Cognitive behavioural therapy for insomnia (CBT-I) in schizophrenia and schizoaffective disorder: protocol for a randomised controlled trial.

INTRODUCTION: Insomnia is a common symptom among patients with schizophrenia and schizoaffective disorder, negatively impacting symptom severity, functioning and well-being; however, it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy (CBT-I). There is some evidence that CBT-I can also be used to treat insomnia in patients with schizophrenia, but only a few randomised controlled trials (RCTs) have been published. The aim of this ongoing RCT is to determine whether we can alleviate symptoms of insomnia and improve the quality of life in patients with schizophrenia and schizoaffective disorder through CBT-I delivered via the internet or in a group mode. METHODS AND ANALYSES: The aim of this study is to recruit 84-120 outpatients from the Psychosis Clinics of Helsinki University Hospital and the City of Helsinki Health Services. The main inclusion criteria are a diagnosis of schizophrenia or schizoaffective disorder and self-reported sleep problems. The study will be performed on a cyclic basis, with a target of 12-24 patients per cycle. Participants are randomly assigned into three groups: (1) a group receiving only treatment as usual (TAU), (2) internet-based individual therapy for insomnia (iCBT-I)+TAU or (3) group therapy for insomnia (GCBT-I) conducted via a virtual platform+TAU. The primary outcome measures are quantitative changes in the Insomnia Severity Index score and/or changes in health-related quality of life using the 15D quality of life measure. Secondary outcomes include self-reported variables for sleep, health, stress and the severity of psychotic and depressive symptoms; objective outcomes include actigraphy and bed sensor data to evaluate circadian rhythms and motor activity. Outcome measures are assessed at baseline and after the treatment period at weeks 12, 24 and 36. ETHICS AND DISSEMINATION: The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, approved the study protocol. The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04144231.

Psychological Treatment of Comorbid Insomnia and Depression: A Double-Blind Randomized Placebo-Controlled Trial.

INTRODUCTION: Insomnia and depression are highly prevalent disorders and commonly occur together. Cognitive behavioral therapy for insomnia, CBT-I, has been shown to be effective in treating insomnia and also comorbid depression. However, it is unclear whether effects of CBT-I on depression are specific or nonspecific. Also, depressive symptoms often remain too high after CBT-I, indicating a need for improved treatments. The objective was to determine whether combining CBT-I with CBT for depression, without increasing treatment length, reduces both insomnia and depression more than CBT for depression with a placebo insomnia intervention. METHODS: A 12-week double-blind randomized controlled trial with a 6-month follow-up in a psychiatric setting using therapist-guided internet-delivered treatments was conducted. Patients (N = 126) were diagnosed with insomnia disorder and major depression by physicians. Primary outcome measures were as follows: self-rating scales Insomnia Severity Index (ISI) and Montgomery-Åsberg Depression Rating Scale (MADRS-S). RESULTS: The combined treatment showed specific effects on insomnia severity over the control treatment (p = 0.007) but was not more effective in reducing depression severity. Within-group effects (Cohen's d) at post and at 6 months were as follows: ISI 1.40 and 1.42 (combined treatment), 0.95 and 1.00 (control); MADRS-S 0.97 and 1.12 (combined), 0.88 and 0.89 (control). CONCLUSIONS: CBT-I shows large specific effects on insomnia severity and is superior to control in this regard. Both treatments had similar effects on depression severity, i.e., combining CBT-I with CBT for depression did not enhance outcomes on depression compared to control. We suggest CBT-I should always be offered to patients with insomnia and depression comorbidity, possibly as the first-hand choice. Combining it with a psychological treatment for depression could be too burdening and may not be beneficial.

The Polysomnographical Meaning of Changed Sleep Quality-A Study of Treatment with Reduced Time in Bed.

BACKGROUND: Reports of poor sleep are widespread, but their link with objective sleep (polysomnography-PSG) is weak in cross-sectional studies. In contrast, the purpose of this study was to investigate the association between changes in subjective and objective sleep variables using data from a study of the reduction in time in bed (TIB). METHODS: One sleep recording was carried out at baseline and one at treatment week 5 (end of treatment) (N = 34). RESULTS: The Karolinska Sleep Quality Index improved and was correlated with improvement in sleep efficiency (r = 0.41, p < 0.05) and reduction in TIB (r = -0.47, p < 0.01) and sleep latency (r = 0.36, p < 0.05). The restorative sleep index showed similar results. Improvements in the insomnia severity index (ISI) essentially lacked correlations with changes in the PSG variables. It was suggested that the latter may be due to the ISI representing a week of subjective sleep experience, of which a single PSG night may not be representative. CONCLUSIONS: It was concluded that changes in the subjective ratings of sleep are relatively well associated with changes in the PSG-based sleep continuity variables when both describe the same sleep.

