Internet-Based Treatment for Insomnia: A Controlled Evaluation.

This study investigated the effects of an Internet-based intervention for insomnia. Participants who met criteria for insomnia (N = 109) were randomly assigned to either a cognitive-behavioral self-help treatment or a waiting list control condition. The 5-week intervention mainly consisted of sleep restriction, stimulus control, and cognitive restructuring. Sleep diary data were collected for 2 weeks at baseline and at posttreatment. The dropout rate was 24% (n = 28). Results showed statistically significant improvements in the treatment group on many outcome measures, including total sleep time, total wake time in bed, and sleep efficiency. However, improvements were also found in the control group. Overall, between-groups effect sizes were low, with the exception of the Beliefs and Attitudes About Sleep Scale (Cohen's d = .81). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-Behavioral Therapy for Insomnia: Comparison of Individual Therapy, Group Therapy, and Telephone Consultations.

Forty-five adults with primary insomnia received cognitive-behavioral therapy (CBT) implemented in a group therapy format, in individual face-to-face therapy or through brief individual telephone consultations. The results indicate that CBT was effective in improving sleep parameters with all 3 methods of treatment implementation, and there was no significant difference across methods of implementation. All 3 treatment modalities produced improvements in sleep that were maintained for 6 months after treatment completion. These results suggest that group therapy and telephone consultations represent cost-effective alternatives to individual therapy for the management of insomnia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A cognitive-behavioral therapy for sleep-maintenance insomnia in older adults.

Older adults (3 men, 4 women, aged 55–68 yrs) with chronic sleep-maintenance insomnia were treated sequentially with relaxation therapy (RXT) and then with a cognitive-behavioral therapy (CBT) specifically designed for alleviating sleep maintenance problems. Sleep diaries and an objective measure of sleep, the sleep assessment device, showed only modest improvements in measures of wake time after sleep onset, sleep efficiency, and night-to-night sleep variability following RXT. However, significant improvements in these measures were observed following CBT and at a 3-mo follow-up. These findings, considered in conjunction with previous reports, suggest that CBT specifically addresses factors that sustain sleep maintenance complaints. Additional trials of CBT with larger samples are warranted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-help treatment for insomnia: Bibliotherapy with and without professional guidance.

Fifty-four adults with primary insomnia were randomly assigned to a self-help treatment (cognitive-behavioral bibliotherapy [BT]), BT with weekly phone consultations, or a waiting-list control (WL) group. Treated participants were mailed 6 treatment booklets at the rate of 1 booklet per week; 1/2 of them also received minimal professional guidance through a 15-min weekly phone consultation. The WL group members continued to monitor their sleep during this period. Participants in both treatment conditions improved significantly on the main outcome variables (total wake time and sleep efficiency) at posttreatment, whereas WL participants remained unchanged. The addition of weekly phone calls slightly enhanced improvements at posttreatment. However, both treatment conditions were comparable at follow-up. These results suggest that BT, with or without minimal professional guidance, is an effective approach for treating primary insomnia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavior therapy for late-life insomnia.

24 older adults with persistent psychophysiological insomnia were randomly assigned to an immediate or a delayed cognitive-behavioral intervention in a waiting-list control group design. Cognitive-behavior therapy consisted of an 8-wk group intervention aimed at changing maladaptive sleep habits and altering dysfunctional beliefs and attitudes about sleeplessness. Treatment was effective in reducing sleep latency, wake after sleep onset, and early morning awakening, and in increasing sleep efficiency. The magnitude of changes obtained on polysomnographic measures was smaller but in the same direction as that obtained on daily sleep diaries. Sleep improvements obtained by the immediate-treatment group were replicated with the delayed treatment condition. Therapeutic gains were well maintained at 3- and 12-mo follow-ups. Clinical validation of outcome was obtained through collateral ratings from the patients and their significant others. Findings indicate that late-life insomnia can be effectively treated with nonpharmacological interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer.

Prior studies have supported the efficacy of cognitive behavioral therapy (CBT) for insomnia comorbid with cancer. This article reports secondary analyses that were performed on one of these studies to investigate the predictive role of changes in dysfunctional beliefs about sleep, adherence to behavioral strategies, and some nonspecific factors on sleep changes assessed subjectively and objectively. Fifty-seven women with chronic insomnia comorbid with breast cancer received CBT for insomnia. At posttreatment, subjective sleep improvements were best predicted by higher initial levels of treatment expectancies, but also by decreased dysfunctional beliefs about sleep; the most consistent predictors of polysomnography (PSG) assessed sleep improvements were reduced dysfunctional beliefs about sleep and a higher avoidance of day napping. At 6-month follow-up, subjectively assessed sleep improvements were best predicted by adherence to behavioral strategies, whereas none of the predictors was significantly associated with PSG-assessed sleep improvements. This study gives some support to the importance of targeting erroneous beliefs about sleep and poor sleep habits in the treatment of cancer-related insomnia, but also to the importance of enhancing patients’ expectancies for improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of sleep-maintenance insomnia in older adults: Sleep period reduction, sleep education, and modified stimulus control.

