Fourteen-Day Inpatient Cognitive-Behavioural Therapy for Insomnia: A Logical and Useful Extension of the Stepped-Care Approach for the Treatment of Insomnia
Authors: Tatjana Crönlein, Berthold Langguth, Peter Geisler, Thomas C. Wetter, Peter Eichhammer
Journal: Psychotherapy and Psychosomatics (2014)

162 insomnia patients participated in this programme between 2009 and 2012 in groups of 7-8 persons.Its evaluation was approved by the Ethical Committee of the University of Regensburg, and all patients signed the informed consent forms.Before treatment, the patients were interviewed and examined by a sleep expert regarding the following inclusion criteria: (1) diagnostic criteria of primary insomnia for at least 1 year according to the International Classification of Sleep Disorders 2 [7] ; (2) evidence of conditioned sleep difficulty and/or heightened arousal in bed, and (3) previous participation in an outpatient CBT-I without success or inability to participate in standard outpatient CBT-I because of disease severity or inability to reduce hypnotics.Exclusion criteria were: (1) untreated organic sleep disorder; (2) severe psychiatric disorders, and (3) inability to participate in a group therapy for any reason.Thirty-one participating patients had to be excluded from the analysis for the following reasons: 4 patients quit the therapy, in 5 patients available data were incomplete and in 22 patients the presence of exclusion criteria (14 with sleep apnoea syndrome, 8 with severe psychiatric disorder) became only apparent during treatment.The remaining 131 patients [mean age 53.6 ± 12.2 years; 110 women; mean Pittsburgh Sleep Quality Index (PSQI) 14.1 ± 3.1] were included in the analysis.The objective measurement of sleep was performed by PSG at the beginning and end of treatment.Subjective insomnia symptoms were quantified at baseline and 6 months after treatment using the PSQI and the Regensburg Insomnia Scale (RIS [8] : a 10-item questionnaire which measures psychological aspects of insomnia over a period of 4 weeks; total range 0-40 points; cut-off for insomnia 12 points) and analysed using paired t tests.Depressive symptoms were assessed by the Beck Depression Inventory.Both PSG data and clinical ratings were compared with paired t tests.Acceptance of the programme by patients was good; only 4 persons quit the therapy prematurely.All 78 patients on a sedativehypnotic regimen before treatment stopped their medication during the therapy.After treatment, time in bed (436.5 ± 35.8 vs. 381.8± 44.6 min; t = 11.786;p < 0.0005), sleep latency (15.8 ± 18.4 vs. 8.1 ± 10.7 min; t = 11.786;p < 0.0005) and wake time after sleep onset (72.9 ± 48.3 vs. 49.8 ± 37.5 min) significantly decreased whereas sleep efficiency (77.2 ± 48.3 vs. 82.3± 13.0%; t = -4.002;p < 0.0005) increased.Total sleep time was shortened (337.9 ± 60.0 vs. 322.3± 81.8 min; t = 2.025; p = 0.045).Clinical ratings at 6 months were available for 97 patients with a significant improvement in the PSQI, the RIS (24.5 ± 5.4 vs. 19.0 ± 6.8; t = 11.281;p < 0.0005) and the Beck Depression Inventory.The improvement was most pronounced in RIS items 'sleep related thinking' and 'hypnotic intake'.However, in spite of the significant improvements, the mean level of insomnia was still moderate to severe.There was no control group, but repeated baseline assessments of insomnia symptoms were performed with an interval of 4-5 months (RIS 0: 24.7 ± 5.7,