Bruce Rybarczyk

A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults.

The present study tested cognitive-behavioral therapy (CBT) for insomnia in older adults with osteoarthritis, coronary artery disease, or pulmonary disease. Ninety-two participants (mean age = 69 years) were randomly assigned to classroom CBT or stress management and wellness (SMW) training, which served as a placebo condition. Compared with SMW, CBT participants had larger improvements on 8 out of 10 self-report measures of sleep. The type of chronic disease had no impact on these outcomes. The hypothesis that CBT would improve daytime functioning more than SMW was only supported by a global rating measure. These results add to findings that challenge the dichotomy between primary and secondary insomnia and suggest that psychological factors are likely involved in insomnias that are presumed to be secondary to medical conditions.

Efficacy of two behavioral treatment programs for comorbid geriatric insomnia.

Older adults with comorbid insomnia and medical illness have been excluded from behavioral treatment research, but recent evidence suggested that such treatments would be effective with this population. In this study, 38 older adults with comorbid insomnia were randomized to 1 of 3 conditions: classroom cognitive-behavioral treatment (CBT), home-based audio relaxation treatment (HART), or delayed-treatment control. Compared to the control group, the CBT group had significant changes in 5 of 7 self-report measures of sleep at the 4-month follow-up. The HART group obtained significant outcomes on 3 of 7 measures. Wrist actigraphy measures and secondary-outcome measures did not yield significant findings for either treatment. Clinically significant changes at follow-up were obtained for 54% of patients in CBT, 35% in HART, and 6% in the control group when treatment dropouts were included. Although not as effective as in-person CBT, home interventions may have utility as a first-line, low-cost treatment.

Examining maladaptive beliefs about sleep across insomnia patient groups.

OBJECTIVES Unhelpful beliefs about sleep have been linked to insomnia, and increasing ones cognitive flexibility about sleep has been linked to posttreatment sleep improvement. This study evaluated whether levels of such beliefs differ across insomnia groups and whether there are particular beliefs that differ for specific insomnia subtypes. METHODS Participants (N=1384) were people with insomnia and good sleepers ranging from 18 to 89 years old (mean=42.6; S.D.=19.4). Data from previous studies at five insomnia clinical sites were pooled to examine responses on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) across differing insomnia groups. RESULTS Group analyses revealed that those from community-based insomnia clinics and those who are hypnotic-dependent generally had the highest levels of unhelpful sleep-related beliefs. With the exception of beliefs about sleep needs (wherein only community sleep clinic patients had high scores relative to good sleepers), all insomnia groups had higher scores on the 16-item DBAS (DBAS-16) than good sleepers. A validity analysis suggested that a DBAS-16 index score of >3.8 represented the level of unhelpful beliefs associated with clinically significant insomnia, although a slightly lower cutoff may be useful for identifying an unhelpful degree of sleep-related beliefs in highly screened primary-insomnia-only and medical patient groups. CONCLUSIONS This study offers descriptive data for the use of DBAS-16 across insomnia subgroups, which will help the user understand what degree of maladaptive sleep beliefs is most strongly associated with clinically significant levels of insomnia. Results also may have implications for cognitive targeting during treatment for particular insomnia groups.

Efficacy of a Cognitive‐Behavioral Treatment for Insomnia and Nightmares in Afghanistan and Iraq Veterans With PTSD

OBJECTIVE Sleep disturbances are a core and salient feature of posttraumatic stress disorder (PTSD). Pilot studies have indicated that combined cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares improves sleep as well as PTSD symptoms. METHOD The present study randomized 40 combat veterans (mean age 37.7 years; 90% male and 60% African American) who served in Afghanistan and/or Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) to 4 sessions of CBT-I with adjunctive IRT or a waitlist control group. Two thirds of participants had nightmares at least once per week and received the optional IRT module. RESULTS At posttreatment, veterans who participated in CBT-I/IRT reported improved subjectively and objectively measured sleep, a reduction in PTSD symptom severity and PTSD-related nighttime symptoms, and a reduction in depression and distressed mood compared to the waitlist control group. CONCLUSION The findings from this first controlled study with OEF/OIF veterans suggest that CBT-I combined with adjunctive IRT may hold promise for reducing both insomnia and PTSD symptoms. Given the fact that only half of the patients with nightmares fully implemented the brief IRT protocol, future studies should determine if this supplement adds differential efficacy to CBT-I alone.

Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial.

To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT‐PI), a cognitive–behavioral pain coping skills intervention (CBT‐P), and an education‐only control (EOC) differed in sleep and pain outcomes.

Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia

Summary Sleep, pain, and fatigue were longitudinally examined in 367 osteoarthritic older adults. Two‐month sleep improvement predicted 18‐month improvements in sleep, pain, and fatigue. ABSTRACT In a primary care population of 367 older adults (aged ≥60 years) with osteoarthritis (OA) pain and insomnia, we examined the relationship between short‐term improvement in sleep and long‐term sleep, pain, and fatigue outcomes through secondary analyses of randomized controlled trial data. Study participants, regardless of experimental treatment received, were classified either as improvers (≥30% baseline to 2‐month reduction on the Insomnia Severity Index [ISI]) or as nonimprovers. After controlling for treatment arm and potential confounders, improvers showed significant, sustained improvements across 18 months compared with nonimprovers in pain severity (P < 0.001, adjusted mean difference = −0.51 [95% CI: −0.80, −0.21), arthritis symptoms (P < 0.001, 0.63 [0.26, 1.00]), and fear avoidance (P = 0.009, −2.27 [−3.95, −0.58]) but not in catastrophizing or depression. Improvers also showed significant, sustained improvements in ISI (P < 0.001, −3.03 [−3.74, −2.32]), Pittsburgh Sleep Quality Index Total (P < 0.001, −1.45 [−1.97, −0.93]) and general sleep quality (P < 0.001, −0.28 [−0.39, −0.16]) scores, Flinders Fatigue Scale (P < 0.001, −1.99 [−3.01, −0.98]), and Dysfunctional Beliefs About Sleep Scale (P = 0.037, −2.44 [−4.74, −0.15]), but no improvements on the Functional Outcomes of Sleep Questionnaire or the Epworth Sleepiness Scale. We conclude that short‐term (2‐month) improvements in sleep predicted long‐term (9‐ and 18‐month) improvements for multiple measures of sleep, chronic pain, and fatigue. These improvements were not attributable to nonspecific benefits for psychological well‐being, such as reduced depression. These findings are consistent with benefits of improved sleep for chronic pain and fatigue among older persons with osteoarthritis pain and comorbid insomnia if robust improvements in sleep are achieved and sustained. Trial Registration: ClinicalTrials.gov Identifier: NCT01142349.

