OBJECTIVES: To compare patients treated with cognitive behavioral therapy for insomnia (CBT-I) with healthy sleepers and individuals with past but not current insomnia on multidimensional sleep health. METHODS: The study evaluates CBT-I on six dimensions of sleep health (regularity, satisfaction, alertness, timing, efficiency, duration) in a sample of individuals with insomnia compared to two other unique sleep samples. Participants were in one of three groups: insomnia (CUR, n = 299), healthy sleeper (HS, n = 122), or past insomnia (PAST, n = 35). Daily diaries and validated measures were employed to capture six dimensions of sleep health. The CUR group received four 60-minute sessions of CBT-I every 2weeks, and sleep health indices were measured at baseline and post-treatment. The HS and PAST groups were measured only at baseline. RESULTS: Results of the pairwise t tests indicated improvements in sleep satisfaction, alertness (fatigue but not sleepiness), timing, efficiency, and duration (Cohen's d=0.22 to 1.55). ANCOVA models revealed significant differences in sleep health scores between treated insomnia patients and the other two sleep groups. Treated patients demonstrated less bedtime and risetime variability, in addition to lower napping duration. Overall, the study observed significant changes in various domains of sleep health after four sessions of cognitive behavioral therapy for insomnia; however, differences remain when compared to the other groups in the study. CONCLUSION: There may be ongoing sleep vulnerability in patients treated with cognitive behavioral therapy for insomnia though future inclusion of a control group would increase internal validity. Borrowing from transdiagnostic sleep modules may be helpful to support remaining deficits after cognitive behavioral therapy for insomnia.
The potential efficacy of psychosocial interventions in the treatment of borderline personality disorder (BPD) is impacted by significant treatment non-completion (TNC), with meta-analytic studies reporting rates of attrition of between 25% and 28%. Increasing patient retention could facilitate outcomes and improve resource utilization, given limited healthcare services. A systematic search of PsycINFO, CINAHL, EMBASE, CENTRAL, and Web of Science Core Collection identified 33 articles that met the criteria for inclusion. Although substantial heterogeneity in terms of methodology and quality of analysis limited conclusions that could be drawn in the narrative review, a few consistent patterns of findings were elucidated, such as Cluster B personality disorder comorbidities and lower therapeutic alliance were associated with TNC. Interestingly, the severity of BPD symptoms was not a predictor of TNC. These findings are discussed in terms of their potential theoretical contribution to TNC. Clinically, there may be value in applying mindfulness and motivational interviewing strategies early on in treatment for individuals who present uncertainty about engaging in treatment. Further research to develop this empirical landscape includes focusing on high-powered replications, examining burgeoning lines of research, and investigating dynamic predictors of TNC.
High school students suffer from mental health challenges and poorer academic performance resulting from sleep disturbances. Unfortunately, approaches to this problem sometimes focus on increasing sleep duration by going to bed early; a strategy with limited success because teens experience a phase delay in bedtimes. There is a need for approaches that leverage behavioural sleep science and are accessible, scalable, and easily disseminated to students. DOZE (Delivering Online Zzz's with Empirical Support) is a self-management app that is grounded in sleep and circadian basic science. Although initial testing supports it as a feasible and acceptable app in a research context, it has not been tested as a strategy to use in schools. The present study tested DOZE in private high schools in Canada. Two-hundred and twenty-three students downloaded the app and completed daily sleep diaries over 4 weeks. Students reported a more regularised routine for bedtime, Mdiff = -0.43 h, p < 0.001, 95% CI [-0.65, -0.21], and rise time, Mdiff = -0.61 h, p < 0.001, 95% CI [-0.84, -0.38], in addition to a higher total sleep time, Mdiff = 0.18 h, p < 0.008, 95% CI [0.05, 0.31]. Students also rated DOZE to be highly acceptable. The evidence suggests that students find DOZE to be acceptable and engagement in this nonclinical population was reasonably high under minimal researcher supervision. This makes DOZE an attractive option and a step towards broad-based sleep health services. High powered replications with control groups are needed to increase empirical rigour.
