Short- and Long-Term Effects of CBT-I in Groups for School-Age Children Suffering From Chronic Insomnia: The KiSS-Program

Objective/Background: This intervention study evaluates the short- and long-term effects of cognitive behavior therapy for insomnia (CBT-I) in groups for school-age children and their parents, named the KiSS-program. CBT-I was implemented in three sessions for children and three sessions for parents. Participants and Methods: All in all, 112 children with chronic childhood insomnia were randomly assigned to a wait-list (WL) control or treatment condition. Results: According to subjective measures as well as objective wrist actigraphy, children in the CBT-I condition reported greater improvements in sleep behavior immediately after the treatment compared to the WL group. Improvements in sleep behavior after CBT-I persisted over the 3-, 6-, and 12-month follow-up assessments. Conclusions: The present study is the first randomized controlled trial that provides evidence for the long-term effectiveness of CBT-I in treating school-age children with chronic insomnia.     

Prospective Randomized Study of Patients with Insomnia and Mild Sleep Disordered Breathing

Background:

Patients with insomnia may present with mild and often unrecognized obstructive sleep apnea (OSA).

Objective:

To evaluate both subjective and objective outcomes of patients with complaints of insomnia and mild OSA who receive surgical treatment for OSA versus behavioral treatment with cognitive behavioral therapy for insomnia (CBT-I).

Methods:

Prospective study with crossover design of 30 patients with complaints of insomnia and mild OSA. Thirty subjects, matched for age and gender, were randomized with stratification to receive either CBT-I or surgical treatment of OSA as primary treatment. Patients were reassessed after completing the initial intervention and reassigned if agreeable to the alternative treatment option and assessed again on completion of both treatment arms. Outcome measures included clinical impression, Epworth Sleepiness Scale (ESS) score, Fatigue Severity Scale (FSS) score, and polysomnography (PSG) results.

Results:

Surgery resulted in greater improvements in total sleep time (TST), slow wave sleep and REM sleep duration, respiratory disturbance index, apnea-hypopnea index, minimum oxygen saturation, FSS, and ESS. CBT-I also improved TST and resulted in shorter sleep latency.

Conclusion:

Surgical intervention for the management of patients with complaints of insomnia and mild OSA demonstrated greater improvement in both subjective and objective outcome measures. Initial treatment of underlying OSA in patients with insomnia was more successful in improving insomnia than CBT-I alone. However CBT-I as initial treatment improved TST compared to baseline; following surgical intervention, it had the additional benefit of further increasing TST and helped to control sleep onset difficulties that may be related to conditioning due to unrecognized symptoms of mild OSA.

Citation:

Guilleminault C; Davis K; Huynh NT. Prospective randomized study of patients with insomnia and mild sleep disordered breathing. SLEEP 2008;31(11):1527–1533     

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

Objectives

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

Methods

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

Results

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

Conclusions

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.     

Mediators of cognitive-behavioral therapy for insomnia: A review of randomized controlled trials and secondary analysis studies

The examination of treatment mechanisms in randomized controlled trials (RCTs) has considerable implications for research and clinical practice. Insomnia is a highly prevalent and distressing disorder, associated with many adverse outcomes. Although extensive work has focused on the cognitive-behavioral treatment of insomnia (CBT-I), few studies have directly examined the mechanisms of this intervention. CBT-I is a short-term, multi-component treatment that has demonstrated strong efficacy in treating insomnia. The purpose of the present study is: (a) to investigate if CBT-I works in accordance with its proposed mechanisms, and (b) to evaluate how the field is progressing in its understanding of these processes. This study comprehensively reviewed CBT-I RCTs for their inclusion of mediator variables. Secondary analysis studies were also surveyed for relevant mediator variables. Results demonstrated that 21 RCTs (39% of the total RCTs) and 11 secondary analysis studies examined at least one of the proposed mediators. Results of this review highlight that, although CBT-I appears to be targeting the hypothesized sleep processes, more research is needed to better understand whether CBT-I works in accordance with its theorized mechanisms. Inclusion of mediational analyses in future RCTs and secondary analysis studies would allow for further refinement of CBT-I and improved treatment outcomes.     

