Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial.

CHRONIC INSOMNIA IS A SERIOUS FORM OF SLEEP DISTURBANCE ASSOCIATED WITH REDUCED QUALITY OF LIFE, INCREASED RISKS FOR SERIOUS PSYCHIATRIC illness, and enhanced healthcare utilization among millions worldwide.1–3 Insomnia may present either as a primary sleep disorder or as a disorder comorbid with another sleep, medical, or psychiatric disorder or a combination thereof. Both primary insomnia (PI) and comorbid insomnia (CMI) are relatively common maladies, but CMI is more prevalent than PI in both clinical venues4,5 and the general population at large.6 Moreover, CMI may be more persistent and have even more serious consequences than PI. Recent data,7 for example, show that insomnia sufferers with comorbid gastrointestinal problems, chronic pain, hypertension, or problems with breathing or urination report more chronic insomnia than do those without such conditions. Furthermore, when insomnia occurs comorbid with a psychiatric illness such as major depression, it complicates disease management and often remains as a residual symptom that enhances risk for both suicide and relapse.8,9 In view of these considerations, patients who present with insomnia and particularly those with CMI warrant early and effective treatment. Pharmacotherapy with benzodiazepine receptor agonists or sedating antidepressants currently remains the most common treatment offered to patients with insomnia.10 However, cognitive behavioral therapy (CBT), designed to address sleep-disruptive beliefs and habits, has become an increasingly well-regarded insomnia treatment.10 Results of meta-analyses (e.g., Smith, et al.11) and head-to-head comparisons12 suggest CBT produces short-term sleep improvements that compare favorably to those achieved with various forms of pharmacotherapy. Furthermore, sleep improvements following CBT appear to endure long after treatment is completed,13 and limited data suggest that patients prefer CBT over treatment with sleep medications.14 Given such observations, CBT has become a popular alternative for insomnia management. Most evidence supporting the efficacy of CBT comes from studies conducted with patients with PI, although there is some limited evidence supporting use of this treatment with CMI as well. Some uncontrolled case series or clinic-based studies have suggested the efficacy of CBT among patients with CMI and mixed psychiatric and medical conditions.15 Other case series or quasi-experimental studies have suggested CBT may be efficacious for treating insomnia in such specific patient groups as those with chronic pain,16 cancer,17 posttraumatic stress disorder,18 and clinical depression19 and those with mixed serious mental disorders.20 In addition, a number of small to moderately sized, single-site, randomized clinical trials have suggested that CBT is efficacious for patients with insomnia and comorbid chronic peripheral pain syndromes,21 treated breast cancer,22 fibromyalgia23, mixed medical disorders,24 mixed psychiatric and medical disorders,25 and alcoholism.26 Despite these findings, it is yet to be determined whether patients with PI or CMI show similar improvement from an equal and standard dose of CBT intervention. The current study tested the relative efficacy of CBT against a sleep hygiene control treatment (SH) in patients with PI and in a group of patients with CMI composed predominantly of individuals with mixed comorbid psychiatric disorders. The study hypotheses predicted that CBT would produce significantly greater short- and longer-term improvements in insomnia symptoms than would sleep hygiene in the sample as a whole. The data obtained were also examined to assess the relative efficacy of CBT in the PI and CMI groups considered separately.