Insomnia disorder update: the benefits of screening and treatment for this common presentation.

Insomnia is a chronic condition and major healthcare problem for Australians across the lifespan. Insomnia's high prevalence and disease burden render it an important target for treatment. Further, and importantly, there exist established bidirectional links between insomnia and a range of health conditions, with insomnia both contributing to risk, maintenance and relapse of comorbid conditions. Recent clinical research demonstrates that treating insomnia in its own right is important for resolution of insomnia and for optimising treatment outcomes for comorbid presenting problems. Due to its effectiveness and favourable side-effect profile, Cognitive Behaviour Therapy-Insomnia (CBT-I) is the recommended first-line treatment even when comorbid conditions are present. CBT-I is a brief treatment often delivered in four to eight consultations. Individual, group and online CBT-I have each demonstrated effectiveness. Outcomes for online CBT-I are often stronger when individualised clinician support is provided. Specifically assessing for and treating insomnia in clinical practice may provide an opportunity to optimise treatment outcome in many patients.

Treating insomnia symptoms with medicinal cannabis: a randomized, crossover trial of the efficacy of a cannabinoid medicine compared with placebo.

STUDY OBJECTIVES: This randomized, double-blind, placebo-controlled, crossover study was conducted to evaluate the safety and efficacy of 2 weeks of nightly sublingual cannabinoid extract (ZTL-101) in treating chronic insomnia (symptoms ≥3 months). METHODS: Co-primary study endpoints were safety of the medication based on adverse event reporting and global insomnia symptoms (Insomnia Severity Index [ISI]). Secondary endpoints included: self-reported (sleep diary), actigraphy-derived, and polysomnography measurements of sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), sleep efficiency (SE); and self-reported assessments of sleep quality (sSQ) and feeling rested upon waking. Adjusted mean differences between placebo and ZTL-101 were calculated. RESULTS: Twenty-three of 24 randomized participants (n = 20 female, mean age 53 ± 9 years) completed the protocol. No serious adverse events were reported. Forty mild, nonserious, adverse events were reported (36 during ZTL-101) with all but one resolving overnight or soon after waking. Compared to placebo, ZTL-101 decreased ISI (-5.07 units [95% CI: -7.28 to -2.86]; p = 0.0001) and self-reported SOL (-8.45 min [95% CI: -16.33 to -0.57]; p = 0.04) and increased self-reported TST (64.6 min [95% CI: 41.70 to 87.46]; p < 0.0001), sSQ (0.74 units [95% CI: 0.51 to 0.97]; p < 0.0001), and feeling of being rested on waking (0.51 units [95% CI: 0.24 to 0.78]; p = 0.0007). ZTL-101 also decreased actigraphy-derived WASO (-10.2 min [95% CI: -16.2 to -4.2]; p = 0.002), and increased actigraphy-derived TST (33.4 min [95% CI: 23.07 to 43.76]; p < 0.001) and SE (2.9% [95% CI: 2.0 to 3.8]; p = 0.005). CONCLUSIONS: Two weeks of nightly sublingual administration of a cannabinoid extract (ZTL-101) is well tolerated and improves insomnia symptoms and sleep quality in individuals with chronic insomnia symptoms. CLINICAL TRIAL: ANZCTR; anzctr.org.au; ACTRN12618000078257.

Enhancing CBT for Chronic Insomnia: A Randomised Clinical Trial of Additive Components of Mindfulness or Cognitive Therapy.

Although cognitive behavioural therapy (CBT) for insomnia has resulted in significant reductions in symptoms, most patients are not classified as good sleepers after treatment. The present study investigated whether additional sessions of cognitive therapy (CT) or mindfulness-based therapy (MBT) could enhance CBT in 64 participants with primary insomnia. All participants were given four sessions of standard CBT as previous research had identified this number of sessions as an optimal balance between therapist guidance and patient independence. Participants were then allocated to further active treatment (four sessions of CT or MBT) or a no further treatment control. The additional treatments resulted in significant improvements beyond CBT on self-report and objective measures of sleep and were well tolerated as evidenced by no dropouts from either treatment. The effect sizes for each of these additional treatments were large and clinically significant. The mean scores on the primary outcome measure, the Insomnia Severity Index, were 5.74 for CT and 6.69 for MBT, which are within the good-sleeper range. Treatment effects were maintained at follow-up. There were no significant differences between CT and MBT on any outcome measure. These results provide encouraging data on how to enhance CBT for treatment of insomnia. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: CBT treatments for insomnia can be enhanced using recent developments in cognitive therapy. CBT treatments for insomnia can be enhanced using mindfulness-based treatments. Both cognitive therapy and mindfulness produce additional clinically significant change.