BACKGROUND: Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia that also improves non-sleep symptoms, such as mood and anxiety. Identifying sleep-specific variables that predict anxiety change after CBT-I treatment may support alternative strategies when people with generalized anxiety disorder (GAD) do not improve from standard GAD treatment. AIMS: To investigate CBT-I on changes in anxiety and evaluate whether changes in sleep-specific variables predict anxiety outcomes. METHODS: Seventy-two participants presenting with insomnia and GAD (GAD-I) completed four sessions of CBT-I. Participants completed daily diaries and self-report measures at baseline and post-treatment. RESULTS: CBT-I in a co-morbid GAD-I sample was associated with medium reductions in anxiety, and large reductions in insomnia severity. Subjective insomnia severity and tendencies to ruminate in response to fatigue predicted post-treatment anxiety change, in addition to younger age and lower baseline anxiety. CONCLUSIONS: The findings suggest that younger GAD-I participants with moderate anxiety symptoms may benefit most from the anxiety-relieving impact of CBT-I. Reducing perceived insomnia severity and the tendency to ruminate in response to fatigue may support reductions in anxiety in those with GAD-I.
OBJECTIVES: Identifying those who are most (and least) likely to benefit from a stepped-care approach to cognitive behavioral therapy for insomnia (CBT-I) increases access to insomnia therapies while minimizing resource consumption. The present study investigates non-targeted factors in a single-session of CBT-I that may act as barriers to early response and remission. METHODS: Participants (N = 303) received four sessions of CBT-I and completed measures of subjective insomnia severity, fatigue, sleep-related beliefs, treatment expectations, and sleep diaries. Subjective insomnia severity and sleep diaries were completed between each treatment session. Early response was defined as a 50% reduction in Insomnia Severity Index (ISI) scores and early remission was defined by < 10 on the ISI after the first session. RESULTS: A single-session of CBT-I significantly reduced subjective insomnia severity scores and diary total wake time. Logistic regression models indicated that lower baseline fatigue was associated with increased odds of early remission (B = -.05, p = .02), and lower subjective insomnia severity (B = -.13, p = .049). Only fatigue was a significant predictor of early treatment response (B = -.06, p = .003). CONCLUSIONS: Fatigue appeared to be an important construct that dictates early changes in perceived insomnia severity. Beliefs about the relationship between sleep and daytime performance may hinder perceived improvements in insomnia symptoms. Incorporating fatigue management strategies and psychoeducation about the relationship between sleep and fatigue may target non-early responders. Future research would benefit from further profiling potential early insomnia responders/remitters.
Cognitive Behavioral Therapy , Sleep Initiation and Maintenance Disorders , Humans , Sleep Initiation and Maintenance Disorders/therapy , Sleep/physiology , Fatigue/therapy , Treatment Outcome
BACKGROUND: Rumination is strongly associated with depressive symptom severity and course. However, changes in rumination during outpatient cognitive behavioral therapy (CBT), and their links to baseline features such as distress tolerance and clinical outcomes, have received limited attention. METHODS: 278 outpatients with depression received group or individual CBT. Measures of rumination, distress tolerance, and depression symptom severity were assessed at baseline and periodically during treatment. Mixed effect and regression-based models evaluated changes over time, and associations between rumination, distress tolerance and depression severity. RESULTS: Depression and rumination decreased throughout acute treatment. Rumination reduction was concurrently associated with depressive symptom reduction. Lower levels of rumination at each time point prospectively predicted lower depressive symptoms at the next time point. Distress tolerance measured at baseline was positively associated with depression symptom severity; the indirect effect on post-treatment depression symptoms via rumination measured mid-treatment was nonsignificant when rumination at baseline was accounted for. Changes in and associations between depression and rumination were replicated in sensitivity analyses; although changes in depression and rumination were smaller in magnitude in patients receiving treatment during COVID-19. LIMITATIONS: Additional assessment points would permit a more nuanced assessment of the role rumination may play in mediating the associations between distress tolerance and depression severity. Additional investigation of treatments in community settings may also further our understanding of variability in rumination during depression treatment. CONCLUSIONS: The current study provides unique real-world support for variability in rumination as a key indicator of change over the course of CBT for depression.