We evaluated a behavioral treatment package consisting of sleep period restriction, sleep education, and modified stimulus control in the treatment of sleep-maintenance insomnia in older adults. A multiple baseline design was used with 4 chronic insomniac subjects, ages 59, 65, 65, and 72. Sleep diaries and an objective behavioral measure of sleep were used to monitor improvement. Results revealed clinically significant reductions in time awake after sleep onset in 3 subjects, coincident with the initiation of treatment. These improvements were maintained at 2- and 6-month follow-ups. The 4th subject showed little improvement; however, a polysomnogram conducted on this subject at the end of the study revealed a fragmented sleep pattern secondary to periodic movements of sleep (nocturnal myoclonus). These encouraging but preliminary results call for further controlled evaluations of the efficacy of this behavioral treatment package for sleep-maintenance insomnia. The importance of conducting polysomnographic studies on elderly insomniacs is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nonpharmacological interventions for insomnia in older adults: A meta-analysis of treatment efficacy.

The benefit of nonpharmacological interventions for insomnia in old age was investigated. A total of 13 single-outcome studies from 1966–1998 involving 388 patients (mean age exceeding 60 years, minimum age in sample, 50 years) were included in a meta-analysis of treatment efficacy. This analysis demonstrated that behavioral interventions produce improvements in sleep parameters of older insomniacs, measured in terms of sleep-onset latency, number of nocturnal awakenings, time awake after sleep onset, and total sleep time. Clinical improvements seen at posttreatment were maintained at followups (averaging 6 months). It is concluded that behavioral treatments produce significant and long-lasting improvements in the sleep pattern of older insomniacs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Placebo-Controlled Test of Cognitive-Behavioral Therapy for Comorbid Insomnia in Older Adults.

The present study tested cognitive-behavioral therapy (CBT) for insomnia in older adults with osteoarthritis, coronary artery disease, or pulmonary disease. Ninety-two participants (mean age = 69 years) were randomly assigned to classroom CBT or stress management and wellness (SMW) training, which served as a placebo condition. Compared with SMW, CBT participants had larger improvements on 8 out of 10 self-report measures of sleep. The type of chronic disease had no impact on these outcomes. The hypothesis that CBT would improve daytime functioning more than SMW was only supported by a global rating measure. These results add to findings that challenge the dichotomy between primary and secondary insomnia and suggest that psychological factors are likely involved in insomnias that are presumed to be secondary to medical conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of two behavioral treatment programs for comorbid geriatric insomnia.

Older adults with comorbid insomnia and medical illness have been excluded from behavioral treatment research, but recent evidence suggested that such treatments would be effective with this population. In this study, 38 older adults with comorbid insomnia were randomized to 1 of 3 conditions: classroom cognitive-behavioral treatment (CBT), home-based audio relaxation treatment (HART), or delayed-treatment control. Compared to the control group, the CBT group had significant changes in 5 of 7 self-report measures of sleep at the 4-month follow-up. The HART group obtained significant outcomes on 3 of 7 measures. Wrist actigraphy measures and secondary-outcome measures did not yield significant findings for either treatment. Clinically significant changes at follow-up were obtained for 54% of patients in CBT, 35% in HART, and 6% in the control group when treatment dropouts were included. Although not as effective as in-person CBT, home interventions may have utility as a first-line, low-cost treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based psychological treatments for insomnia in older adults.

The review describes evidence-based psychological treatments (EBTs) for insomnia in older adults. Following coding procedures developed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology, two treatments were found to meet EBT criteria: sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy. One additional treatment (stimulus control therapy) partially met criteria, but further corroborating studies are needed. At the present time, there is insufficient evidence to consider other psychological treatments, including cognitive therapy, relaxation, and sleep hygiene education, as stand-alone interventions beneficial for treating insomnia in older adults. Additional research is also needed to examine the efficacy of alternative-complementary therapies, such as bright light therapy, exercise, and massage. This review highlights potential problems with using coding procedures proposed in the EBT coding manual when reviewing the existing insomnia literature. In particular, the classification of older adults as persons age 60 and older and the lack of rigorous consideration of medical comorbidities warrant discussion in the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypnotic taper with or without self-help treatment of insomnia: A randomized clinical trial.

This study aimed to assess the efficacy of a minimal intervention focusing on hypnotic discontinuation and cognitive-behavioral treatment (CBT) for insomnia. Fifty-three adult chronic users of hypnotics were randomly assigned to an 8-week hypnotic taper program, used alone or combined with a self-help CBT. Weekly hypnotic use decreased in both conditions, from a nearly nightly use at baseline to less than once a week at posttreatment. Nightly dosage (in lorazepam equivalent) decreased from 1.67 mg to 0.12 mg. Participants who received CBT improved their sleep efficiency by 8%, whereas those who did not remained stable. Total wake time decreased by 52 min among CBT participants and increased by 13 min among those receiving the taper schedule alone. Total sleep time remained stable throughout withdrawal in both CBT and taper conditions. The present findings suggest that a systematic withdrawal schedule might be sufficient in helping chronic users stop their hypnotic medication. The addition of a self-help treatment focusing on insomnia, a readily available and cost-effective alternative to individual psychotherapy, produced greater sleep improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Who is a candidate for cognitive-behavioral therapy for insomnia?

Chronic insomnia impacts 1 in 10 adults and is linked to accidents, decreased quality of life, diminished work productivity, and increased long-term risk for medical and psychiatric diseases such as diabetes and depression. Recent National Institutes of Health consensus statements and the American Academy of Sleep Medicine's Practice Parameters recommend that cognitive-behavioral therapy for insomnia (CBT-I) be considered the 1st line treatment for chronic primary insomnia. Growing research also supports the extension of CBT-I for patients with persistent insomnia occurring within the context of medical and psychiatric comorbidity. In the emerging field of behavioral sleep medicine, there has yet to be a consensus point of view about who is an appropriate candidate for CBT-I and how this determination is made. This report briefly summarizes these issues, including a discussion of potential contraindications, and provides a schematic decision-to-treat algorithm. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sommeil, insomnie et psychopathologie.

Sleep plays a critical role in psychological well-being and adaptation. Not surprisingly, sleep disturbance is a frequent problem among individuals facing situational psychological difficulties as well as among those with more chronic psychopathology. This article examines the relationship among sleep, insomnia, and psychopathology. In the first section, we address the issue of comorbidity by examining prevalence rates of sleep disturbances in the general population and among subgroups of individuals with selected psychopathologies and, conversely, rates of psychological symptoms/syndromes among individuals with and without sleep disturbances. The data indicate high rates of psychological syndromes (40%) associated with insomnia among community-based samples, and even higher rates (80%) of sleep disturbances among selected samples of patients with psychopathology. Comorbidity is particularly high among patients with insomnia, major depression, and generalized anxiety disorder. Although insomnia is often a symptom of an underlying psychopathology, longitudinal studies show that it can also be an important risk factor for a new onset major depressive disorder. The second section of this article summarizes the main subjective and EEG sleep impairments in selected anxiety disorders, mood disorders, and schizophrenia. Insomnia is a common clinical feature or even a diagnostic criterion of several of those disorders. Other related symptoms such as fatigue, low energy and poor concentration are shared across insomnia, major depression, and generalized anxiety disorder, suggesting some common mechanisms among those conditions. In addition to subjective sleep complaints, there is also evidence of EEG sleep abnormalities, such as impairment of sleep continuity, reduced slow wave sleep, and altered REM sleep patterns, with the latter two features being more specific to mood disorders. The third section of this article examines the effects of insomnia treatment on co-existing psychological symptoms or disorders and, conversely, the effects of treatment of selected anxiety and mood disorders on sleep. These results indicate that treatments of depression and anxiety may produce some sleep improvements but, in many cases, residual sleep disturbances persist and may actually increase the risk of subsequent relapse. The main implication is that treatment should directly target both co-existing conditions. Additional implications for the treatment and prevention of comorbid sleep disturbances and psychopathology and for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral and cognitive treatments of geriatric insomnia.

Geriatric insomnia is a prevalent problem that has not received adequate controlled evaluation of psychological treatments. The present study evaluated behavioral and cognitive methods, relative to a wait-list control condition, for treating 27 elderly subjects (mean age?=?67 years) with sleep-maintenance insomnia. Both treatment methods, stimulus control and imagery training, produced significant improvement on the main outcome measure of awakening duration. Stimulus control yielded higher improvement rates than either imagery training or the control condition on awakening duration and total sleep-time measures. Sleep improvements were maintained by the two treatment methods at 3- and 12-month follow-ups. The results were corroborated by collateral ratings obtained from significant others. Subjective estimates of awakening duration and sleep latency correlated highly with objective measures recorded on an electromechanical timer. The findings suggest that geriatric insomnia can be effectively treated with psychological interventions and that behavioral procedures are more beneficial than cognitive procedures for sleep maintenance problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral self-control therapy for children: A components analysis.

27 non-self-controlled 8–12 yr olds (as measured by the Self-Control Rating Scale) were randomly assigned to a cognitive-behavioral treatment, a behavioral treatment, or an attention-control condition. Ss were administered the Peabody Picture Vocabulary Test, Matching Familiar Figures Test, Piers-Harris Children's Self-Concept Scale, and Wide Range Achievement Test. All Ss received 12 sessions of individual therapist contact focusing on psychoeducational, play, and interpersonal tasks and situations, with the cognitive-behavioral treatment including self-instructional training via modeling and behavioral contingencies and the behavioral treatment involving modeling and contingencies. The cognitive-behavioral intervention improved teachers' blind ratings of self-control, and both the cognitive-behavioral and behavioral treatments improved teachers' blind ratings of hyperactivity. Several performance measures (cognitive style, academic achievement) showed improvements for the cognitive-behavioral and behavioral conditions, whereas only the cognitive-behavioral treatment improved children's self-concept. Normative comparisons and 10-wk follow-up provided additional support for the efficacy of the cognitive-behavioral treatment; 1-yr follow-up did not show significant differences across conditions. (35 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral treatment of chronic insomnia in psychiatrically ill patients

BACKGROUND: Psychiatric patients often have residual intractable insomnia as a serious problem. METHOD: Forty-eight psychiatrically ill patients (DSM-IV diagnoses) who had failed to respond to medicinal treatment for chronic insomnia were referred for and completed behavioral therapy as an adjunct to the pharmacologic treatment of their insomnia. The behavioral treatments included structured sleep hygiene, progressive muscle relaxation, stimulus control, and sleep restriction. The treatment program was accomplished in 6 sessions over 2 months. Follow-up evaluations were completed at 2, 6, and 12 months from the beginning of the treatment program. The outcome of the treatment program was evaluated in terms of the change in (1) self-reported specific sleep parameters, (2) self-ratings of sleep-related day-time state, (3) self-rating of quality of sleep, (4) the use of sleep medication, and (5) the therapist's global rating of improvement. RESULTS: There was a statistically significant change from the baseline in all self-reported specific sleep parameters after 2 months that was sustained after 6 and 12 months. Sleep-related characteristics of daytime state showed statistically significant changes after 2 and 6 months that were maintained after 12 months. Sleep quality had a statistically significant change after 2 months, continued to improve statistically after 6 months, and was maximum after 12 months. Over half the patients (52.7%; 20 of 38) either reduced their sleep medication by half or stopped it completely. The therapist's global rating showed an improvement in 29.2% (N = 14) of patients after 2 months, 56.2% (N = 27) after 6 months, and 68.7% (N = 33) after 12 months. CONCLUSION: The use of concomitant behavioral and pharmacologic treatment of chronic insomnia in psychiatrically ill patients results in improving sleep and sleep-related state and reduces the risk of return of insomnia for 10 months after finishing active treatment.     

Cognitive–behavioral treatment of insomnia secondary to chronic pain.

Sixty participants with insomnia secondary to chronic pain were assigned randomly to either a cognitive–behavioral therapy (CBT) or a self-monitoring/waiting-list control condition. The therapy consisted of a multicomponent 7-week group intervention aimed at promoting good sleep habits, teaching relaxation skills, and changing negative thoughts about sleep. Treated participants were significantly more improved than control participants on self-report measures of sleep onset latency, wake time after sleep onset, sleep efficiency, and sleep quality, and they showed less motor activity in ambulatory recordings of nocturnal movement. At a 3-month follow-up assessment, treated participants showed good maintenance of most therapeutic gains. These results provide the 1st evidence from a randomized controlled trial that CBT is an effective treatment for insomnia that is secondary to chronically painful medical conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relaxation treatment for insomnia: A component analysis.

Compared 4 relaxation treatments—progressive relaxation, progressive relaxation without tension release, imagery with tension release, and imagery without tension release—for sleep onset insomnia with a waiting-list control (no treatment). Analysis of data from 44 19–71 yr old insomniacs recruited from the community showed all treatment conditions to be superior to no treatment in reducing latency of sleep onset and ratings of fatigue. The presence of muscle-tension release was unrelated to outcome. There was a nonsignificant trend for visual imagery treatments to be superior to somatic-focusing treatments in reducing sleep onset latencies. Treatments using visual focusing were superior to somatic-focusing treatments in reducing the number of nocturnal awakenings. At 6 mo follow-up, only the imagery treatments showed significant improvement over pretreatment levels on latency of sleep onset. Visual-focusing treatments produced significantly greater reductions in sleep onset latency at follow-up than did the somatic-focusing treatments. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)