Training of professionals in cognitive behavioural therapy for insomnia - A systematic review of peer-reviewed studies.

Insomnia is common, and causes substantial individual suffering and costs for society. The recommended first-line treatment is cognitive behavioural therapy for insomnia (CBT-I), which is under-used partly due to a lack of trained providers. To train providers is thus important, but what is the current situation regarding CBT-I training? A systematic search of databases was conducted to identify scientific peer-reviewed papers describing CBT-I training with regards to: existing amounts of training, proposed curricula, trainees, delivery context, content of training, modes of delivery, evaluation of the training from a trainee perspective, and effects on patients. This systematic review shows that research on training in CBT-I is an emerging field, with the literature presenting a limited number of papers, with varying objectives. One group of papers investigate the amount of training that exists in a region or educational context and/or propose training curricula; and another group evaluate training initiatives and describe CBT-I training trainees, context, content, modes of delivery, and outcomes on trainees and on treated patients. The studies show that little training is currently provided and proposed curricula vary, and evaluations present promising results: training is feasible in different contexts and modes, digital training may be used to disseminate training efforts at a large scale, trainees' skills increase and positive effects on patients can be seen. To move the field forward, more high-quality studies on CBT-I training are needed, and we propose that training in CBT-I should be targeted towards varying levels of expertise, matching a stepped-care model.

Clinical feasibility of cognitive behavioural therapy for insomnia in a real-world mixed sample at a specialized psychiatric outpatient clinic.

BACKGROUND: A majority of psychiatric patients suffer from insomnia or insomnia-like problems. In addition to impairing quality of life, sleep problems can worsen psychiatric conditions, such as depression and anxiety, and can make treatment of various psychiatric conditions less successful. Several international guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first line treatment. However, patients in psychiatric care are rarely offered this treatment, and there is a lack of studies evaluating the treatment in regular psychiatric settings. In this pilot study, we aimed to determine the clinical feasibility of a group-based CBT-I intervention in an outpatient clinical setting for patients with depression, bipolar disorder, anxiety disorders and PTSD. We also aimed to investigate if symptoms of insomnia, depression and anxiety changed after CBT-I. METHODS: Seventeen patients at an out-patient psychiatric clinic for mixed psychiatric problems of anxiety, affective disorders and PTSD, were enrolled in a six-week long group-based CBT-I intervention. Primary outcomes were pre-defined aspects of treatment feasibility. Secondary outcomes were changes in self-reported symptoms of insomnia severity, depression, and anxiety between pre - and post intervention. Assessment of insomnia severity was also performed 3 months after treatment. Feasibility data is reported descriptively, changes in continuous data from pre- to post-treatment were analysed with dependent t-tests. RESULTS: All feasibility criteria were met; there were enough patients to sustain at least one group per semester (e.g., minimum 8), 88% of included patients attended the first session, mean of attended sessions was 4.9 of 6, and drop-out rate was 5.9%. Therapists, recruited from clinical staff, found the treatment manual credible, and possible to use at the clinic. Symptoms of insomnia decreased after treatment, as well as symptoms of depression and anxiety. CONCLUSION: CBT-I could prove as a clinically feasible treatment option for insomnia in a psychiatric outpatient setting. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT05379244. Retrospectively registered 18/05/2022.

Clinically sufficient classification accuracy and key predictors of treatment failure in a randomized controlled trial of Internet-delivered Cognitive Behavior Therapy for Insomnia.

