Sleep restriction therapy may be effective for people with insomnia and depressive complaints: evidence from a case series.

BACKGROUND: Insomnia and depression are clearly interrelated. Several studies showed that treating insomnia with cognitive behavioural therapy positively affects concurrent depressive symptoms. However, it is unclear what treatment component is responsible for the change in depressive symptoms. AIMS: To develop the evidence base we employed a case series design in which we administered a single component sleep restriction treatment to individuals with both insomnia and depressive symptoms. METHOD: Seven patients were included, of whom six completed the intervention. Patients completed weekly assessments during the 4-week wait period and 6-week treatment phase. RESULTS: At the post-assessment, two out of six patients showed clinical improvement in depressive symptoms. All six patients showed clinically meaningful improvement at the 3-month follow-up assessment, and two patients had maintained gains at 6-month follow-up. CONCLUSIONS: This case series study shows that, especially at 3-month follow-up, sleep restriction therapy is associated with clinically relevant treatment gains in patients with both insomnia and depressive symptoms.

Does online insomnia treatment reduce depressive symptoms? A randomized controlled trial in individuals with both insomnia and depressive symptoms.

BACKGROUND: Insomnia is effectively treated with online Cognitive Behavioral Therapy for Insomnia (CBT-I). Previous research has suggested the effects might not be limited to sleep and insomnia severity, but also apply to depressive symptoms. Results, however, are mixed. METHODS: In this randomized controlled trial we investigated the effects of guided online CBT-I on depression and insomnia in people suffering from symptoms of both. Participants (n = 104) with clinical insomnia and at least subclinical depression levels were randomized to (1) guided online CBT-I and sleep diary monitoring (i-Sleep) or (2) control group (sleep diary monitoring only). The primary outcome was the severity of depressive symptoms (Patient Health Questionnaire-9 without sleep item; PHQ-WS). Secondary outcomes were insomnia severity, sleep diary parameters, fatigue, daytime consequences of insomnia, anxiety, and perseverative thinking. RESULTS: At post-test, participants in the i-Sleep condition reported significantly less depressive symptoms (PHQ-WS) compared with participants in the sleep-diary condition (d = 0.76). Large significant effects were also observed for insomnia severity (d = 2.36), most sleep diary parameters, daytime consequences of insomnia, anxiety, and perseverative thinking. Effects were maintained at 3 and 6 month follow-up. We did not find significant post-test effects on fatigue or total sleep time. CONCLUSIONS: Findings indicate that guided online CBT-I is not only effective for insomnia complaints but also for depressive symptoms. The effects are large and comparable with those of depression therapy. CLINICAL TRIAL REGISTRATION NUMBER: NTR6049 (Netherlands Trial Register).

[Nightmares: prevalence and treatment in secondary mental healthcare]. / Nachtmerries: prevalentie en behandeling in de specialistische ggz.

BACKGROUND: Nightmares are highly prevalent in the general population (2-8%) and are associated with mental problems. As a result, nightmares are likely to be more prevalent among patients in secondary mental healthcare. They can be treated with 'imagery rehearsal therapy' (IRT). With IRT the scenario of a recurring nightmare is changed, after which the 'new dream' is imagined several times a day.
AIM: To assess the prevalence of nightmares and their associated problems in secondary mental healthcare and to find out whether IRT is also effective in patients with diverse mental disorders.
METHOD: A patient group was asked about their nightmares at the start of their treatment in secondary mental healthcare. Another group of patients with nightmares received six sessions with IRT in addition to their conventional treatment and the results were compared to a group of patients that had only received conventional treatment.
RESULTS: 30% patients had severe nightmares and had higher mental distress than patients without nightmares. With IRT there was a reduction in both the number and intensity of nightmares and the psychiatric symptoms.
CONCLUSION: Nightmares are an underestimated problem for patients with diverse psychiatric disorders in secondary mental healthcare. However, nightmares can also be treated effectively with IRT in this population.

Guided Internet-delivered cognitive behavioural treatment for insomnia: a randomized trial.

BACKGROUND: Insomnia is a prevalent problem with a high burden of disease (e.g. reduced quality of life, reduced work capacity) and a high co-morbidity with other mental and somatic disorders. Cognitive behavioural therapy (CBT) is effective in the treatment of insomnia but is seldom offered. CBT delivered through the Internet might be a more accessible alternative. In this study we examined the effectiveness of a guided Internet-delivered CBT for adults with insomnia using a randomized controlled trial (RCT). METHOD: A total of 118 patients, recruited from the general population, were randomized to the 6-week guided Internet intervention (n = 59) or to a wait-list control group (n = 59). Patients filled out an online questionnaire and a 7-day sleep diary before (T0) and after (T1) the 6-week period. The intervention group received a follow-up questionnaire 3 months after baseline (T2). RESULTS: Almost three-quarters (72.9%) of the patients completed the whole intervention. Intention-to-treat (ITT) analysis showed that the treatment had statistically significant medium to large effects (p < 0.05; Cohen's d between 0.40 and 1.06), and resulted more often in clinically relevant changes, on all sleep and secondary outcomes with the exception of sleep onset latency (SOL) and number of awakenings (NA). There was a non-significant difference in the reduction in sleep medication between the intervention (a decrease of 6.8%) and control (an increase of 1.8%) groups (p = 0.20). Data on longer-term effects were inconclusive. CONCLUSIONS: This study adds to the growing body of literature that indicates that guided CBT for insomnia can be delivered through the Internet. Patients accept the format and their sleep improves.

Do better nights lead to better days? Guided internet-based cognitive behavioral therapy for insomnia in people suffering from a range of mental health problems: Protocol of a pragmatic randomized clinical trial.

