Abstract
Brief behavioral treatment for insomnia (BBTI) is an efficacious treatment of insomnia in older adults. Behavioral treatments for insomnia can also improve depression. However, it is unknown if BBTI is feasible or has an effect in patients with insomnia and late-life treatment-resistant depression (LLTRD). The aims of this study were twofold: to test (1) the feasibility (defined by acceptability and retention rates) of BBTI and (2) the therapeutic potency of BBTI on symptoms of insomnia and depression. Eleven older Veterans with LLTRD and insomnia were recruited in a randomized control trial to receive immediate (4 weeks of BBTI followed by 3 weeks of phone call check-ins and a final in-person 8-week assessment) or delayed [3 weeks of treatment as usual (wait-list control) followed by 4 weeks of BBTI and a final in-person 8-week assessment] BBTI. The primary outcome measures included the Patient Health Questionnaire (minus the sleep item) and the Insomnia Severity Index. BBTI was found to be feasible in older Veterans with insomnia and LLTRD; all participants recommended BBTI and retention rates were 90.9%. There was no difference in treatment effect between the immediate BBTI and delayed BBTI groups at week 4. After both groups (immediate and delayed) received BBTI, improvements were seen in both insomnia (d = 1.06) and depression (d = 0.54) scores. BBTI is a feasible treatment for insomnia in older adults with LLTRD. BBTI may be an effective adjunctive treatment for depression. Larger adequately powered trials are required to confirm these preliminary findings.
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References
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). 2013.
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6(2):97–111.
Avidan AY, et al. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc. 2005;53(6):955–62.
Spira AP, et al. Association between insomnia symptoms and functional status in U.S. older adults. J Gerontol B Psychol Sci Soc Sci. 2014;69(Suppl 1):S35–41.
Qaseem A, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2016;165(2):125–33.
Schutte-Rodin S, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504.
National Institutes of H, National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13–15, 2005. Sleep. 2005. 28(9): p. 1049–57.
Harsora P, Kessmann J. Nonpharmacologic management of chronic insomnia. Am Fam Physician. 2009;79(2):125–30.
Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–95.
Wilson SJ, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24(11):1577–601.
Chesson AL Jr, et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999;22(8):1128–33.
Morgenthaler T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006;29(11):1415–9.
American Geriatrics Society Beers Criteria Update Expert. P., American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.
Mulsant BH, et al. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med. 2014;30(3):517–34.
Lenze EJ, et al. Incomplete response in late-life depression: getting to remission. Dialogues Clin Neurosci. 2008;10(4):419–30.
Franzen PL, Buysse DJ. Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues Clin Neurosci. 2008;10(4):473–81.
Dew MA, et al. Temporal profiles of the course of depression during treatment. Predictors of pathways toward recovery in the elderly. Arch Gen Psychiatry. 1997;54(11):1016–24.
Gallo JJ, et al. Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care. BMJ. 2013;346:f2570.
Whiteford HA, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86.
Callahan CM, et al. Treatment of depression improves physical functioning in older adults. J Am Geriatr Soc. 2005;53(3):367–73.
Butters MA, et al. Pathways linking late-life depression to persistent cognitive impairment and dementia. Dialogues Clin Neurosci. 2008;10(3):345–57.
Campbell DG, et al. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. J Gen Intern Med. 2007;22(6):711–8.
Fortney JC, et al. Reasons for antidepressant nonadherence among veterans treated in primary care clinics. J Clin Psychiatry. 2011;72(6):827–34.
Matsuwaka S, Martin J, Alessi C. Insomnia in older veterans: prevalence, self-rated health, and talking to a doctor about sleep problems. Hawai’i J Med Publ Health. 2013;72(9 Suppl 4):63.
Manber R, et al. Efficacy of cognitive-behavioral therapy for insomnia combined with antidepressant pharmacotherapy in patients with comorbid depression and insomnia: a randomized controlled trial. J Clin Psychiatry. 2016;77(10):e1316–23.
Carney CE, et al., Cognitive behavioral insomnia therapy for those with insomnia and depression: a randomized controlled clinical trial. Sleep, 2017. 40(4).
Blom K, et al. Internet treatment addressing either insomnia or depression, for patients with both diagnoses: a randomized trial. Sleep. 2015;38(2):267–77.
Manber R, et al. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008;31(4):489–95.
Norell-Clarke A, et al. Group cognitive behavioural therapy for insomnia: effects on sleep and depressive symptomatology in a sample with comorbidity. Behav Res Ther. 2015;74:80–93.