Background: In Adaptive Treatment Strategies, each patient's outcome is predicted early in treatment, and treatment is adapted for those at risk of failure. It is unclear what minimum accuracy is needed for a classifier to be clinically useful. This study aimed to establish a empirically supported benchmark accuracy for an Adaptive Treatment Strategy and explore the relative value of input predictors. Method: Predictions from 200 patients receiving Internet-delivered cognitive-behavioral therapy in an RCT was analyzed. Correlation and logistic regression was used to explore all included predictors and the predictive capacity of different models. Results: The classifier had a Balanced accuracy of 67 %. Eleven out of the 21 predictors correlated significantly with Failure. A model using all predictors explained 56 % of the outcome variance, and simpler models between 16 and 47 %. Important predictors were patient rated stress, treatment credibility, depression change, and insomnia symptoms at week 3 as well as clinician rated attitudes towards homework and sleep medication. Conclusions: The accuracy (67 %) found in this study sets a minimum benchmark for when prediction accuracy could be clinically useful. Key predictive factors were mainly related to insomnia, depression or treatment involvement. Simpler predictive models showed some promise and should be developed further, possibly using machine learning methods.

Effects of cognitive behavioral therapy for insomnia (CBT-I) on quality of life: A systematic review and meta-analysis.

The effects of cognitive behavioral therapy for insomnia (CBT-I) have consistently been shown to improve insomnia symptoms and other health-related outcomes, but the effects on QoL have been inconsistent. Many factors including the type CBT-I delivery and type of instrument used to assess QoL make the topic complex. The present systematic review and meta-analysis synthesized the evidence of CBT-I efficacy on QoL outcomes across different populations, delivery modes, and methodological aspects. Following the guidelines on preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a literature search was conducted through PubMed, Web of Science, Scopus, and PsycINFO using keywords from relevant MeSH terms based on PICOS (Participants, Intervention, Comparison, Outcome and Study) criteria. Clinical trials investigating the effect of CBT-I as an intervention on QoL with any kind of control group were eligible if they reported mean scores and variation of QoL. Meta-analysis using a random-effect model was conducted to calculate the standardized mean differences (SMDs) in a set including all identified studies, as well as in three sub-sets: face-to-face CBT-I using randomized controlled trials (RCTs), online CBT-I using RCTs, and one-group pre- and post-treatment design. A total of 24 studies comprising 1977 participants (808 in an intervention group) from 12 countries were eligible for meta-analysis. The overall pooled estimate of SMD of QoL when all 24 studies were included was 0.47 (95% CI: 0.22; 0.72; I2 = 84.5%; tau2 = 0.31; p < 0.001). The overall pooled estimate of SMD of QoL was 0.46 (95% CI: 0.01-0.90; I2 = 87.5%; tau2 = 0.48, p < 0.001) for intervention groups with face-to-face CBT-I compared to controls; 0.47 (95% CI: 0.02-0.92; I2 = 88.3%; tau2 = 0.36; p = 0.04) for intervention groups with digital CBT-I compared to controls, and 0.46 (95% CI: 0.12-0.80; I2 = 52.9%; tau2 = 0.07; p = 0.08) for one-group pre- and post-comparison using CBT-I intervention compared to baseline. Moreover, effects of CBT-I on QoL were different across populations (pooled SMD = 0.59 for patients with insomnia; 0.29 for patients with insomnia comorbid with another major disorder; and 0.48 for other conditions) and types of QoL instruments (pooled SMD = 0.36 for disease-specific QoL instrument not on insomnia, 0.43 for generic QoL instrument, and 0.67 for a single-QoL-item instrument). The probability of publication bias was ruled out in overall and design specific sub-group analysis based on funnel plot and Egger's test. In conclusion, this meta-analysis confirmed a moderate, overall effect of CBT-I in improving QoL. However, due to small power and heterogeneity, future studies are needed to better explore the impact of moderating factors such as mode of delivery and type of QoL measure for assessment used.

Very long-term outcome of cognitive behavioral therapy for insomnia: one- and ten-year follow-up of a randomized controlled trial.

