Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Cognitive therapy and behavioral therapy for insomnia disorder: efficacy, moderators and mediators
Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.ORCID iD: 0000-0001-5966-5451
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Insomnia disorder is the second most prevalent mental disorder and the most prevalent sleep disorder. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the treatment of choice with well-documented effects. Nevertheless, a significant proportion of patients fail to respond, and an even larger proportion fail to remit from the condition. In addition, very little is known about the effects of CBT-I's separate components or about what moderates and mediates their effect. Gaining knowledge about components, predictors, and mediators could be one route for optimizing and tailoring CBT-I and ultimately enhancing outcomes.

The overall aim of this thesis was to advance our theoretical and clinical knowledge about CBT-I by exploring Cognitive Therapy (CT) and Behavior Therapy's (BT) comparative efficacy and their potential moderators and mediators.

To pursue the study aims, one large randomized controlled trial was performed that involved 219 individuals with insomnia disorder randomized to CT, BT, or a waitlist control group. Study 1 examined CT and BT's comparative efficacy against a waitlist control on a broad range of outcomes. Study 2 examined theoretically derived constructs from both therapy models, and insomnia-associated correlates as potential predictors and moderators of outcome for the two therapies. Study 3 examined theoretically driven process variables from the cognitive model as mediators of outcome in both CT and BT.

Study I showed that both therapies outperformed the waitlist and turned out as comparably effective treatments on the majority of outcomes. BT was associated with significantly more adverse events, whereas CT received significantly more minutes of telephone support.

Study II showed that early morning waketime and bedtime variability moderated the effect of both CT and BT. Those experiencing lower early morning waketime and bedtime variability achieved greater insomnia severity reductions in CT. In contrast, those experiencing greater early morning waketime and bedtime variability achieved larger insomnia severity reductions in BT. The findings also showed that greater insomnia severity, waketime after sleep onset, and lower sleep efficiency at baseline predicted greater insomnia severity at posttreatment.

Study III provided evidence that reductions in dysfunctional beliefs and monitoring for sleep during treatment acted as drivers of the reduction in insomnia severity in CT. The results also indicated that reductions in safety behaviors and dysfunctional beliefs mediated reductions in insomnia severity in BT, although not as clear as the drivers of change for CT since they were also reciprocally predicted by reductions in insomnia severity.

Study I indicate that CT and BT achieve similar effects and that both therapies are effective as standalone therapies for insomnia disorder. Study II provided evidence that the two therapies in CBT-I can depend on different patient characteristics at baseline to be effective. The results from study II thus suggest that the therapies in CBT-I could be tailored based on patient's characteristics before treatment to optimize outcomes. Study III provided support for the role of cognitive processes as important routes to remediate insomnia and underscore the value of assessing and targeting dysfunctional beliefs, monitoring, and safety behaviors to achieve reductions in insomnia severity and emphasize the importance of these concepts in understanding insomnia.

Place, publisher, year, edition, pages
Stockholm: Department of Psychology, Stockholm University , 2021. , p. 79
Keywords [en]
Behavior Therapy, Cognitive Therapy, Insomnia, internet-delivered, efficacy, mediators, moderators, personalized medicine
National Category
Applied Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:su:diva-190724ISBN: 978-91-7911-450-3 (print)ISBN: 978-91-7911-451-0 (electronic)OAI: oai:DiVA.org:su-190724DiVA, id: diva2:1532052
Public defence
2021-04-14, David Magnussonsalen (U31), Frescati Hagväg 8 and online via Zoom, public link is available at the department website, Stockholm, 13:15 (English)
Opponent
Supervisors
Funder
Swedish Research Council, 421-2013-996Available from: 2021-03-22 Created: 2021-03-01 Last updated: 2022-02-25Bibliographically approved
List of papers
1. Comparing internet-delivered cognitive therapy and behavior therapy with telephone support for insomnia disorder: a randomized controlled trial
Open this publication in new window or tab >>Comparing internet-delivered cognitive therapy and behavior therapy with telephone support for insomnia disorder: a randomized controlled trial
Show others...
2020 (English)In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 43, no 2, article id zsz245Article in journal (Refereed) Published
Abstract [en]

Study Objectives: Our aim was to compare the effects of Internet-delivered cognitive therapy (CT) and behavior therapy (BT) against a waitlist (WL) condition to better understand their unique contribution in the treatment of insomnia.

Methods: Two hundred and nineteen participants with insomnia disorder were randomized to CT (n = 72), BT (n = 73), or WL (n = 74). The treatment arms consisted of 10 weekly internet-delivered modules with 15 min of telephone support per week. At pre, post, and follow-up, participants completed measures of insomnia severity, sleep diaries, functional impairment, anxiety, depression, quality of life, adverse events, satisfaction and perception of content, workload, and activity in treatment. Measures of completed exercises, modules, therapist support, and platform logins were also measured at posttreatment.

Results: Moderate to large effect sizes for both CT and BT outperformed the WL on the majority of outcomes, with significant differences in favor of both therapy groups. Both treatment groups had significantly larger proportion of treatment remitters (CT: 35.8%, BT: 40%, WL: 2.7%) and responders (CT: 74.6%, BT 58.6%, WL: 10.8%) compared to the WL at posttreatment. There were no significant differences between the two therapy groups in terms of outcomes, except for sleep onset latency in favor of BT (6 min difference at posttreatment) and adverse events in favor of CT (CT 14.1% vs BT 43.2%).

