for insomnia in 51 persons with chronic pain to determine the rate of clinically significant change and to identify predictors of successful treatment response. Outcome measures consisted of the Pittsburgh Sleep Quality Index (PSQI) and diary measures of sleep latency and sleep continuity. Using reliable change indices, 57% of participants were statistically improved on the PSQI after 7 weeks of treatment, but only 18% were considered fully recovered from their sleep problems. No demographic variables predicted treatment response but persons who reliably improved on the PSQI had a lower sleep self-efficacy at baseline. Improvers showed a significant increase in sleep self-efficacy ratings and a decrease in self-reported levels of distress and pain-related disability. These results suggest that patients with insomnia secondary to chronic medical conditions can be helped with cognitive-behavior therapy, although most individuals continue to have mild or subthreshold sleep problems at posttreatment.     

Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep?

STUDY OBJECTIVES: This study was conducted to exam the degree to which cognitive-behavioral insomnia therapy (CBT) reduces dysfunctional beliefs about sleep and to determine if such cognitive changes correlate with sleep improvements. DESIGN: The study used a double-blind, placebo-controlled design in which participants were randomized to CBT, progressive muscle relaxation training or a sham behavioral intervention. Each treatment was provided in 6 weekly, 30-60-minute individual therapy sessions. SETTING: The sleep disorders center of a large university medical center. PARTICIPANTS: Seventy-five individuals (ages 40 to 80 years of age) who met strict criteria for persistent primary sleep-maintenance insomnia were enrolled in this trial. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Participants completed the Dysfunctional Beliefs and Attitudes About Sleep (DBAS) Scale, as well as other assessment procedures before treatment, shortly after treatment, and at a six-month follow-up. Items composing a factor-analytically derived DBAS short form (DBAS-SF) were then used to compare treatment groups across time points. Results showed CBT produced larger changes on the DBAS-SF than did the other treatments, and these changes endured through the follow-up period. Moreover, these cognitive changes were correlated with improvements noted on both objective and subjective measures of insomnia symptoms, particularly within the CBT group. CONCLUSIONS: CBT is effective for reducing dysfunctional beliefs about sleep and such changes are associated with other positive outcomes in insomnia treatment.     

Self-help treatment for insomnia: a randomized controlled trial

STUDY OBJECTIVES: Insomnia is a prevalent health complaint that often remains untreated. Several interventions are efficacious but they are not widely available. This study evaluated the efficacy of a self-help behavioral intervention for insomnia. DESIGN: The study used a 2 (conditions; self-help treatment, no treatment control) x 3 (assessments; pretreatment, posttreatment, 6-month follow-up) mixed factorial design. SETTING: This study was part of a larger epidemiologic study conducted with a randomly selected sample of 2001 adults of the province of Quebec in Canada. PARTICIPANTS: One-hundred ninety-two adults (n = 127 women, 65 men; mean age, 46 years) with insomnia, selected from a larger community-based epidemiologic sample, were randomly assigned to self-help treatment (n = 96) or no-treatment control (n = 96). INTERVENTIONS: The self-help intervention included 6 educational booklets mailed weekly to participants and providing information about insomnia, healthy sleep practices, and behavioral sleep scheduling and cognitive strategies. MEASUREMENTS AND RESULTS: Participants completed sleep diaries and questionnaires at pretreatment, posttreatment, and 6-month follow-up. Significant but modest improvements were obtained on subjective sleep parameters for treatment but not control participants. Treated participants averaged nightly gains of 21 minutes of sleep and a reduction of 20 minutes of wakefulness, with a corresponding increase of 4% in sleep efficiency. Improvements were also obtained on measures of insomnia severity (Insomnia Severity Index) and of sleep quality (Pittsburgh Sleep Quality Index), and those changes were maintained at follow-up. CONCLUSIONS: A self-help behavioral intervention was effective in alleviating a broad range of insomnia symptomatology in a community sample. Self-help may be a promising approach to make effective intervention more widely available.