Insomnia is a common and chronic disorder, and cognitive behavioral therapy (CBT) is the recommended treatment. Very long-term follow-ups of CBT are very rare, and this study aimed to investigate if improvements were stable one and ten years after CBT for insomnia (CBT-i). Based on a three-armed randomized controlled trial of bibliotherapeutic CBT-i, participants received an insomnia-specific self-help book and were randomized to therapist guidance, no guidance, or a waitlist receiving unguided treatment after a delay. Six weeks of treatment was given to 133 participants diagnosed with insomnia disorder. After one and ten years, participants were assessed with self-reports and interviews. Improvements were statistically significant and well maintained at one- and ten-year follow-ups. Average Insomnia Severity Index score [95%CI] was 18.3 [17.7-18.8] at baseline, 10.1 [9.3-10.9] at post-treatment, 9.2 [8.4-10.0] at one- and 10.7 [9.6-11.8] at ten-year follow-up, and 64% and 66% of participants no longer fulfilled criteria for an insomnia diagnosis at one and ten years, respectively. Positive effects of CBT were still present after ten years. Insomnia severity remained low, and two-thirds of participants no longer fulfilled criteria for an insomnia diagnosis. This extends previous findings of CBT, further confirming it as the treatment of choice for insomnia.

Large-scale implementation of insomnia treatment in routine psychiatric care: patient characteristics and insomnia-depression comorbidity.

Treating comorbid insomnia is important for recovery from, and prevention of, depression. The objective of this study was to compare comorbidity and patient characteristics among patients having treatment for depression before and after implementation of cognitive behavioural therapy for insomnia (CBT-I) in a routine care internet treatment clinic. We hypothesized that insomnia comorbidity would be lower among patients having treatment for depression after the treatment for insomnia became available, and that depression levels would be high among patients in the insomnia treatment group compared to previous studies of insomnia. Patients were assessed face-to-face by physicians and guided through internet-delivered treatment by psychologists in a psychiatric setting. We retrieved patient data from 3 years before and 3 years after the CBT-I implementation. Measures were the Montgomery-Åsberg Depression Rating Scale-Self rated (MADRS-S) and Insomnia Severity Index (ISI). Pretreatment symptom levels were high in both the depression (MADRS-S = 23, n = 1467) and insomnia treatment (ISI = 20, n = 552) groups, indicating a true psychiatric sample. Contrary to the hypothesis, there were no significant changes in the group having treatment for depression regarding insomnia severity or comorbid insomnia diagnosis (from 66% to 68%) after CBT-I implementation. Also contrary to the hypothesis, comorbid depression levels among insomnia patients having CBT-I were similar to or slightly higher than in previous studies. It is likely that more patients with this comorbidity, who currently receive treatment for depression, would benefit from CBT-I. We suggest an emphasis on information on the benefits of CBT-I among patients and clinical staff involved in the implementation of treatments for insomnia in psychiatry, and further research into possible differences between patients actively seeking treatment for insomnia or depression.

Initial Low Levels of Suicidal Ideation Still Improve After Cognitive Behavioral Therapy for Insomnia in Regular Psychiatric Care.

Insomnia disorder is highly prevalent, and has been identified as a risk factor for many psychiatric problems, including depression, suicide ideation and suicide death. Previous studies have found that cognitive behavioral therapy for insomnia (CBT-I) reduce depression and suicidal ideation in samples with high levels of suicidal ideation. This study aims to investigate associations of CBT-I with suicidal ideation in a sample of 522 patients primarily seeking internet-delivered treatment for insomnia in regular psychiatric care. The sample had high pretreatment insomnia severity levels and a relatively high level of comorbid depression symptoms. Suicidal ideation levels were relatively low pretreatment but still improved significantly after CBT-I. Contrary to previous findings, the strongest predictor of changes in suicidal ideation were improvements in depressive symptoms, rather than improvements in insomnia. We conclude that suicidal ideation may not be a major problem in these patients primarily seeking treatment for insomnia, despite comorbid depressive symptoms, but that suicidal ideation still improves following CBT-i. Considering the increased risk for patients with untreated insomnia to develop depression, this finding is of interest for prevention of suicidal ideation.

An investigation and replication of sleep-related cognitions, acceptance and behaviours as predictors of short- and long-term outcome in cognitive behavioural therapy for insomnia.