Conclusions: This study indicates that both Internet-delivered CT and BT are effective as stand-alone therapies for insomnia disorder. Results highlight the need for examining which therapy and subcomponents that are necessary for change.

ClinicalTrials.gov Identifier: NCT02984670

Keywords
behavior therapy, cognitive therapy, cognitive behavior therapy, insomnia, internet-delivered
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-180527 (URN)10.1093/sleep/zsz245 (DOI)000548323400020 ()
Note

This study has received funding from Vetenskapsrådet (421-2013-996).

Available from: 2020-03-31 Created: 2020-03-31 Last updated: 2024-02-19Bibliographically approved
2. Predictors and moderators of cognitive therapy and behavior therapy for insomnia disorder
Open this publication in new window or tab >>Predictors and moderators of cognitive therapy and behavior therapy for insomnia disorder
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Introduction: Little is known on what pretreatment patient characteristics the outcome of Cognitive Therapy (CT) and Behavioral Therapy (BT) for insomnia disorder depends on. Identifying for whom treatment is most useful is an essential step toward treatment optimization and personalized care. Therefore, the purpose with this investigation was to examine both theory-driven constructs and insomnia-associated clinical variables as potential predictors and moderators of outcome in CT and BT.

Materials and Methods: One hundred and forty-four participants diagnosed with insomnia disorder were randomized to 10 weekly internet-delivered modules of CT or BT with 15 minutes of telephone support per week. General clinical predictors and theory-driven moderators (cognitive and behavioral processes), assessed in a former RCT, were analyzed using multiple linear regression with insomnia severity as the outcome.

Results: Bedtime variability and early morning waketime interacted with treatment and indicated that lower bedtime variability and early morning waketime were associated with a higher effect for CT, whereas the opposite was true for BT. Waketime after sleep onset, insomnia severity index, and sleep efficiency emerged as predictors that indicated prognostic value of treatment outcome.

Conclusions: Five constructs provided predictive values in the outcome of cognitive therapy and behavior therapy. The moderator findings are in line with the theoretical models of CT and BT and may have implications for future research and clinical practice of CBT-I, should they be replicated. Clinically, this could implicate the ability to match therapy to patient features in order to optimize outcomes.

Keywords
Moderators, personalized care, Behavior Therapy, Cognitive Therapy, Insomnia
National Category
Applied Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-190721 (URN)
Funder
Swedish Research Council, (421-2013-996)
Available from: 2021-02-26 Created: 2021-02-26 Last updated: 2024-02-19Bibliographically approved
3. Mediators of cognitive therapy and behavior therapy for insomnia disorder: a test of the processes in the cognitive model
Open this publication in new window or tab >>Mediators of cognitive therapy and behavior therapy for insomnia disorder: a test of the processes in the cognitive model
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: To examine if the processes in the cognitive model mediate cognitive therapy (CT) and behavior therapy (BT) for insomnia.

Method: Individuals diagnosed insomnia disorder (n=219) were randomized to telephone supported internet-delivered cognitive therapy (n=72), behavior therapy (n=73), or a waitlist (n=74). Cognitive processes (worry, dysfunctional beliefs, monitoring and safety behaviors) proposed to maintain insomnia and treatment outcome (insomnia severity; ISI) were assessed biweekly. Criteria for evaluating mediators were assessed via parallel process growth modeling and cross-lagged panel models.

Results: Parallel process growth modeling showed that dysfunctional beliefs, monitoring and safety behaviors significantly mediated the effects of both CT and BT. Cross-lagged panel models confirmed that dysfunctional beliefs and monitoring, which approached significance, drove the change for CT. In BT, however, prior changes in ISI predicted later changes in worry and monitoring, and reciprocal influences among processes and outcomes were observed for dysfunctional beliefs and safety behaviors. The effect of safety behavior on outcome was significantly larger for BT compared to CT.

Conclusion: Together, the findings support the role of dysfunctional beliefs and monitoring as processes of change in CT, and safety behaviors as a specific mediator in BT. Limited evidence was provided for worry as a mediator. These findings have relevance for the conceptualizations of insomnia, future research, and clinical management.

Keywords
Behavior Therapy, Cognitive Therapy, Cognitive processes, Insomnia, internet-delivered, mediators.
National Category
Applied Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-190722 (URN)
Funder
Swedish Research Council, 421-2013-996
Available from: 2021-02-26 Created: 2021-02-26 Last updated: 2024-02-19Bibliographically approved

Open Access in DiVA

Cognitive therapy and behavioral therapy for insomnia disorder: efficacy, moderators and mediators(2857 kB)373 downloads
File information
File name FULLTEXT01.pdfFile size 2857 kBChecksum SHA-512
5204f7ed84ddc3e71a8369311516af11d87549e9a2445e3de73214d9ba3c708b0488ecbccdd9b856b3785ce5c6469c024473499b93f5c7ad1a7a5f2147b4106b
Type fulltextMimetype application/pdf

Authority records

Sunnhed, Rikard

Search in DiVA

By author/editor
Sunnhed, Rikard
By organisation
Clinical psychology
Applied Psychology

Search outside of DiVA

GoogleGoogle Scholar
Total: 376 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 1186 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf