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CBT for Insomnia in Patients with High and Low Depressive Symptom Severity: Adherence and Clinical Outcomes
Rachel Manber, Ph.D.; Rebecca A. Bernert, Ph.D.; Sooyeon Suh, Ph.D.; Sara Nowakowski; Allison T. Siebern, Ph.D.; Jason C. Ong, Ph.D.
FOCUS 2014;12:90-98. doi:10.1176/appi.focus.12.1.90

Study Objectives  To evaluate whether depressive symptom severity leads to poorer response and perceived adherence to cognitive behavioral therapy for insomnia (CBTI) and to examine the impact of CBTI on well-being, depressive symptom severity, and suicidal ideation.

Design  Pre- to posttreatment case replication series comparing low depression (LowDep) and high depression (HiDep) groups (based on a cutoff of 14 on the Beck Depression Inventory [BDI]).

Participants  127 men and 174 women referred for the treatment of insomnia.

Interventions  Seven sessions of group CBTI.

Measurements and Results  Improvement in the insomnia severity, perceived energy, productivity, self-esteem, other aspects of wellbeing, and overall treatment satisfaction did not differ between the HiDep and LowDep groups (p > 0.14). HiDep patients reported lower adherence to a fixed rise time, restricting time in bed, and changing expectations about sleep (p < 0.05). HiDep participants experienced significant reductions in BDI, after removing the sleep item. Levels of suicidal ideation dropped significantly among patients with pretreatment elevations (p < 0.0001).

Conclusion  Results suggest that pre- to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefits of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity.
(Reprinted with permission from Journal of Clinical Sleep Medicine 2011;7(6):645 652) 

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Table 1.TCAS: Adherence to Individual Treatment Components
Table Footer Note

TCAS, Treatment Components Adherence Scale.

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Table 2.TCAS: Perceived Helpfulness of Individual Treatment Components
Table Footer Note

TCAS, Treatment Components Adherence Scale.

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Table 3.Descriptive Statistics for Measures
Table Footer Note

ISI, Insomnia Severity Index; BDI, Beck Depression Inventory.

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Table 4.Change in Sleep Diary Measures
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Table 5.TCAS Adherence
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Table 6.TCAS Helpfulness


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