Manifestations of Insomnia in Sleep Apnea: Implications for Screening and Treatment

The aims of this study were to examine the presence, type, and severity of insomnia complaints in obstructive sleep apnea (OSA) patients and to assess the utility of the Sleep Symptom Checklist (SSC) for case identification in primary care. Participants were 88 OSA patients, 57 cognitive-behavioral therapy for insomnia (CBT-I) patients, and 14 healthy controls (Ctrl). Each completed a sleep questionnaire as well as the SSC, which includes insomnia, daytime functioning, psychological, and sleep disorder subscales. Results showed that OSA patients could be grouped according to 3 insomnia patterns: no insomnia (OSA), n = 21; insomnia (OSA-I), n = 30, with a subjective complaint and disrupted sleep; and noncomplaining poor sleepers (OSA-I-NC), n = 37. Comparisons among the OSA, CBT-I, and Ctrl groups demonstrate distinct profiles on the SSC subscales, indicating its potential utility for both case identification and treatment planning.     

Effect of cognitive behavioural therapy for insomnia on sleep architecture and sleep EEG power spectra in psychophysiological insomnia

There is now an overwhelming preponderance of evidence that cognitive behavioural therapy for insomnia (CBT-I) is effective, as effective as sedative hypnotics during acute treatment (4-8 weeks), and is more effective in long term (following treatment). Although the efficacy of CBT-I in the treatment of chronic insomnia is well known, however there is little objective data on the effects of CBT-I on sleep architecture and sleep EEG power densities. The present study evaluated, first, subjective change in sleep quality and quantity, and secondly the modifications occurring in polysomnography and EEG power densities during sleep after 8 weeks of CBT-I. Nine free drug patients with psychophysiological insomnia, aged 33-62 years (mean age 47 +/- 9.7 years), seven female and two male participated in the study. Self-report questionnaires were administered 1 week before and 1 week after CBT-I, a sleep diary was completed each day 1 week before CBT-I, during CBT-I and 1 week after CBT-I. Subjects underwent two consecutive polysomnographic nights before and after CBT-I. Spectral analysis was performed the second night following 16 h of controlled wakefulness. After CBT-I, only scales assessing insomnia were significantly decreased, stages 2, REM sleep and SWS durations were significantly increased. Slow wave activity (SWA) was increased and the SWA decay shortened, beta and sigma activity were reduced. In conclusion CBT-I improves both subjective and objective sleep quality of sleep. CBT-I may enhance sleep pressure and improve homeostatic sleep regulation.     

Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy

Insomnia and disturbed sleep are common during pregnancy. This study investigated the effectiveness of group cognitive-behavioral therapy for insomnia (CBT-I) delivered in pregnancy. Thirteen pregnant women with insomnia participated in five weekly CBT-I group sessions. All participants completed the study and provided baseline and follow-up data. Significant reductions in insomnia symptoms and increases in subjective sleep quality were observed over the course of the study. Diary and actigraphy assessments of sleep also changed, such that participants reported less time in bed (TIB), shorter sleep onset latency (SOL), increased sleep efficiency (SE), and increased subjective total sleep time (TST). Additionally, symptoms of depression, pregnancy-specific anxiety, and fatigue all decreased over the course of treatment. Effect sizes ranged from medium to large. CBT-I delivered during pregnancy was associated with significant improvements in sleep and mood. The next step in this area of inquiry is to better establish effectiveness via a randomized controlled trial.     

