We know CBT-I works, now what?

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be efficacious and now is considered the first-line treatment for insomnia for both uncomplicated insomnia and insomnia that occurs comorbidly with other chronic disorders (comorbid insomnia). The purposes of this review are to provide a comprehensive summary of the efficacy data (for example, efficacy overall and by clinical and demographic considerations and by CBT-I formulation) and to discuss the future of CBT-I (for example, what next steps should be taken in terms of research, dissemination, implementation, and practice)

Why Treat Insomnia?

“Why treat insomnia?” This question grows out of the perspective that insomnia is a symptom that should only receive targeted treatment when temporary relief is needed or until more comprehensive gains may be achieved with therapy for the parent or precipitating medical or psychiatric disorders. This perspective, however, is untenable given recent data regarding the prevalence, course, consequences, and costs of insomnia. Further, the emerging data that the treatment of insomnia may promote better medical and mental health (alone or in combination with other therapies) strongly suggests that the question is no longer “why treat insomnia,” but rather “when isn’t insomnia treatment indicated?” This perspective was recently catalyzed with the American College of Physicians’ recommendation that chronic insomnia should be treated and that the first line treatment should be cognitive-behavioral therapy for insomnia (CBT-I)

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.Peer reviewe

Are sleep continuity disturbance and fatigue prodromal symptoms of cancer development?

Sleep continuity disturbance (also known as insomnia) and fatigue are common complaints of individuals diagnosed with cancer. Traditionally, many have believed that sleep continuity disturbance and fatigue are caused, in large measure, by the impact of the cancer diagnosis and treatment. Recent prospective research suggests however, that sleep continuity disturbance and fatigue may actually precede a cancer diagnosis. We suggest that sleep continuity disturbance and fatigue may in fact represent prodromal symptoms of cancer. We review the current perspectives of this sequence of events and present a revised schematic that accounts for the role of biological, behavioural, and cognitive factors that contribute to the development and maintenance of sleep continuity disturbances in cancer patients. Monitoring emergent and unexplained patient-reported fatigue, sleepiness, and insomnia may serve as early warning signs of new onset cancer, providing opportunity for early detection and early intervention

0348 Cognitive Behavioral Therapy for Insomnia in African Americans: A Pilot Study

Abstract Introduction Co-morbid sleep continuity disturbance (SCD) and insufficient sleep duration (ISD) disproportionately affect the sleep health of Black Americans (BA). Simultaneously, treating SCD and ISD may improve health and reduce disparities experienced by this community. Although standard cognitive behavioral therapy for insomnia (CBT-I) ranges from six to eight sessions and directly addresses SCD, standard CBT-I does not appreciably increase total sleep time (TST) and therefore does not adequately address ISD during treatment. This report presents the overall study outcomes of CBT-I (without respect to dose of CBT-I) in BA. Methods Twelve BA adults (83% female, Mage 46.0±13.9yrs) were recruited from the Philadelphia area. CBT-I was provided by one of four master CBT-I therapists via telehealth for up to 16 sessions. Two follow-up assessments were conducted at 3 and 6 months. Participants completed daily measures of sleep continuity (sleep diaries) and weekly measures of insomnia severity (ISI). Results Overall, 75% of participants exhibited a treatment response corresponding to a reduction of 58% (effect size [ES]=-2.3) on the ISI. With respect to sleep continuity (measured in minutes), there was a 61% (ES=-1.4) reduction in sleep latency (30.1 to 11.8), 76% (ES=-1.7) reduction in wake-after-sleep onset (32.4 to 7.8), 81% (ES=-1.2) reduction in early morning awakenings (32.2 to 6.3), 7% (ES=0.3) increase in TST (381.3 to 408.0), a 9% (ES=-0.6) reduction in time in bed (476.0 to 433.7), and an overall 16% (ES=2.9) improvement in sleep efficiency. Conclusion Results from this pilot study indicate that standard CBT-I produces robust effects in BA with insomnia. Analyses are ongoing and will examine group interactions and treatment durability at follow-up. Support (if any) K24AG05560

