Cognitive Behaviour Therapy for Insomnia in Co-morbid
9.1 Introduction
9.1.4 CBT for Insomnia Associated with Depressive Disorders It is very common for patients presenting with depression to also report difficulty initiat-
ing and/or maintaining sleep. In fact, epidemiological evidence suggests that up to 90%
of patients presenting with depression also suffer from insomnia (Tsuno et al. 2005;
Riemann and Voderholzer 2003). This finding is perhaps to be expected, given that both depression and insomnia share the same neurotransmitter pathophysiology (principally involving serotonergic and dopaminergic systems; Harvey et al. 2011). Moreover, insomnia has been clearly shown to be a risk factor for the development of depression, with an overall odds ratio of 2.1 (95 percent confidence intervals of 1.9–2.4; Baglioni et al. 2011). The association is so common that some primary care physicians base their diagnosis of depression solely on the presence of insomnia (Krupinski and Tiller 2001).
Depressed patients with insomnia have significantly poorer clinical outcomes with respect to symptom ratings, attrition and remission rates and the stability of response to treatment when compared to depressed patients without insomnia (Dew et al. 1997; Thase et al. 1997). Furthermore, there is a growing evidence to demon- strate that insomnia is not just a correlate or symptom of depression. Rather, it affects the course of the depressive illness and the response to treatment, and when insomnia is unresolved, it poses an important risk factor for relapse (de Wild- Hartmann et al. 2013; Pigeon et al. 2008; Perlis et al. 1997). Insomnia is further associated with both suicidal thinking (McCall et al. 2010) and completed suicide (Bjørngaard et al. 2011; Fawcett et al. 1990). Understandably, therefore, there has been much interest in the usefulness of CBT-I in patients with depression.
As noted previously, the AASM in 2006 first suggested the potential benefits of CBT for insomnia on improving the mood of patients with depression. This work has been subsequently built upon by an encouraging, albeit small, case series study (Taylor et al. 2007a, b; see Table 9.1 for further details).
The strongest evidence, however, comes from two recent randomized controlled trials. In the first, a pilot study of 30 patients with major depression was randomly assigned to a combined treatment of CBT-I and anti-depressant medication or a com- bination of sham psychotherapy for insomnia and anti-depressant medication (Manber et al. 2008). Both the CBT-I and sham psychological treatments were administered for the same length of time and at the same frequency. As expected, CBT-I was effective in reducing insomnia symptoms, so much so, that remission (as measured by normal ISI scores) was significantly higher in patients receiving CBT-I (50% vs 8%). Therefore, the addition of CBT-I provided enhanced sleep outcomes, as compared to those who just received anti-depressant medication alone
Table 9.1Characteristics of studies supporting CBT-I for patients with co-morbid psychiatric disorders Co-morbid psychiatric diagnosisAuthor et al., yearRandomizationControl groupCBT componentsTreatment sessionsTreatment formatOutcome measures DepressionMorawetz (2003)No–Sleep education, sleep hygiene, sleep scheduling, stimulus control, cognitive therapy, relaxation 6Self-help (book and audio cassette)
Sleep diary DepressionTaylor et al. (2007a, b)No–Sleep hygiene, stimulus control, relaxation6IndividualSleep diary, Beck Depression Inventory DepressionManber et al. (2008)YesSleep education, sleep hygiene
Sleep education, sleep hygiene, sleep scheduling, stimulus control, genitive therapy, relaxation, relapse prevention
7IndividualSleep diary, ISI, actigraphy, HRSD17 DepressionWatanabe et al. (2011)YesTAUSleep education, sleep hygiene, sleep rescheduling, stimulus control, relapse prevention
4IndividualSleep diary, ISI, PSQI, HDRS, GRID- HAMD, medication (anti-depressant and hypnotic) use PTSDDeViva et al. (2005)No–Stimulus control, sleep rescheduling, cognitive restructuring, sleep hygiene
5IndividualSleep diary PTSDUlmer et al. (2011)YesTAUSleep hygiene, sleep rescheduling, stimulus control, imagery rehearsal therapy
6 over 12 weeksIndividualElectronic sleep diary, ISI, PSQI, PCL-M, PHQ-2 Alcohol dependenceGreeff and Conradie (1998)YesNo treatmentRelaxation10GroupQuestionnaire Alcohol dependenceCurrie et al. (2004)YesWait listSleep education, sleep hygiene, stimulus control, sleep restriction, cognitive therapy, relaxation 5Individual or self-help (book) with telephone support Sleep diary, actigraph, PSQI
Alcohol dependenceArnedt et al. (2007)NoNoSleep education (including effects of alcohol on sleep), sleep hygiene, stimulus control, sleep restriction, cognitive therapy, relapse prevention 8Individual (four face-to-face and four via telephone)
Sleep diary, ISI, DBAS-SF, questionnaires on fatigue, anxiety, depression, interviews regarding alcohol intake Alcohol dependenceArnedt et al. (2011)YesBehavioural placebo treatment