Effects of Cognitive Behavioral Therapy for Insomnia on Sleep-Related Cognitions Among Patients With Stable Heart Failure

Objective/Background: Cognitive behavioral therapy for insomnia (CBT-I) improves insomnia and fatigue among chronic heart failure (HF) patients, but the extent to which sleep-related cognitions explain CBT-I outcomes in these patients is unknown. We examined the effects of CBT-I on sleep-related cognitions, associations between changes in sleep-related cognitions and changes in sleep and symptoms after CBT-I, and the extent to which cognitions mediated the effects of CBT-I. Participants: Stable New York Heart Association Class II-III HF patients (total n = 51; n = 26 or 51.0% women; M age = 59.1 ± 15.1 years). Methods: HF patients were randomized in groups to group CBT-I (n = 30) or attention control (HF self-management education, n = 21) and completed actigraphy, the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep (DBAS) and Sleep Disturbance Questionnaires (SDQ), and self-reported fatigue, depression, anxiety, and sleepiness (baseline, immediately after treatment, six months). We used mixed-effects modeling, mediation analysis with a bootstrapping approach, and Pearson correlations. Results: There was a statistically significant group × mult time effect on DBAS. DBAS mediated the effects of CBT-I on insomnia severity and partially mediated CBT-I effects on fatigue. Improvements in dysfunctional cognitions were associated with improved sleep quality, insomnia severity, sleep latency and decreased fatigue, depression, and anxiety, with sustained effects at six months. Conclusions: Improvement in dysfunctional sleep-related cognitions is an important mechanism for CBT-I effects among HF patients who are especially vulnerable to poor sleep and high symptom burden.     

Patient Perceptions of Treatment Delivery Platforms for Cognitive Behavioral Therapy for Insomnia

Objective: Stepped care has given rise to the proliferation of abbreviated CBT-I programs and delivery formats. This includes interventions delivered by allied health professionals and those delivered electronically through the Internet. This article aims to explore patient perceptions between electronic and face-to-face (FTF) delivery platforms for (abbreviated) CBT-I. Participants: Patients with insomnia from specialist sleep or psychology clinics and those from the general community in Sydney, Australia. Method: Semistructured interviews were conducted with patients with insomnia, guided by a schedule of questions and a choice task to explore patient perceptions of the different CBT-I treatment delivery platforms (e.g., perceived advantages and disadvantages or willingness to engage with either platform). Interviews were transcribed verbatim and analyzed using Framework Analysis. Participants also completed a battery of clinical mood and insomnia measures. Results: Fifty-one interviews were conducted with patients with insomnia from specialist sleep or psychology clinics (n = 22) and the general community (n = 29). Synthesis of the qualitative data set revealed three themes pertinent to the patients’ perspective toward electronic and FTF CBT-I delivery: Concepts of Efficacy, Concerns About Treatment, and Treatment on My Terms. Participants’ choice to engage with either platform was also informed by diverse factors including perceived efficacy of treatment, personal commitments, lifestyle, and beliefs about sleep and insomnia. Conclusion: Clarifying patient treatment priorities and allaying potential concerns about engaging with an electronic treatment platform represent important steps for disseminating eCBT-I into mainstream practice.     

Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial

Sleep disturbances play an important role in the exacerbation of pain and other troubling symptoms reported by patients with fibromyalgia (FM). The objective of this trial was to analyze the efficacy of a cognitive-behavioral therapy for insomnia (CBT-I) versus a sleep hygiene (SH) education program at improving sleep and other clinical manifestations in FM. Sixty-four FM women with insomnia were randomly assigned to the CBT-I or the SH groups, and 59 completed the treatments (30 in the CBT-I group and 29 in the SH group). Participants completed several self-report questionnaires at pre-, post-treatment and follow-ups. The CBT-I group reported significant improvements at post-treatment in several sleep variables, fatigue, daily functioning, pain catastrophizing, anxiety and depression. The SH group only improved significantly in subjective sleep quality. Patients in the CBT-I group showed significantly greater changes than those in the SH group in most outcome measures. The findings underscore the usefulness of CBT-I in the multidisciplinary management of FM.     