0412 Long-Term Treatment Outcomes for CBT-I in Black Americans: 3 & 6-Months Pilot Study Results

Abstract Introduction In the US, Black Americans (BA) are disproportionately impacted by sleep continuity disturbance (SCD; i.e. insomnia) and insufficient sleep duration (ISD; i.e., standard 8) will effectively address ISD. This study evaluates insomnia severity and sleepiness outcomes at 3- and 6- months post CBT-I treatment follow-ups. Methods Twelve BA adults (83% female, Mage 46.0±13.9yrs) were recruited from the Philadelphia area to receive CBT-I treatment by a master CBT-I therapist via telehealth for up to 16 sessions. Participants completed daily measures of sleep continuity (sleep diaries) and weekly measures of insomnia severity. Follow-up assessments were conducted at 3 and 6 months. Descriptive statistics are provided to show change in insomnia severity and sleepiness from baseline to post, baseline to 3-months and baseline to 6 months among the sample. Analyses were conducted using SPSSv27. Results Overall, on average, insomnia severity was reduced by 58% (effect size [ES]=1.3) at post, 61% (ES=1.8) at 3 months, and 67% at 6 months (ES=1.9). For sleepiness, on average, severity was reduced by 18% (ES=.2) at post, increased to 38% (ES=.7) at 3 months, and reduced to 28% (ES=.4) at 6 months. Conclusion Results from this pilot study indicate that standard CBT-I may produce robust effects. Reductions in insomnia severity and sleepiness remained durable at 6 months follow-up. Future studies with larger sample sizes are needed to explore further the use of CBT-I to treat sleep health problems in BA. Support (if any) K24AG055602; T32HL166609-0

Cognitive Behavioral Therapy for Insomnia in Posttraumatic Stress Disorder: A Randomized Controlled Trial

Study objectivesExamine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning.DesignRANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control.SettingDepartment of Veterans Affairs (VA) Medical Center.ParticipantsForty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females).InterventionsEight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist.Measurements and resultsMeasures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares.ConclusionsCognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine.Clinical trial informationTRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647.Registration numberNCT00881647

The natural history of insomnia: Does sleep extension differentiate between those that do and do not develop chronic insomnia?

According to the “3P model” of insomnia, the variable that mediates the transition from acute insomnia (AI) to chronic insomnia is “sleep extension” (the behavioural tendency to expand sleep opportunity to compensate for sleep loss). In the present analysis, we sought to evaluate how time in bed (TIB) varies relative to the new onset of AI and chronic insomnia. A total of 1,248 subjects were recruited as good sleepers (GS). Subjects were monitored over 1 year with sleep diaries. State transitions were defined, a priori, for AI, recovered from AI (AI-REC), and for chronic insomnia (AI-CI). Two additional groupings were added based on profiles that were unanticipated: subjects that exhibited persistent poor sleep following AI (AI-PPS [those that neither recovered or developed chronic insomnia]) and subjects that recovered from chronic insomnia (CI-REC). All the groups (GS, AI-REC, AI–CI, AI-PPS and CI-REC) were evaluated for TIB differences with longitudinal mixed effects models. Post hoc analyses for the percentage of the groups that were typed as TIB “restrictors, maintainers, and expanders” were conducted using longitudinal mixed effects models and contingency analyses. Significant differences for pre–post AI TIB were not detected for the insomnia groups. Trends were apparent for the AI-CI group, which suggested that minor increases in TIB occurred weeks before the declared onset of AI. Additionally, it was found that a significantly larger percentage of AI-CI subjects engaged in sleep extension (as compared to GS). The present data suggest that transition from AI to chronic insomnia does not appear to be initiated by sleep extension and the transition may occur before the elapse of 3 months of ≥3 nights of sleep continuity disturbance. Given these findings, it may be that the mismatch between sleep ability and sleep opportunity is perpetuated over time given the failure to “naturally” engage in sleep restriction (as opposed to sleep extension). © 2021 European Sleep Research Society12 month embargo; first published: 14 April 2021This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]