Sleep education (including effects of alcohol on sleep), sleep hygiene, stimulus control, sleep restriction, cognitive therapy, relapse prevention
8IndividualSleep diary, ISI, questionnaires on daytime functioning, drinking and treatment fidelity PsychosisMyers et al. (2011)No–Sleep education, sleep hygiene, stimulus control, relaxation, relapse prevention
4IndividualISI, PSQI, G-PTS, PSYRATS, CAPS, DASS BPADHarvey et al. (2015)YesPsycho- educationSleep education, case formulation, stimulus control, sleep restriction (limited to 6.5h in bed), relaxation therapy, cognitive therapy, improving daytime functioning, relapse prevention
8IndividualSCID, YMRS, IDS-C, ISI, Sleep Diary, PSQI, PROMIS-D, SDS, Q-LES-Q-SF, CEQ Abbreviations: ISI Insomnia Severity Index, HRSD17 - 17 item Hamilton Rating Scale for Depression, PSQI Pittsburgh Sleep Questionnaire Index, GRID- HAMD GRID-Hamilton Depression Rating Scale, TAU Treatment as Usual, PTSD post-traumatic stress disorder, PCL-M PTSD Checklist Military Version, PHQ-2 Patient Health Questionnaire Version 2, DBAS-SF dysfunctional beliefs and attitudes about sleep—short form, G-PTS Green Paranoid Thought Scales, PSYRATS Psychotic Symptom Rating Scale: Delusions Subscale, CAPS Cardiff Anomalous Perception Scale, DASS Depression Anxiety Stress Scale, BPAD Bipolar Affective Disorder, SCID Structured Clinical Interview for the Diagnostic and Statistical Manual Version V, YMRS Young Mania Rating Scale, IDS-C Inventory of Depressive Symptomatology—Clinician, PROMIS-SD Patient-Reported Outcomes Measurement Information System—Sleep Disturbance, SDS Sheehan Disability Scale, Q-LES-Q-SF Quality of Life Enjoyment and Satisfaction Questionnaire, CEQ Credibility/Expectancy Questionnaire
(i.e. two active treatments are better than one). Moreover, depression remission (as measured by the Hamilton Rating Scale for Depression [HRSD]) was approximately twice as high for those receiving CBT-I (61.5% vs 33.3%). Even when items relating to sleep in the HRSD were removed, the effect size was equivalent (i.e. the improve- ment in HRSD scores did not just occur because sleep parameters had improved).
Hence, CBT-I markedly enhanced the depression treatment response (Table 9.1).
The second larger trial, undertaken by Watanabe et al. (2011), echoed this con- clusion. In their trial, 73 outpatients with depression and co-morbid insomnia, which was refractory to adequate pharmacotherapy, were randomized to treatment as usual or treatment as usual plus four weekly 1-h individual sessions of CBT- I. After treatment, the CBT-I group had significantly lower insomnia and depression scores (even after sleep items were removed), as well as higher remission rates for both insomnia and depression.
These studies clearly suggest that independent targeting of both conditions provides the optimal outcome for patients suffering from co-morbid insomnia and depression. Moreover, they tally with previous pharmacotherapy studies, which also demonstrated that independent treatment of insomnia in patients with depression is possible and results in better depression outcomes (Fava et al.
2006).
9.1.4.1 CBT for Insomnia Associated with Bipolar Affective Disorder
Sleep difficulties go hand-in-hand with bipolar affective disorder (BPAD) and can be challenging to manage, as they do not always respond to pharmacotherapy (Gruber et al. 2011). Reduced need for sleep is a symptom of mania, which worsens as the episode unfolds (Jackson et al. 2003); and both insomnia and hypersomnia are seen during episodes of depression (American Psychiatric Association 2012).
Even between episodes, up to 70% of patients with BPAD report significant sleep difficulties (Harvey et al. 2005), which are associated with mood symptoms, impaired daytime functioning, relapse, and suicide attempts (Sylvia et al. 2012).
In their pilot randomised control trial, Harvey and colleagues are the first to com- pare two psychosocial treatments (i.e. modified CBT-I vs. psycho-education) for patients with inter-episode BPAD and co-morbid insomnia (Harvey et al. 2015).
During the 6-month follow-up, patients assigned to CBT-I (n = 30) had fewer days in a bipolar episode (3.3 days vs. 25.5 days) compared to those in the psycho-edu- cation group (n = 28). Furthermore, patients who underwent CBT-I showed enhanced mood stability, improved daytime functioning, and had a significantly lower hypomania/mania relapse rate (4.6% vs. 31.6%). Immediately post-treatment, the CBT-I group had higher rates of insomnia remission (72.7% vs. 14.3%), which remained higher at 6 months follow-up (63.6% vs. 21.1%).
Although the study size was small (which is emphasised by the authors), it clearly demonstrates the value of developing treatments aimed to improve sleep in patients with BPAD. By treating the co-morbid insomnia, BPAD symptoms and daytime functioning were improved.