The objectives were to investigate the potential for sleep-related behaviours, acceptance and cognitions to predict outcome (insomnia severity) of cognitive behavioural therapy for insomnia (CBT-I). Baseline and outcome data from four randomised controlled trials (n = 276) were used. Predictors were the Dysfunctional Beliefs and Attitudes about Sleep-10 (DBAS-10), Sleep-Related Behaviours Questionnaire (SRBQ), and Sleep Problems Acceptance Questionnaire (SPAQ), and empirically derived factors from a factor analysis combining all items at baseline (n = 835). Baseline values were used to predict post-treatment outcome, and pre-post changes in the predictors were used to predict follow-up outcomes after 3-6 months, 1 year, or 3-10 years, measured both as insomnia severity and as better or worse long-term sleep patterns. A majority (29 of 52) of predictions of insomnia severity were significant, but when controlling for insomnia severity, only two (DBAS-10 at short-term and SRBQ at mid-term follow-up) of the 12 predictions using established scales, and three of the 40 predictions using empirically derived factors, remained significant. The strongest predictor of a long-term, stable sleep pattern was insomnia severity reduction during treatment. Using all available predictors in an overfitted model, 21.2% of short- and 58.9% of long-term outcomes could be predicted. We conclude that although the explored constructs may have important roles in CBT-I, the present study does not support that the DBAS-10, SRBQ, SPAQ, or factors derived from them, would be unique predictors of outcome.

A very brief self-report scale for measuring insomnia severity using two items from the Insomnia Severity Index - development and validation in a clinical population.

OBJECTIVE: To develop a very brief scale with selected items from the Insomnia Severity Index (ISI), and to investigate the psychometric properties of the proposed scale in a psychiatric sample. METHODS: Patient data from seven Cognitive Behavioral Therapy (CBT) for insomnia trials and from regular care were used in psychometric analyses (N = 280-15 653). The samples included patients screening (N = 6936) or receiving treatment (N = 1725) for insomnia and other psychiatric conditions. Six criteria relating to component structure, sensitivity to change and clinical representativeness were used to select items. Psychometric analyses for the proposed very brief scale were performed. RESULTS: One item representing satisfaction/dissatisfaction with current sleep pattern and one item representing interferences with daily functioning, were selected to create the 2-item ISI version. Correlations with the full scale were high at screening, pre and post, and for change (0.82-0.94). Categorical omega was ⍵C = 0.86. With a cut-off of 6 points, the scale could detect Insomnia Disorder with a sensitivity of 84% and a specificity of 76%, which was close to the full ISI showing 86% and 80% respectively. CONCLUSIONS: The systematic psychometric evaluation based on a large sample from different contexts makes the proposed 2-item ISI version (ISI-2) a strong candidate for a very brief scale measuring insomnia, both for detecting cases and for measuring change during CBT with an overall high discriminative validity. ISI-2 is especially useful in clinical settings or population studies where there is a need to measure more than one condition at a time without overburdening patients. CLINICAL TRIALS: Trials used in this analysis: ClinicalTrials.gov identifier: NCT01105052 (https://www.clinicaltrials.gov/ct2/show/NCT01105052) (sample b), ClinicalTrials.gov identifier: NCT01256099 (https://clinicaltrials.gov/ct2/show/NCT01256099) (sample c and d), German clinical trial (DRKS), registration ID: DRKS00008745 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008745) (sample e), ClinicalTrials.gov identifier: NCT01663844 (https://clinicaltrials.gov/ct2/show/NCT01663844) (sample f and g), ClinicalTrials.gov Identifier: NCT02743338 (https://clinicaltrials.gov/ct2/show/NCT02743338) (sample h).

Sleep During Pelvic-Abdominal Radiotherapy for Cancer: A Longitudinal Study With Special Attention to Sleep in Relation to Nausea and Quality of Life.

BACKGROUND: Poor sleep, nausea, psychological distress, and a lowered quality of life are common during radiotherapy for cancer. There is a lack of studies on the relationship between radiotherapy-induced nausea and sleep. This longitudinal study analyzes data from 196 patients who underwent pelvic-abdominal radiotherapy for cancer. OBJECTIVE: The aim of this study was to investigate sleep parameters weekly before, during, and after radiotherapy in relation to nausea and other patient characteristics, clinical characteristics, psychological distress, and quality of life. METHODS: Patients (n = 196, 84% women; mean age, 63 years; 68% had gynecological tumor, 28% had colorectal tumor, and 4% had other tumors) longitudinally answered questionnaires before, during, and after their radiotherapy over the abdominal and pelvic fields. RESULTS: Poor sleep was experienced by 30% of the participants, and sleep (quality and difficulty falling asleep) improved during and after treatment compared with baseline. Experiencing nausea during treatment was associated with worse sleep quality during radiotherapy. Baseline anxiety was associated with worse sleep quality before, during, and after treatment. Poor sleep was associated with worse quality of life. CONCLUSION: Nausea, more than a number of other variables, is a possible predictor of poor sleep in patients during radiotherapy for cancer. IMPLICATIONS FOR PRACTICE: The results indicate that effectively managing nausea may be important for sleep quality, and possibly quality of life, in patients undergoing radiotherapy for cancer. More research is needed before recommendations for practice can be made.