Effectiveness of Group Cognitive Behavioral Therapy for Insomnia (CBT-I) in a Primary Care Setting

Objective/Background: Primary care is where many patients with insomnia first ask for professional help. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia. Although CBT-I’s efficacy is well established, its effectiveness in real-life primary care has seldom been investigated. We examined the effectiveness of CBT-I as routinely delivered in a Canadian primary care setting. Participants: The patients were 70 women and 11 men (mean age = 57.0 years, SD = 12.3); 83% had medical comorbidity. Methods: For the first 81 patients who took the six-session group program we compared initial and postprogram sleep diaries, sleep medication use, Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS), and visits to the family physician. Results: Sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and ISI scores improved significantly (p < .001). Mood ratings also improved (p < .001). Use of sleep medication decreased (p < .001). Effect sizes were medium to large. Eighty-eight percent of patients no longer had clinically significant insomnia (ISI score ≤ 14) by the last session; 61% showed at least “moderate” improvement (ISI score reduction > 7). Wait-list data from 42 patients showed minimal sleep and mood improvements with the passage of time. Number of visits to the family physician six months postprogram decreased, although not significantly (p = .108). Conclusions: The CBT-I program was associated with improvement on all sleep and mood measures. Effect sizes were similar to, or larger than, those found in randomized controlled trials, demonstrating the real-world effectiveness of CBT-I in an interdisciplinary primary care setting.     

Predictors of Interest in Psychological Treatment for Insomnia Among Older Primary Care Patients With Disturbed Sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.     

The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial

Insomnia is a very common and disabling symptom. Whilst evidence for the efficacy of cognitive behavioural therapy for people diagnosed with insomnia (CBT-I) is strong, few people seek help and not many services offer CBT-I. Less intensive adaptations of CBT-I have been shown to be valuable, and given the size of the problem and low rates of help-seeking, an accessible intervention with a large capacity is needed. Day-long CBT-I psycho-educational workshops (each for up to 30 people), to which members of the public with insomnia symptoms could self-refer, have been developed. This randomised controlled trial aimed to evaluate the effectiveness of these workshops. Baseline measures were taken from 151 participants, who were then randomised to experimental or waiting-list control groups. Scores of the experimental group and the control group were compared 3 months after baseline. Random effects models found a significant interaction between time and group, indicating differences between the control and experimental groups on the Insomnia Severity Index (ISI). Post hoc analyses indicated that ISI scores decreased significantly in the experimental group, but not in the control group. Promising results were also found on corroborative sleep diary measures. Access to the workshops was good, with 50% of participants having never previously sought help for sleep difficulties from their GP. CBT-I workshops proved to be both accessible and effective in reducing insomnia symptoms in the medium term. They may represent a feasible brief intervention with the potential to address unmet treatment needs of adults complaining of insomnia symptoms.     

Predictors of interest in psychological treatment for insomnia among older primary care patients with disturbed sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.     

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial

Study ObjectivesCognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I).MethodsA total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step.ResultsResults indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores.Conclusion(s)The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients.Trial registrationClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).     

Efficacy of cognitive behavioural therapy for insomnia or sleep disturbance in pregnant women: A systematic review ad meta-analysis

