Skip to main content
Log in

Brief behavioral treatment for insomnia in older adults with late-life treatment-resistant depression and insomnia: a pilot study

  • Original Article
  • Published:
Sleep and Biological Rhythms Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). 2013.

  2. Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6(2):97–111.

    Article  PubMed  Google Scholar 

  3. 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.

    Article  PubMed  Google Scholar 

  4. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. 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.

    PubMed  PubMed Central  Google Scholar 

  7. 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.

  8. Harsora P, Kessmann J. Nonpharmacologic management of chronic insomnia. Am Fam Physician. 2009;79(2):125–30.

    PubMed  Google Scholar 

  9. Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–95.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 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.

    Article  CAS  PubMed  Google Scholar 

  11. 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.

    Article  PubMed  Google Scholar 

  12. 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.

    Article  PubMed  Google Scholar 

  13. 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.

    Article  Google Scholar 

  14. Mulsant BH, et al. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med. 2014;30(3):517–34.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Lenze EJ, et al. Incomplete response in late-life depression: getting to remission. Dialogues Clin Neurosci. 2008;10(4):419–30.

    PubMed  PubMed Central  Google Scholar 

  16. Franzen PL, Buysse DJ. Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues Clin Neurosci. 2008;10(4):473–81.

    PubMed  PubMed Central  Google Scholar 

  17. 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.

    Article  CAS  PubMed  Google Scholar 

  18. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 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.

    Article  PubMed  Google Scholar 

  20. Callahan CM, et al. Treatment of depression improves physical functioning in older adults. J Am Geriatr Soc. 2005;53(3):367–73.

    Article  PubMed  Google Scholar 

  21. Butters MA, et al. Pathways linking late-life depression to persistent cognitive impairment and dementia. Dialogues Clin Neurosci. 2008;10(3):345–57.

    PubMed  PubMed Central  Google Scholar 

  22. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Fortney JC, et al. Reasons for antidepressant nonadherence among veterans treated in primary care clinics. J Clin Psychiatry. 2011;72(6):827–34.

    Article  PubMed  Google Scholar 

  24. 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.

    Google Scholar 

  25. 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.

    Article  PubMed  Google Scholar 

  26. Carney CE, et al., Cognitive behavioral insomnia therapy for those with insomnia and depression: a randomized controlled clinical trial. Sleep, 2017. 40(4).

  27. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 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.

    Article  PubMed  Google Scholar 

  30. 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.

    Article  PubMed  Google Scholar 

  31. 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.

    Article  PubMed  Google Scholar 

  32. 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.

    PubMed  Google Scholar 

  33. Souery D, Mendlewicz J. Compliance and therapeutic issues in resistant depression. Int Clin Psychopharmacol. 1998;13(Suppl 2):S13-8.

    PubMed  Google Scholar 

  34. Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62(Suppl 16):10–7.

    CAS  PubMed  Google Scholar 

  35. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382–9.

    Article  CAS  PubMed  Google Scholar 

  36. Morin CM, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 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.

    Article  PubMed  Google Scholar 

  38. 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.

    Article  PubMed  Google Scholar 

  39. Savard MH, et al. Empirical validation of the insomnia severity index in cancer patients. Psychooncology. 2005;14(6):429–41.

    Article  PubMed  Google Scholar 

  40. Carney CE, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep. 2012;35(2):287–302.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Buysse DJ, et al. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29(9):1155–73.

    Article  PubMed  Google Scholar 

  42. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. 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.

    Article  PubMed  Google Scholar 

  44. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. 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.

    PubMed  Google Scholar 

  46. Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012;10(4):266–79.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Cohen. Statistical power analysis for the behavioral sciences. New York: Routledge Academic; 1988.

    Google Scholar 

  48. 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.

    Article  CAS  PubMed  Google Scholar 

  49. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  50. W H, G. D, and K. P, International Population reports, U.S.C. Bereau, Editor. 2016: Washington, DC. p. 95/16-1.

  51. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249–65.

    Article  PubMed  Google Scholar 

  52. Hunkeler EM, et al. Psychiatric symptoms, impaired function, and medical care costs in an HMO setting. Gen Hosp Psychiatry. 2003;25(3):178–84.

    Article  PubMed  Google Scholar 

  53. Katon WJ, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry. 2003;60(9):897–903.

    Article  PubMed  Google Scholar 

  54. 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.

    Article  CAS  PubMed  Google Scholar 

  55. 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.

    Article  PubMed  Google Scholar 

  56. 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.

    Article  PubMed  Google Scholar 

  57. 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.

    Article  PubMed  Google Scholar 

  58. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 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.

    Article  CAS  PubMed  Google Scholar 

  60. Stevens J, et al. Advances and controversies in the design of obesity prevention trials. Obesity (Silver Spring). 2007;15(9):2163–70.

    Article  Google Scholar 

  61. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  62. 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.

    Article  PubMed  Google Scholar 

  63. Waterman L, et al., Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression. Depress Anxiety, 2016.

Download references

Acknowledgements

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.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marie Anne Gebara.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s41105-019-00211-6

Keywords

Navigation