Self-guided online cognitive behavioural therapy for insomnia: A naturalistic evaluation in patients with potential psychiatric comorbidities.

BACKGROUND: Insomnia is the most prevalent sleep disorder worldwide, and regularly co-occurs with anxiety and depression. Cognitive behavioural therapy is the gold standard treatment for insomnia (CBT-I), however demand for treatment providers drastically exceeds supply. Internet-delivered programs for insomnia (iCBT-I) improve treatment access. However the effects of unguided iCBT-I for individuals with comorbidities within a naturalistic setting remains unexplored. We developed a novel unguided iCBT-I program and evaluated its impact on insomnia, psychological distress, and wellbeing when accessed by the public. METHODS: 317 participants experiencing insomnia for over 3 months enrolled in the program. The program consisted of 4 lessons delivered online with automated web support. Insomnia symptoms, psychological distress, and general wellbeing were assessed at lesson 1 and 4. Intention-to-treat linear mixed models were used to examine effects on insomnia, distress, and wellbeing. RESULTS: Participants experienced large (g = 1.11) and significant reductions in insomnia, moderate (g = 0.55) and significant reductions in distress, and small (g = 0.37) but significant improvements in wellbeing. 65% of participants who reported pre-treatment insomnia severity at clinical levels remitted following treatment. LIMITATIONS: To examine the program in a naturalistic setting, we did not employ a control group or follow participants beyond the completion of treatment. CONCLUSIONS: Unguided iCBT-I is effective for individuals in the community who experience insomnia and are likely experiencing comorbid mental health problems. These effects in the absence of guided contact strengthen the utility of unguided iCBT-I as a scalable and cost-effective method of disseminating treatments for this disorder.

The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models.

Research in developmental psychopathology and clinical staging models has increasingly sought to identify trans-diagnostic biomarkers or neurocognitive deficits that may play a role in the onset and trajectory of mental disorders and could represent modifiable treatment targets. Less attention has been directed at the potential role of cognitive-emotional regulation processes such as ruminative response style. Maladaptive rumination (toxic brooding) is a known mediator of the association between gender and internalizing disorders in adolescents and is increased in individuals with a history of early adversity. Furthermore, rumination shows moderate levels of genetic heritability and is linked to abnormalities in neural networks associated with emotional regulation and executive functioning. This review explores the potential role of rumination in exacerbating the symptoms of alcohol and substance misuse, and bipolar and psychotic disorders during the peak age range for illness onset. Evidence shows that rumination not only amplifies levels of distress and suicidal ideation, but also extends physiological responses to stress, which may partly explain the high prevalence of physical and mental co-morbidity in youth presenting to mental health services. In summary, the normative developmental trajectory of rumination and its role in the evolution of mental disorders and physical illness demonstrates that rumination presents a detectable, modifiable trans-diagnostic risk factor in youth.