Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3019 — Effectiveness of Cognitive Behavior Therapy for Primary and Co-Morbid Insomnia

Edinger JD (VAMC, Durham) , Means MK (VAMC, Durham), Lineberger MK (Duke University Medical Center), Stechuchak KM (VAMC, Durham), Olsen MK (VAMC, Durham), Goodin A (VAMC, Durham), Carney CE (Duke University Medical Center)

Cognitive-Behavioral Therapy (CBT) has proven efficacious for primary insomnia (PI) and for insomnia co-morbid to a sleep-disruptive medical or psychiatric condition (CMI). This study compared CBT to a control therapy in both PI and CMI patients.

VA outpatients with insomnia were screened via structured interviews, a sleep diary, and polysomnography. Those enrolled met Research Diagnostic Criteria for insomnia disorder and had an average diary total wake time (TWT) > 60 minutes. Forty PI and 41 CMI patients enrolled and completed pre-therapy sleep diaries (2 weeks), actigraphy (1 week), and questionnaires to assess insomnia symptoms, dysfunctional beliefs about sleep, mood, and quality of life. They then were randomized and underwent either 4 biweekly sessions of CBT (20 PI; 21 CMI) or a generic sleep hygiene (SH) therapy (20 PI and 20 CMI). All pre-therapy assessment procedures were re-administered during 2-week periods immediately after treatment and again 6 months later. Linear mixed models were used to test the relative efficacy of CBT for PI and CMI patients.

Pre-to-post-therapy changes showed benefits of CBT over SH in both PI and CMI groups. For PI patients, CBT produced greater improvements than did SH in objective (actigraphy) TWT, wakefulness after sleep onset (WASO), and sleep efficiency (SE), as well as in measures of global insomnia symptoms (ISQ) and confidence about sleep. CBT-treated CMI patients showed greater improvements in subjective (diary) TWT and sleep onset latency as well as their dysfunctional sleep-related beliefs than did SH-treated patients. At follow-up, CBT continued to show benefits over SH in the PI group on the ISQ and both TWT and WASO taken from actigraphy. In contrast, none of the comparisons showed benefits of CBT over SH at the 6-month follow-up within the CMI group.

Results suggest only PI patients have a relatively better long-term response to CBT than they do to SH. Findings imply that modifications to CBT may be needed to improve its relative efficacy for CMI.

CBT is useful for managing insomnia among veterans with PI. For CMI patients, CBT’s relative value is that of providing more rapid subjective sleep improvements than those provided by generic SH approaches.