Studies highlight insomnia-depression link, underscore role for brief CBT

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.