4031 — A Small Randomized Trial of CBT for Insomnia among Primary Care Patients Endorsing Suicidal Ideation

Lead/Presenter: Wilfred Pigeon, 
All Authors: Pigeon WR (Center of Excellence for Suicide Prevention) Funderburk J (Center for Integrated Healthcare) Bishop TM (Center of Excellence for Suicide Prevention) Crean HF (Center of Excellence for Suicide Prevention)

Objectives:
Insomnia frequently co-occurs with major depression (MDD) and posttraumatic stress disorder (PTSD). All three conditions are highly prevalent among primary care (PC) patients and are independent risk factors for suicidal ideation (SI) and suicide attempts. The study was designed to test whether CBT for insomnia (CBT-I) delivered to patients with MDD and/or PTSD would contribute to reductions in symptom severity of each disorder as well as reductions in SI.

Methods:
54 participants receiving VHA primary care services with insomnia, recent SI and either MDD and/or PTSD were randomized to treatment-as-usual (TAU) for MDD and/or PTSD or to CBT-I plus TAU. CBT-I was delivered in four brief individual sessions lasting 20-40 minutes. Assessments (Insomnia Severity Index [ISI], the Physicians Health Questionnaire for depression [PHQ-9], and the Columbia Suicide Severity Rating Scale's SI intensity subscale) were completed by a blinded rater prior to randomization and at post-treatment. General linear models with adjustments for covariates were used to test time x group interactions for ISI, PHQ-9 and SI intensity.

Results:
The analysis includes N = 50 subjects (21% female; 33% minorities; mean age = 55.3) with complete data (4 lost to follow-up). Mean (SD) baseline scores did not differ by group and were: ISI = 18.4(4.1); PHQ-9 = 16.0(5.3) and SI intensity = 13.2(3.0). CBT-I, compared to TAU, was associated with significant reductions in ISI (p < .001) and PHQ-9 (p < .01). Significant reductions in SI intensity were observed in both conditions (7.8 points in CBT-I; 4.3 points in TAU), although the time x group interaction was not significant. Effect sizes (Cohen's d) were large for insomnia (d = 1.79) and depression (d = 1.13) and modest for SI Intensity (d = .44).

Implications:
Brief CBT-I formatted for delivery in PC reduces insomnia and depressive symptoms in patients also presenting with SI. The findings suggest that SI intensity may be less amenable to modification from improved sleep than other depressive symptoms. Whether large reductions in insomnia and depression severity combined with modest reductions in SI intensity represent a meaningful reduction in suicide risk remains to be demonstrated.

Impacts:
It is feasible to treat insomnia in the context of suicidal ideation and attain improvements in mood. Insomnia treatment may be a powerful adjuvant to suicide specific interventions.