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.     

The Experience of Chronic Insomnia in Chinese Adults: A Study Using Focus Groups and Insomnia Experience Diaries

The subjective experience in 43 Chinese adults with chronic primary insomnia was assessed using focus groups and insomnia experience diaries. Participants recruited from the community and a sleep clinic were diagnosed with DSM-IV-TR insomnia disorder and had sleep difficulties on 3 or more nights per week for at least 6 months. Six focus groups, of 6–8 participants each, were conducted; it was stopped as thematic saturation emerged in the last 2 groups. Using grounded theory approach, we identified 4 themes and 16 subthemes, covering beliefs about the nature and treatment of insomnia, behavioral responses to insomnia, cognitive-emotional and physiological arousal, and emotional experiences associated with insomnia. The findings are in general compatible with qualitative studies in the West, but some subthemes are influenced by Chinese cultural beliefs and values, in particular, use of the traditional Chinese medicine concept, being modest in sleep expectation, and a letting go attitude. Strategies for cultural adaptation of cognitive-behavioral therapy for insomnia in a Chinese society using patients’ subjective experience are discussed.     

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.     

Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer

This study investigated the efficacy of a multimodal cognitive-behavioral intervention for women who had been treated for nonmetastatic breast cancer. Ten participants were enrolled in the treatment protocol in a multiple-baseline design. Intervention time series analyses of daily sleep diary data revealed significant improvements of sleep efficiency and total wake time. These results were corroborated by polysomnographic data. In addition, insomnia treatment was associated with significant improvements of mood, general and physical fatigue, and global and cognitive dimensions of quality of life. These findings suggest that cognitive-behavioral therapy, previously found effective for primary insomnia, is also of clinical benefit for insomnia secondary to cancer.     

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.     

Recent advances in the assessment and treatment of insomnia.

Persistent insomnia has multiple potential causes such as medical, pharmacological, life-style, personality, and behavioral factors. Although many poor sleepers use hypnotic medications, a wide array of cognitive-behavioral interventions are available that target somatic and cognitive arousal, dysfunctional thoughts, and learned maladaptive sleep habits. Outcome research conducted over the past decade reveals that the single treatments of stimulus control and sleep restriction produced the best results, reducing self-reported target complaints by 50-60%. Approximately half of insomniacs show reliable change although only about one third become good sleepers. Multicomponent methods offer considerable promise but on the whole have not surpassed results achieved with the simpler stimulus control. Recommended new directions of pursuit include (a) examination of a broader range of insomnia sufferers, (b) use of multimodal assessment and more objective verification of self-reported benefits (c) research on treatments tailored to individual causal and maintaining factors, and (d) further scrutiny of newer interventions like sleep restriction and more comprehensive multifaceted strategies.     

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.     

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.     

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.     

Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia

BACKGROUND: Previous studies of insomnia focused mainly on the improvement of sleep condition and ignored the effects of sleep-related psychological activity and daytime function after pharmacological and behavioral treatments. We compared the clinical effects of both therapies on sleep condition, sleep-related psychological activity and daytime function in chronic insomnia. METHODS: Seventy-one patients with chronic insomnia were randomly divided into 4 groups and either received cognitive-behavior therapy (CBT, n = 19), pharmacological therapy (PCT, n = 17), CBT plus medication (Combined, n = 18) or placebo (n = 17). The treatments lasted for 8 weeks with follow-ups conducted at 3 and 8 months. On the day after treatment ended, all patients were assessed using a polysomnogram (PSG), a sleep diary and a psychological assessment. RESULTS: The three active treatments were more effective than placebo at the time the treatments were completed. Subjective sleep-onset latency, sleep efficacy and total sleep time were better in the PCT group than in the CBT group. At the 3-month follow-up, subjective and objective sleep-onset latency, sleep efficacy and total sleep time were better in the CBT group than in both the PCT and the Combined group. At the 8-month follow-up, the CBT group showed a steady comfortable sleep state, while the PCT and Combined groups were gradually returning to the pre-treatment condition. The Combined group showed a variable long-term effect. On the other hand, pre-sleep arousal at nighttime, dysfunctional beliefs about sleep as well as daytime functioning in the CBT group not only improved, but was better than in the other active treatment groups. CONCLUSION: Medication and Combined therapy produced a short-term effect on chronic insomnia while CBT had a long-term effect of improved sleep-related psychological activity and daytime functioning.     