An open trial of cognitive therapy for chronic insomnia.

We describe the development of a cognitive therapy intervention for chronic insomnia. The therapy is based on a cognitive model which suggests that the processes that maintain insomnia include: (1) worry and rumination, (2) attentional bias and monitoring for sleep-related threat, (3) unhelpful beliefs about sleep, (4) misperception of sleep and daytime deficits and (5) the use of safety behaviors that maintain unhelpful beliefs. The aim of cognitive therapy for insomnia is to reverse all five maintaining processes during both the night and the day. In an open trial 19 patients meeting diagnostic criteria for primary insomnia were treated with cognitive therapy for insomnia. Assessments were completed pretreatment, posttreatment and at 3-, 6- and 12-month followup. The significant improvement in both nighttime and daytime impairment evident at the posttreatment assessment was retained up to the 12 month followup.

An investigation of interpretive bias in insomnia: an analog study comparing normal and poor sleepers.

STUDY OBJECTIVES: Cognitive theories state that psychological disorders are associated with, and are possibly maintained by, interpretive biases, which are tendencies to make threatening interpretations of ambiguous stimuli. Recent models of insomnia have highlighted the importance of cognitive processes. The aim of this study was to empirically evaluate whether an interpretive bias is present in poor sleepers. DESIGN: A mixed-design analysis of covariance was employed with group (normal sleepers vs poor sleepers) as a between-subjects variable and sentence type (insomnia-related vs anxiety related) as a within-subjects variable. The dependent variables were the extent to which participants interpreted insomnia-related and anxiety-related sentences as having a threatening meaning. Sleepiness was used as a covariate. SETTING: Treatment and research clinic at a university department of psychiatry. PARTICIPANTS: Forty-one normal and 34 poor sleepers. MEASUREMENTS AND RESULTS: A set of ambiguous scenarios were administered to participants who gave open-ended and forced-choice interpretations of the scenarios. Each scenario could be interpreted in a threat (insomnia or anxiety)-related or neutral manner. Even after controlling for sleepiness, poor sleepers were found to make significantly more threat-related interpretations of ambiguous scenarios than did normal sleepers. CONCLUSIONS: These findings suggest that there is a bias toward threat-related interpretations among poor sleepers and that the exploration of biased interpretations may be an important avenue for future research among individuals who meet full diagnostic criteria for insomnia.

Interpretive biases in chronic insomnia: an investigation using a priming paradigm.

Disorder-congruent interpretations of ambiguous stimuli characterize several psychological disorders and have been implicated in their maintenance. Models of insomnia have highlighted the importance of cognitive processes, but the possibility that biased interpretations are important has been minimally investigated. Hence, a priming methodology was employed to investigate the presence of an interpretive bias in insomnia. A sample of 78 participants, differing in the presence of a diagnosis of insomnia, severity of sleep disturbance, and sleepiness, was required to read ambiguous sentences and make a lexical decision about target words that followed. Sleepiness at the time of the experiment was associated with the likelihood with which participants made insomnia and threat consistent interpretations of ambiguous sentences. The results suggest that there is a general bias towards threatening interpretations when individuals are sleepy and suggests that cognitive accounts of insomnia require revision to include a role for interpretative bias when people are sleepy. Future research is required to investigate whether this interpretive bias plays a causal role in the maintenance of insomnia.

Attempts to control unwanted thoughts in the night: development of the thought control questionnaire-insomnia revised (TCQI-R).

The attempted control of intrusive, uncontrollable thoughts has been implicated in the maintenance of a range of psychological disorders. The current paper describes the refinement of the Thought Control Questionnaire Insomnia (TCQI; Behav. Cogn. Psychoth. 29 (2001)) through its administration to a sample (n=385) including good sleepers and individuals with insomnia. Several items with poor psychometric properties were discarded, resulting in a 35-item revised TCQI. Factor analysis revealed six factors; aggressive suppression, cognitive distraction, reappraisal, social avoidance, behavioural distraction, and worry. The attempted management of unwanted thoughts was compared across individuals with insomnia and good sleepers, and the impact of these strategies on sleep quality, anxiety and depression was investigated. With the exception of cognitive distraction, individuals with insomnia, relative to good sleepers, more frequently used every thought control strategy. The strategies of aggressive suppression and worry, in particular, appeared to be unhelpful, with the use of these strategies predicting sleep impairment, anxiety and depression. The strategy of cognitive distraction appeared to be helpful, with the use of this strategy predicting better sleep quality.