COVID-19 , Cognitive Behavioral Therapy , Humans , Depression/therapy , Depression/psychology , Tertiary Healthcare , Outpatients
STUDY OBJECTIVE: Cognitive Behavioral Insomnia Therapy (CBT-I) is the gold standard insomnia treatment and the Insomnia Severity Index (ISI) is a frequently used treatment outcome measure. The ISI has strong psychometric properties and is purported to measure perceived insomnia symptom severity. However, little is known about the factors that drive insomnia severity perception and the psychometric properties of the ISI post-CBT-I. METHODS: Participants were treatment-seeking adults meeting DSM-5 Insomnia Disorder criteria (n = 203, ages 18-77, M = 45.95 years). Participants completed sleep and mood questionnaires, including the ISI, pre- and post-CBT-I. They completed daily Consensus Sleep Diaries each morning throughout two pre-treatment weeks, eight weeks of treatment and two weeks post-treatment. A hierarchical regression analysis examined what predicted post-CBT-I ISI scores and Cronbach's alpha was computed to examine post-treatment reliability of the ISI. RESULTS: The regression analysis revealed that lower post-treatment ISI scores were associated with lower pre-treatment ISI, and greater decreases in fatigue and generalized anxiety symptoms. The model did not significantly improve when pre-treatment sleep effort or changes in sleep diary indices were added. The post-treatment ISI Cronbach's alpha was .88. CONCLUSIONS: Although the ISI has been shown to have sound psychometric properties, clinicians should consider that post CBT-I ISI scores are not related to their sleep improvements. Instead, they seem to be related to whether patients perceive themselves as poor sleepers pre-treatment and whether they felt less tired and anxious after CBT-I. Researchers should consider the impact of factors other than sleep when using the ISI at post-treatment. Patients are telling us that CBT-I should focus on addressing symptoms of fatigue and general anxiety; perhaps CBT-I could be improved further to address these concerns more effectively. SUMMARY: This investigation shows that when individuals are rating their symptom severity after CBT-I, they are also integrating how they felt before treatment and whether they experienced a change in their fatigue or anxiety.
Sleep Initiation and Maintenance Disorders , Adult , Humans , Adolescent , Young Adult , Middle Aged , Aged , Sleep Initiation and Maintenance Disorders/therapy , Reproducibility of Results , Sleep , Treatment Outcome , Fatigue , Cognition
OBJECTIVES: Providers of Cognitive-Behavioral Therapy for Insomnia (CBT-I) are often asked whether the behavioral recommendations (e.g., stimulus control, sleep restriction) must be adhered to ad infinitum. We examined whether changes in sleep habits/behaviors are a life sentence, or whether patients who remit can relax their adherence while maintaining their treatment gains at 1-year follow-up (FU). METHODS: Participants (N = 179) completed 2 weeks of sleep diaries and measures of insomnia severity and safety behaviors at baseline and following four sessions of CBT-I. Of the 137 patients that achieved remission, 77 completed these measures at 1-year FU. RESULTS: Improvements in insomnia severity and total wake time (TWT) at post-treatment were maintained at FU (ps ≥ .52). Similarly, reductions in safety behaviors were maintained at FU (p - 1.00), whereas lingering in bed reduced during treatment (p < .001) but increased at FU (p < .001). Changes in sleep habits after treatment did not predict insomnia severity at FU. However, increases in time in bed positively predicted TWT at FU (p = .001). CONCLUSIONS: Those who remit after CBT-I may generally relax their adherence to behavioral recommendations without significantly impacting their perceived insomnia symptoms 1 year after treatment despite some increases in TWT. Results increase our confidence in CBT-I as a brief and durable intervention.
Cognitive Behavioral Therapy , Sleep Initiation and Maintenance Disorders , Humans , Sleep Initiation and Maintenance Disorders/therapy , Treatment Outcome , Sleep , Cognitive Behavioral Therapy/methods