BACKGROUND: Insomnia is the transdiagnostically shared most common complaint in disorders of anxiety, stress and emotion regulation. Current cognitive behavioral therapies (CBT) for these disorders do not address sleep, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of CBT. This transdiagnostic randomized control trial (RCT) evaluates whether guided internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) (1) improves sleep, (2) affects the progression of emotional distress and (3) enhances the effectiveness of regular treatment of people with clinically relevant symptoms of emotional disorders across all mental health care (MHC) echelons. METHODS: We aim for 576 completers with clinically relevant symptoms of insomnia as well as at least one of the dimensions of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), posttraumatic stress disorder (PTSD) or borderline personality disorder (BPD). Participants are either pre-clinical, unattended, or referred to general- or specialized MHC. Using covariate-adaptive randomization, participants will be assigned to a 5 to 8-week iCBT-I (i-Sleep) or a control condition (sleep diary only) and assessed at baseline, and after two and eight months. The primary outcome is insomnia severity. Secondary outcomes address sleep, severity of mental health symptoms, daytime functioning, mental health protective lifestyles, well-being, and process evaluation measures. Analyses use linear mixed-effect regression models. DISCUSSION: This study can reveal for whom, and at which stage of disease progression, better nights could mean substantially better days. TRIAL REGISTRATION: International Clinical Trial Registry Platform (NL9776). Registered on 2021-10-07.

Network Intervention Analyses of cognitive therapy and behavior therapy for insomnia: Symptom specific effects and process measures.

Cognitive therapy (CT) and behavior therapy (BT) are both effective for insomnia. In this study we applied Network Intervention Analysis to investigate specific effects of CT and BT on outcomes and process measures. The analysis was based on a randomized controlled trial comparing CT (n = 65), BT (n = 63) and cognitive behavioral therapy for insomnia (n = 60; not included in this study). In the first networks, the separate items of the Insomnia Severity Index and sleep efficiency were included. In the second networks, the pre-specified process measures for BT and CT, sleep efficiency, and the sum-score of the Insomnia Severity Index were included. At the different time points, we found CT-effects on worry, impaired quality of life, dysfunctional beliefs, and monitoring sleep-related threats, and BT-effects on sleep efficiency, difficulty maintaining sleep, early morning awakening, time in bed, sleep incompatible behaviors and bed- and rise time variability. These observed effects of CT and BT were consistent with their respective theoretical underpinnings. This study provided new information on the mechanisms of change in CT and BT. In the future, this may guide us to the most effective treatment modules or even subsets of interventions.

Re-evaluating randomized clinical trials of psychological interventions: Impact of response shift on the interpretation of trial results.

BACKGROUND: Effectiveness of psychological treatment is often assessed using patient-reported health evaluations. However, comparison of such scores over time can be hampered due to a change in the meaning of self-evaluations, called 'response shift'. Insight into the occurrence of response shift seems especially relevant in the context of psychological interventions, as they often purposefully intend to change patients' frames of reference. AIMS: The overall aim is to gain insight into the general relevance of response shift for psychological health intervention research. Specifically, the aim is to re-analyse data of published randomized controlled trials (RCTs) investigating the effectiveness of psychological interventions targeting different health aspects, to assess (1) the occurrence of response shift, (2) the impact of response shift on interpretation of treatment effectiveness, and (3) the predictive role of clinical and background variables for detected response shift. METHOD: We re-analysed data from RCTs on guided internet delivered cognitive behavioural treatment (CBT) for insomnia in the general population with and without elevated depressive symptoms, an RCT on meaning-centred group psychotherapy targeting personal meaning for cancer survivors, and an RCT on internet-based CBT treatment for persons with diabetes with elevated depressive symptoms. Structural equation modelling was used to test the three objectives. RESULTS: We found indications of response shift in the intervention groups of all analysed datasets. However, results were mixed, as response shift was also indicated in some of the control groups, albeit to a lesser extent or in opposite direction. Overall, the detected response shifts only marginally impacted trial results. Relations with selected clinical and background variables helped the interpretation of detected effects and their possible mechanisms. CONCLUSION: This study showed that response shift effects can occur as a result of psychological health interventions. Response shift did not influence the overall interpretation of trial results, but provide insight into differential treatment effectiveness for specific symptoms and/or domains that can be clinically meaningful.

Cognitive processes mediate the effects of insomnia treatment: evidence from a randomized wait-list controlled trial.

INTRODUCTION: Both guided online and individual face-to-face cognitive behavioral therapy for insomnia (CBT-I) are effective in improving insomnia symptoms and sleep efficiency. Little is known about the underlying mechanisms generating this effect. The present study tests the assumption that pre-sleep arousal, sleep-related worry and dysfunctional beliefs about sleep are mediators in the effect of cognitive behavioral treatment for insomnia. METHODS: A secondary analysis was performed on data previously collected from a randomized controlled trial (N = 90). In this trial, participants were randomized to either a face-to-face CBT-I condition, an internet-delivered CBT-I condition, or a wait-list group. This article reports on the efficacy of these interventions on pre-sleep arousal, sleep-related worry, and dysfunctional beliefs. Furthermore, we investigated whether these measures mediated the treatment effect on insomnia severity and sleep efficiency. RESULTS: Both treatment modalities were efficacious for these cognitive measures; however, face-to-face treatment showed superiority over the online treatment. All three cognitive measures mediated the effect on insomnia severity. Sleep-related worry and pre-sleep arousal mediated the effect on sleep efficiency, but dysfunctional beliefs did not. CONCLUSION: Overall, these results point toward the importance of cognitive processes in the treatment of insomnia, implying that psychological treatments for insomnia may best be guided by (also) targeting these cognitive processes.