Clinical Management of Insomnia with Brief Behavioral Treatment (BBTI)

Insomnia is a highly prevalent and debilitating sleep disorder. It is well documented that psychological treatments, including cognitive-behavioral therapy for insomnia (CBTI), are efficacious treatments, with effect sizes of comparable magnitude to that of pharmacologic treatment. However, a critical shortage of specialty-trained clinicians with experience in sleep medicine and cognitive-behavioral therapy principles has limited the widespread dissemination of CBTI. A brief (four sessions; two of which may be phone sessions) treatment, titled "Brief Behavioral Treatment for Insomnia" (BBTI), was developed to address many of the barriers to widespread dissemination associated with standard CBTI. Specifically, BBTI has an explicit behavioral focus, is overtly linked to a physiological model of sleep regulation, and utilizes a hardcopy workbook that facilitates its concise delivery format and ease of training clinicians. BBTI has demonstrated efficacy in treating older adults with insomnia ( Buysse et al., 2011 ). This article describes the rationale for the development of BBTI, provides a session-by-session guide to the delivery of the treatment, and concludes with a discussion of contraindications, combined pharmacotherapy treatment, and future directions for the use of BBTI in diverse populations and utilizing different modalities of delivery.     

Treatment of insomnia in adults and children: a practice-friendly review of research

Chronic insomnia affects nearly 16% of adults and up to 25% of children. Many clinicians are unfamiliar with the research and practice of psychological treatments of insomnia and thus do not use them with their patients. The primary goals of this article were to (a) review the research support for psychological treatments of adult and child insomnia, and (b) describe those treatments with the highest level of research support in enough detail to allow practitioners to begin to utilize them with their own patients. The adult psychological treatments with the best research support are stimulus control, progressive muscle relaxation, and multimodal cognitive-behavioral therapy, followed by multimodal behavioral therapy, sleep restriction, biofeedback, and paradoxical intention. The child psychological treatments with the highest level of research support are preventive parent education, unmodified extinction, and extinction with parental presence, followed by graduated extinction, bedtime fading/positive routines, and scheduled awakenings.     

Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations

Forty-five adults with primary insomnia received cognitive-behavioral therapy (CBT) implemented in a group therapy format, in individual face-to-face therapy or through brief individual telephone consultations. The results indicate that CBT was effective in improving sleep parameters with all 3 methods of treatment implementation, and there was no significant difference across methods of implementation. All 3 treatment modalities produced improvements in sleep that were maintained for 6 months after treatment completion. These results suggest that group therapy and telephone consultations represent cost-effective alternatives to individual therapy for the management of insomnia.     

Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report

Insomnia is highly prevalent, has associated daytime consequences which impair job performance and quality of life, and is associated with increased risk of comorbidities including depression. These practice parameters provide recommendations regarding behavioral and psychological treatment approaches, which are often effective in primary and secondary insomnia. These recommendations replace or modify those published in the 1999 practice parameter paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature since 1999 and to grade the evidence regarding non-pharmacological treatments of insomnia. Recommendations were developed based on this review using evidence-based methods. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Psychological and behavioral interventions are effective in the treatment of both chronic primary insomnia (Standard) and secondary insomnia (Guideline). Stimulus control therapy, relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of chronic insomnia (Standard) and sleep restriction therapy, multicomponent therapy (without cognitive therapy), biofeedback and paradoxical intention are individually effective therapies in the treatment of chronic insomnia (Guideline). There was insufficient evidence to recommend sleep hygiene education, imagery training and cognitive therapy as single therapies or when added to other specific approaches. Psychological and behavioral interventions are effective in the treatment of insomnia in older adults and in the treatment of insomnia among chronic hypnotic users (Standard).     

Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia

STUDY OBJECTIVE: Insomnia impacts the course of major depressive disorder (MDD), hinders response to treatment, and increases risk for depressive relapse. This study is an initial evaluation of adding cognitive behavioral therapy for insomnia (CBTI) to the antidepressant medication escitalopram (EsCIT) in individuals with both disorders. DESIGN AND SETTING: A randomized, controlled, pilot study in a single academic medical center. PARTICIPANTS: 30 individuals (61% female, mean age 35 +/- 18) with MDD and insomnia. INTERVENTIONS: EsCIT and 7 individual therapy sessions of CBTI or CTRL (quasi-desensitization). Measurements and results: Depression was assessed with the HRSD17 and the depression portion of the SCID, administered by raters masked to treatment assignment, at baseline and after 2, 4, 6, 8, and 12 weeks of treatment. The primary outcome was remission of MDD at study exit, which required both an HRSD17 score < or =7 and absence of the 2 core symptoms of MDD. Sleep was assessed with the insomnia severity index (ISI), daily sleep diaries, and actigraphy. EsCIT + CBTI resulted in a higher rate of remission of depression (61.5%) than EsCIT + CTRL (33.3%). EsCIT + CBTI was also associated with a greater remission from insomnia (50.0%) than EsCIT + CTRL (7.7%) and larger improvement in all diary and actigraphy measures of sleep, except for total sleep time. CONCLUSIONS: This pilot study provides evidence that augmenting an antidepressant medication with a brief, symptom focused, cognitive-behavioral therapy for insomnia is promising for individuals with MDD and comorbid insomnia in terms of alleviating both depression and 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。     

Telehealth‐delivered CBT‐I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: A pilot randomized controlled trial

Cognitive behavioural therapy for insomnia is the recommended treatment for chronic insomnia. However, up to a quarter of patients dropout from cognitive behavioural therapy for insomnia programmes. Acceptance, mindfulness and values‐based actions may constitute complementary therapeutic tools to cognitive behavioural therapy for insomnia. The current study sought to evaluate the efficacy of a remotely delivered programme combining the main components of cognitive behavioural therapy for insomnia (sleep restriction and stimulus control) with the third‐wave cognitive behavioural therapy acceptance and commitment therapy in adults with chronic insomnia and hypnotic dependence on insomnia symptoms and quality of life. Thirty‐two participants were enrolled in a pilot randomized controlled trial: half of them were assigned to a 3‐month waiting list before receiving the four “acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia” treatment sessions using videoconference. The primary outcome was sleep quality as measured by the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. All participants also filled out questionnaires about quality of life, use of hypnotics, depression and anxiety, acceptance, mindfulness, thought suppression, as well as a sleep diary at baseline, post‐treatment and 6‐month follow‐up. A large effect size was found for Insomnia Severity Index and Pittsburgh Sleep Quality Index, but also daytime improvements, with increased quality of life and acceptance at post‐treatment endpoint in acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants. Improvement in Insomnia Severity Index and Pittsburgh Sleep Quality Index was maintained at the 6‐month follow‐up. Wait‐list participants increased their use of hypnotics, whereas acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants evidenced reduced use of them. This pilot study suggests that web‐based cognitive behavioural therapy for insomnia incorporating acceptance and commitment therapy processes may be an efficient option to treat chronic insomnia and hypnotic dependence.     

Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review

This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.     

Self-efficacy and adherence to cognitive-behavioral treatment of insomnia

This study describes a self-efficacy (SE) scale and examines its usefulness in predicting adherence to cognitive-behavioral therapy (CBT) of insomnia. The SE scale, which included three subscales (global, task-related, and self-regulation), was administered to 39 patients receiving CBT for primary insomnia. Participants'daily sleep diaries were used to estimate their adherence to treatment. The results showed that the SE scale has adequate psychometric properties. Treatment adherence increased from Week 2 to Week 7 and decreased during the week following the last therapy session. In general, the global self-efficacy measure was more strongly associated with adherence during the first week of treatment, whereas the task-related efficacy was more strongly associated with adherence behaviors from Weeks 4 to 8. These findings suggest that self-efficacy perceptions are useful in predicting adherence to CBT of insomnia.     

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.