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.

Predicting treatment failure in regular care Internet-Delivered Cognitive Behavior Therapy for depression and anxiety using only weekly symptom measures.

OBJECTIVE: Therapist guided Internet-Delivered Cognitive Behavior Therapy (ICBT) is effective, but as in traditional CBT, not all patients improve, and clinicians generally fail to identify them early enough. We predict treatment failure in 12-week regular care ICBT for Depression, Panic disorder and Social anxiety disorder, using only patients' weekly symptom ratings to identify when the accuracy of predictions exceed 2 benchmarks: (a) chance, and (b) empirically derived clinician preferences for actionable predictions. METHOD: Screening, pretreatment and weekly symptom ratings from 4310 regular care ICBT-patients from the Internet Psychiatry Clinic in Stockholm, Sweden was analyzed in a series of regression models each adding 1 more week of data. Final score was predicted in a holdout test sample, which was then categorized into Success or Failure (failure defined as the absence of both remitter and responder status). Classification analyses with Balanced Accuracy and 95% Confidence intervals was then compared to predefined benchmarks. RESULTS: Benchmark 1 (better than chance) was reached 1 week into all treatments. Social anxiety disorder reached Benchmark 2 (> 65%) at week 5, whereas Depression and Panic Disorder reached it at week 6. CONCLUSIONS: For depression, social anxiety and panic disorder, prediction with only patient-rated symptom scores can detect treatment failure 6 weeks into ICBT, with enough accuracy for a clinician to take action. Early identification of failing treatment attempts may be a viable way to increase the overall success rate of existing psychological treatments by providing extra clinical resources to at-risk patients, within a so-called Adaptive Treatment Strategy. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment.

Insomnia, the most prevalent sleep disorder worldwide, confers marked risks for both physical and mental health. Furthermore, insomnia is associated with considerable direct and indirect healthcare costs. Recent guidelines in the US and Europe unequivocally conclude that cognitive behavioural therapy for insomnia (CBT-I) should be the first-line treatment for the disorder. Current treatment approaches are in stark contrast to these clear recommendations, not least across Europe, where, if any treatment at all is delivered, hypnotic medication still is the dominant therapeutic modality. To address this situation, a Task Force of the European Sleep Research Society and the European Insomnia Network met in May 2018. The Task Force proposed establishing a European CBT-I Academy that would enable a Europe-wide system of standardized CBT-I training and training centre accreditation. This article summarizes the deliberations of the Task Force concerning definition and ingredients of CBT-I, preconditions for health professionals to teach CBT-I, the way in which CBT-I should be taught, who should be taught CBT-I and to whom CBT-I should be administered. Furthermore, diverse aspects of CBT-I care and delivery were discussed and incorporated into a stepped-care model for insomnia.

Development of a very brief scale for detecting and measuring panic disorder using two items from the Panic Disorder Severity Scale-Self Report.

OBJECTIVE: To minimize the burden in detecting and monitoring Panic Disorder and Agoraphobia by developing a very brief scale with selected items from the Panic Disorder Severity Scale-Self Report (PDSS-SR), and to investigate the proposed scale's psychometric properties in a comorbid sample. METHODS: A sample of 5103 patients from the Internet Psychiatry Clinic in Sweden, diagnosed and treated with Internet-based cognitive behavioral therapy for panic disorder (n = 1390), social anxiety disorder (n = 1313) or depression (n = 2400), responded to the PDSS-SR. Six criteria related to factor structure, sensitivity to change and clinical representativeness were used to select items. Psychometric analyses for the selected very brief scale were performed. RESULTS: Items 2 (distress during panic attacks) and 4 (agoraphobic avoidance), were selected to create the very brief PDSS-SR version. Correlations with the full scale were high at screening, pre and post, and for change (0.87-0.93). Categorical Omega was ⍵C = 0.74. With a cut-off of 3 points, the scale could detect panic disorder in a psychiatric sample with a sensitivity of 85% and a specificity of 66%. LIMITATIONS: Limitations include lack of healthy controls and lack of blinding on secondary outcome measures. CONCLUSION: The proposed 2-item PDSS-SR version is a good candidate for a very brief panic disorder questionnaire, both for detecting cases and for measuring change. This is especially useful in clinical settings when measuring more than one condition at a time.

Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients.

OBJECTIVE: This study aimed to demonstrate proof of concept for an adaptive treatment strategy in Internet-delivered cognitive-behavioral therapy (ICBT), where risk of treatment failure is assessed early in treatment and treatment for at-risk patients is adapted to prevent treatment failure. METHODS: A semiautomated algorithm assessed risk of treatment failure early in treatment in 251 patients undergoing ICBT for insomnia with therapist guidance. At-risk patients were randomly assigned to continue standard ICBT or to receive adapted ICBT. The primary outcome was self-rated insomnia symptoms using the Insomnia Severity Index in a linear mixed-effects model. The main secondary outcome was treatment failure (having neither responded nor remitted at the posttreatment assessment). RESULTS: A total of 102 patients were classified as at risk and randomly assigned to receive adapted ICBT (N=51) or standard ICBT (N=51); 149 patients were classified as not at risk. Patients not at risk had significantly greater score reductions on the Insomnia Severity Index than at-risk patients given standard ICBT. Adapted ICBT for at-risk patients was significantly more successful in reducing symptoms compared with standard ICBT, and it decreased the risk of failing treatment (odds ratio=0.33). At-risk patients receiving adapted ICBT were not more likely to experience treatment failure than those not at risk (odds ratio=0.51), though they were less likely to experience remission. Adapted treatment required, on average, 14 more minutes of therapist-patient time per remaining week. CONCLUSIONS: An adaptive treatment strategy can increase treatment effects for at-risk patients and reduce the number of failed treatments. Future studies should improve accuracy in classification algorithms and identify key factors that boost the effect of adapted treatments.

The effects of component-specific treatment compliance in individually tailored internet-based treatment.

The objective of this study was to explore the effects of treatment compliance in a guided individually tailored internet-based treatment (TAIL) in relation to depression and co-morbid symptoms. Compliance with the homework in the different treatment components in TAIL, each aimed at a specific condition, was rated for 207 participants by independent assessors. Six subgroups (n = 34-131) were constructed consisting of participants with co-occurring symptoms of worry, panic, social anxiety, stress, insomnia, or pain. For each group, hierarchical regression was used to investigate whether the total sum of compliance points, Overall Compliance, predicted reductions in depression and in condition-specific symptoms. Also, in each subgroup, it was tested whether working with specific treatment components, Specific Compliance, predicted reduction of the targeted symptoms. Overall Compliance predicted 15% of the reduction in depression symptoms. For participants with worry, panic, social anxiety, stress, or insomnia, Overall Compliance also predicted symptom reductions in that specific condition. Specific Compliance predicted reduction in the targeted symptoms for participants with social anxiety, stress, and insomnia. Specific Compliance with stress and insomnia components also predicted reductions in depression. Our results strengthen the importance of compliance in internet-based treatments. Because compliance with stress and insomnia components was particularly important for broad symptom reductions, these conditions should not be ignored when treating patients with co-morbid symptoms.

Effectiveness of guided Internet-delivered treatment for major depression in routine mental healthcare - An open study.

Depression is one of the most prevalent mental health disorders and is estimated to become the leading cause of disability worldwide by 2030. Increasing access to effective treatment for depression is a major societal challenge. In this context, the increasing use of computers in the form of laptops or smartphones has made it feasible to increase access to mental healthcare through digital technology. In this study, we examined the effectiveness of a 14-week therapist-guided Internet-delivered program for patients with major depression undergoing routine care. From 2015 to 2018, 105 patients were included in the study. For depressive symptoms, we identified significant within-group effect sizes (post-treatment: d = 0.96; 6-month follow-up: d = 1.21). We also found significant effects on secondary anxiety and insomnia symptoms (d = 0.55-0.92). Clinically reliable improvement was reported by 48% of those undergoing the main parts of the treatment, whereas 5% of the participants reported a clinically significant deterioration. However, a large proportion of patients showed no clinically reliable change. In summary, the study identified large treatment effects, but also highlighted room for improvement in the usability of the treatment.