Watanabe N, et al. Brief behavioral therapy for refractory insomnia in residual depression: an assessor-blind, randomized controlled trial. J Clin Psychiatry. 2011;72(12):1651–8.
Ritterband LM, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA Psychiatry. 2017;74(1):68–75.
Germain A, et al. Effects of a brief behavioral treatment for late-life insomnia: preliminary findings. J Clin Sleep Med. 2006;2(4):403–6.
Souery D, Mendlewicz J. Compliance and therapeutic issues in resistant depression. Int Clin Psychopharmacol. 1998;13(Suppl 2):S13-8.
Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62(Suppl 16):10–7.
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382–9.
Morin CM, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–8.
Nasreddine ZS, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.
Bastien CH, Vallieres A, Morin CM. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307.
Savard MH, et al. Empirical validation of the insomnia severity index in cancer patients. Psychooncology. 2005;14(6):429–41.
Carney CE, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep. 2012;35(2):287–302.
Buysse DJ, et al. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29(9):1155–73.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–33.
Lenze EJ, et al. Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomised, double-blind, placebo-controlled trial. Lancet. 2015;386(10011):2404–12.
Munder T, et al. Working Alliance Inventory-Short Revised (WAI-SR): psychometric properties in outpatients and inpatients. Clin Psychol Psychother. 2010;17(3):231–9.
Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012;10(4):266–79.
Cohen. Statistical power analysis for the behavioral sciences. New York: Routledge Academic; 1988.
Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59(1):12–9.
Germain A, et al. Treatment for insomnia in combat-exposed OEF/OIF/OND military veterans: preliminary randomized controlled trial. Behav Res Ther. 2014;61:78–88.
W H, G. D, and K. P, International Population reports, U.S.C. Bereau, Editor. 2016: Washington, DC. p. 95/16-1.
Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249–65.
Hunkeler EM, et al. Psychiatric symptoms, impaired function, and medical care costs in an HMO setting. Gen Hosp Psychiatry. 2003;25(3):178–84.
Katon WJ, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry. 2003;60(9):897–903.
Unutzer J, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA. 1997;277(20):1618–23.
Cuijpers P, Twisk VN, Kleiboer J, Li A, Penninx J. BW, Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses. Am J Psychiatry. 2014;171(4):453–62.
Whiteford HA, Rehm DL, Baxter J, Ferrari AJ, Erskine AJ, Charlson HE, Norman FJ, Flaxman RE, Johns AD, Burstein N, Murray R, Vos CJ. T, Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86.
Callahan CM, Counsell KK, Hendrie SR, Perkins HC, Katon AJ, Noel W, Harpole PH, Hunkeler L, Unützer EM, J and I. Investigators. Treatment of depression improves physical functioning in older adults. J Am Geriatr Soc. 2005;53(3):367–73.
Gallo JJ, Bogner MK, Raue HR, Zee PJ, Bruce J, ML, Reynolds CF 3rd. Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care. BMJ. 2013;346:f2570.
Bruce ML, Reynolds THT, Katz CF 3rd, Schulberg II, Mulsant HC, Brown BH, McAvay GK, Pearson GJ, Alexopoulos JL. GS., Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291(9):1081–91.
Stevens J, et al. Advances and controversies in the design of obesity prevention trials. Obesity (Silver Spring). 2007;15(9):2163–70.
Lichstein KL, et al. Telehealth cognitive behavior therapy for co-occurring insomnia and depression symptoms in older adults. J Clin Psychol. 2013;69(10):1056–65.
Kraemer HC, et al. Caution regarding the use of pilot studies to guide power calculations for study proposals. Arch Gen Psychiatry. 2006;63(5):484–9.
Waterman L, et al., Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression. Depress Anxiety, 2016.
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The contents of this article do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
Funding
This work was supported by the Veterns Integrated Service Network (VISN) 4 Mental Illness Research, Education, and Clinical Center Pilot Project Funds (PI: Gebara) at the Veternans Affairs Pittsburgh Healthcare System and T32 MH019986.
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Gebara, M.A., DiNapoli, E.A., Lederer, L.G. et al. Brief behavioral treatment for insomnia in older adults with late-life treatment-resistant depression and insomnia: a pilot study. Sleep Biol. Rhythms 17, 287–295 (2019). https://doi.org/10.1007/s41105-019-00211-6
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DOI: https://doi.org/10.1007/s41105-019-00211-6