During pregnancy many women may experience negative emotions and sleep disturbances. This systematic review and meta-analysis was conducted to assess the efficacy of cognitive behavioural therapy for insomnia (CBT-I) or sleep disturbance in pregnant women. From the earliest available publications to 15 April 2022, seven electronic literature databases were searched: PubMed, Web of Science, Cochrane Library, Embase, Chinese National Knowledge Infrastructure, Wanfang Data, and VIP Database for Chinese Science and Technology Journal. Randomised controlled trials of CBT-I in pregnant women with insomnia or sleep disorders were included. The methodological bias of the included studies was assessed using the Cochrane risk of bias tool. The meta-analysis was performed using RevMan 5.4 software. Stata Statistical Software: Release 15 was used for sensitivity analysis and publication bias. We included eight randomised controlled trials involving 743 pregnant women. Meta-analysis showed that, compared with the control group, CBT-I significantly improved the Insomnia Severity Index (mean difference [MD] = −4.25, 95% confidence interval [CI, −6.32, −2.19], p < 0.001), The Pittsburgh Sleep Quality Index (MD = −3.30, 95% CI [−4.81, −1.79], p < 0.001), sleep onset latency (standardised mean difference [SMD] = −1.25, 95% CI [−2.01, −0.50], p = 0.001), anxiety (SMD = −0.99, 95% CI [−1.32, −0.67], p < 0.001), and depression (SMD = −0.40, 95% CI [−0.72, −0.07], p = 0.02). No significant differences were found in total sleep time (SMD = 0.31, 95% CI [−0.54, 1.17], p = 0.47) and sleep efficiency (SMD = 0.80, 95% CI [−0.53, 2.13], p = 0.24). CBT-I significantly improved pregnant women's sleep quality, insomnia severity, depression, and anxiety. This meta-analysis provides evidence that CBT-I is valid for insomnia or sleep disturbances during pregnancy.     

An open‐ended primary‐care group intervention for insomnia based on a self‐help book – A randomized controlled trial and 4‐year follow‐up

Chronic insomnia is a common and burdensome problem for patients seeking primary care. Cognitive behavioural therapy has been shown to be effective for insomnia, also when presented with co‐morbidities, but access to sleep therapists is limited. Group‐treatment and self‐administered treatment via self‐help books have both been shown to be efficacious treatment options, and the present study aimed to evaluate the effect of an open‐ended group intervention based on a self‐help book for insomnia, adapted to fit a primary‐care setting. Forty primary‐care patients with insomnia (mean age 55 years, 80% women) were randomized to the open‐ended group intervention based on a cognitive behavioural therapy for insomnia self‐help book or to a care as usual/wait‐list control condition. Results show high attendance to group sessions and high treatment satisfaction. Participants in the control group later received the self‐help book, but without the group intervention. The book‐based group treatment resulted in significantly improved insomnia severity, as well as shorter sleep‐onset latency, less wake time after sleep onset, and less use of sleep medication compared with treatment as usual. The improvements were sustained at a 4‐year follow‐up assessment. A secondary analysis found a significant advantage of the combination of the book and the open‐ended group intervention compared with when the initial control group later used only the self‐help book. An open‐ended treatment group based on a self‐help book for insomnia thus seems to be an effective and feasible intervention for chronic insomnia in primary‐care settings.     

Feasibility of a Preventive Intervention for Insomnia in Women with Breast Cancer Receiving Chemotherapy

ABSTRACT

Objective/Background: Breast cancer patients display high rates of insomnia and chemotherapy treatments appear to contribute significantly to the development of sleep disturbances among this population. The efficacy of cognitive-behavioral therapy for insomnia (CBT-I) is now well established for treating insomnia comorbid with cancer but is not widely accessible and is also fairly costly. Its capacity to prevent the onset of insomnia symptoms in cancer patients who are at a high risk of developing these difficulties remains to be demonstrated. The purpose of this study was to assess the feasibility of a brief self-administered preventive intervention of insomnia in breast cancer patients about to undergo chemotherapy.

Participants/Methods: A sample of 20 women with breast cancer and with no insomnia were recruited and received the preventive intervention, taking the form of a short booklet, at their first chemotherapy treatment. One month later, a semi-structured phone interview was conducted to assess their satisfaction with different aspects of the booklet (e.g., format, content) and their adherence to the proposed strategies and to collect qualitative information. A 3-month follow-up evaluation was also conducted.

Results: Patients reported a higher level of satisfaction than expected (mean score corresponding to “a lot” on the scale) and a moderate level of adherence falling only slightly under the hypothesized level. The open comments collected corroborated the good acceptability of this minimal preventive CBT-I in breast cancer patients initiating chemotherapy.

Conclusions: Overall, findings of this study confirm that a self-administered preventive intervention for insomnia is feasible and a promising approach in breast cancer patients about to initiate chemotherapy.