A Classroom Mind/Body Wellness Intervention for Older Adults With Chronic Illness: Comparing Immediate and 1-Year Benefits

Abstract The authors tested the efficacy of a mind/body wellness intervention for older adults with chronic illness. They randomly assigned 243 physician-referred patients from an urban HMO to a classroom intervention or a wait-list control group. The intervention provided instruction on mind/body relationships; relaxation training; cognitive restructuring; problem-solving; communication; and behavioral treatment for insomnia, nutrition, and exercise. At post-treatment, the intervention group had significant decreases in self-reported sleep difficulties, pain, anxiety, and depression symptoms compared with controls. The intervention also led to a significant decrease in “chance” and “powerful others” health locus of control beliefs. At 1-year follow-up, the intervention group maintained benefits in sleep and health locus of control and also reported a significant increase in health behaviors compared with controls. Pain, anxiety, and depression benefits were not maintained. This type of classroom intervention appears to have some lasting effects on health behaviors and beliefs.

Effectiveness of Abbreviated CBT for Insomnia in Psychiatric Outpatients: Sleep and Depression Outcomes

OBJECTIVE To test the efficacy of cogntive-behavioral therapy for insomnia (CBT-I) as a supplement treatment for psychiatric outpatients. Comorbid insomnia is prevalent among individuals with varied psychiatric disorders and evidence indicates that CBT-I may be effective for reducing insomnia and other psychiatric symptoms. METHOD The present study randomly assigned 30 psychiatric outpatients (mean duration of treatment = 3.6 years) with low sleep quality and residual depressive symptoms to two sessions of CBT-I or a treatment as usual control group. Assessment included the Pittsburgh Sleep Quality Index (PSQI) for insomnia and the Patient Health Questionnaire (PHQ-9) for depression at pretreatment and 4 and 8 weeks posttreatment. RESULTS Patients who received CBT-I demonstrated within group changes in PSQI and the PHQ-9 scores at both 4 and 8 weeks posttreatment, but did not show between-group differences. Additionally, 38% of the treatment participants achieved normal sleep at follow-up compared with none in the control condition. CONCLUSIONS This study provides preliminary evidence that abbreviated behavioral treatment has beneficial effects on residual insomnia and depression in long-term psychiatric outpatients.

Diversity in adjustment to a leg amputation: Case illustrations of common themes

Purpose: To provide in-depth case descriptions that illustrate the common themes in the research literature on psychological adjustment to a lower-extremity amputation as well as capture the uniqueness of each individuals response to this prevalent acquired disability. Method: Four cases were chosen based on the diversity of adjustment issues they represented. These case presentations were reconstructed from evaluations completed by the authors, all psychologists, as part of routine care on an inpatient rehabilitation service. Identifying information was changed to protect confidentiality. Conclusions: Taken together, these four cases serve to underscore the importance attending to common issues such as post-amputation depression and anxiety, body image, feelings of vulnerability, social support changes, grief, pre-amputation psychological issues and phantom limb pain and sensations. Psychological assessment and referrals for treatment should be included as part of the routine care provided to individuals with amputations, irrespective of the length of time that has passed since the amputation.

Frequency of comorbid insomnia, pain, and depression in older adults with osteoarthritis: predictors of enrollment in a randomized treatment trial.

OBJECTIVE This paper examines the prevalence and severity of comorbid pain, insomnia, and depression in a population sample of older adults with osteoarthritis (OA), and assesses characteristics distinguishing participants from non-participants in a randomized clinical trial to improve pain and sleep. METHODS Potential subjects were Group Health Cooperative members, aged 60+, who had an electronic medical record OA diagnosis in the prior 3 years. Participants were recruited using a low-cost mailed survey. Fifty-five percent of surveys were completed and returned (n=3321). Persons with Grade II-IV arthritis pain on the Graded Chronic Pain Scale and reporting sleep difficulties 3+ nights/week during the past month with daytime dysfunction (n=834) were invited to participate in one of three group-format behavioral self-management interventions. A total of 367 participants attended the first group class. RESULTS One-third (36.4%) of survey respondents had clinically elevated levels of OA pain and insomnia. Group participants and non-participants did not differ in ratings of pain severity, sleep disturbance, depression, or receipt of prescription medications for pain or sleep. Participants were significantly older (p<.001) and more likely to be retired (p<.001) than subjects who were eligible to participate but did not. CONCLUSION Participation in a group-format behavioral intervention for pain and insomnia was not related to participant clinical characteristics, but only to factors associated with ability to attend a daytime class (age and retirement status). We conclude that population-based recruitment yielded randomized trial participants who are clinically generalizable to the population of OA patients with significant pain and insomnia.