Cognitive behaviour therapy for insomnia and depression among older adults : A mixed methods randomised controlled clinical trial
- Authors: Sadler, Paul
- Date: 2018
- Type: Text , Thesis , PhD
- Full Text:
- Description: Background A strong relationship exists between insomnia and depression, particularly among older adults (aged 65 years and older). Recently experts in the field of behavioural sleep medicine established cognitive behaviour therapy (CBT) was an effective treatment for comorbid insomnia, however, it was unknown whether cognitive behaviour therapy for insomnia (CBT-I) benefitted older adults with co-occurring depression (literature review published in Cognitive Behaviour Therapy). A mixed-methods randomised controlled clinical trial (RCT) was warranted within a community mental health setting to investigate the efficacy of CBT-I for older adults with comorbid insomnia and depression. Furthermore, no study had tested whether an advanced form of CBT-I that included additional positive mood-enhancing strategies produced better outcomes compared to a standard form of CBT-I that only targeted insomnia. It was anticipated that the results from such a trial could influence the evolution of treatment for older adults with these highly prevalent comorbid conditions. Methodology An RCT was conducted between 2014 and 2016 across Victoria, Australia, through Latrobe Regional Hospital‟s and Peninsula Health‟s Community Mental Health Services (protocol published in Trials). Seventy-two older adults with diagnosed comorbid insomnia and depression were randomly assigned to one of three group therapy conditions: cognitive behaviour therapy for insomnia (CBT-I, standard), cognitive behaviour therapy for insomnia plus positive mood strategies (CBT-I+, advanced), psychoeducation control group (PCG, control). The primary outcomes were insomnia severity (Insomnia Severity Index) and depression severity (Geriatric Depression Scale). Primary and secondary measures were collected at pre (week 0), post (week 8), and follow-up (week 20). Participants who completed the experiential conditions were invited to provide feedback in the form of semi- xvii structured focus groups following the final session of treatment. Thirty-one participants from six groups reflected on their experiences of participating in CBT-I and CBT-I+. Results Quantitative analyses demonstrated the experiential CBT conditions both generated significantly greater reductions in insomnia and depression severity compared to PCG from pre to post, which were maintained at follow-up. The standard and advanced conditions showed similar reductions on insomnia and depression severity at post and follow up. These results were also consistent for the secondary measures across conditions. Both active treatments demonstrated large effect sizes, high retention, and strong remission rates for older adults with insomnia and depression (published in journal SLEEP). A qualitative analysis was also conducted to explore the participants‟ experiences of treatment. Interview data from the reflective focus groups was transcribed into 424 sentences and 60 codes were extracted. Thirty-four initial themes emerged, which were finally transformed into 3 themes and 10 subthemes. The three themes were (1) positive experiences, (2) negative experiences, and (3) suggested modifications. The positive subthemes were (1a) therapists, (1b) togetherness, (1c) use of strategies reduced symptoms, and (1d) acceptance. The negative subthemes were (2a) persistent symptoms, (2b) program too condensed, and (2c) attendance obstacles. The suggested modifications were (3a) lengthen program, (3b) multi-dimensional learning, and (3c) multi-modal delivery options (manuscript under review in Aging and Mental Health). Conclusion This is the first RCT to demonstrate that specifically treating comorbid insomnia with CBT has an additional positive effect of improving depression for older adults with multiple comorbidities. Both CBT programs were effective at reducing insomnia and depression severity for older adults with comorbidity. Replication of this study is necessary with a larger sample size to conclusively establish whether the two interventions have different or equivalent effects. It was suggested mental health services that deliver treatment for comorbid insomnia with CBT may improve recovery outcomes for older adults with depression. Future CBT-I programs for older adults may be improved by increasing the length of therapy (e.g., 8 sessions to 12 sessions), adding multi-dimensional learning opportunities (e.g., visual/audio/mentorship), and offering various modes of treatment delivery (e.g., group, individual, internet, telephone).
- Description: Doctor of Philosophy
- Authors: Sadler, Paul
- Date: 2018
- Type: Text , Thesis , PhD
- Full Text:
- Description: Background A strong relationship exists between insomnia and depression, particularly among older adults (aged 65 years and older). Recently experts in the field of behavioural sleep medicine established cognitive behaviour therapy (CBT) was an effective treatment for comorbid insomnia, however, it was unknown whether cognitive behaviour therapy for insomnia (CBT-I) benefitted older adults with co-occurring depression (literature review published in Cognitive Behaviour Therapy). A mixed-methods randomised controlled clinical trial (RCT) was warranted within a community mental health setting to investigate the efficacy of CBT-I for older adults with comorbid insomnia and depression. Furthermore, no study had tested whether an advanced form of CBT-I that included additional positive mood-enhancing strategies produced better outcomes compared to a standard form of CBT-I that only targeted insomnia. It was anticipated that the results from such a trial could influence the evolution of treatment for older adults with these highly prevalent comorbid conditions. Methodology An RCT was conducted between 2014 and 2016 across Victoria, Australia, through Latrobe Regional Hospital‟s and Peninsula Health‟s Community Mental Health Services (protocol published in Trials). Seventy-two older adults with diagnosed comorbid insomnia and depression were randomly assigned to one of three group therapy conditions: cognitive behaviour therapy for insomnia (CBT-I, standard), cognitive behaviour therapy for insomnia plus positive mood strategies (CBT-I+, advanced), psychoeducation control group (PCG, control). The primary outcomes were insomnia severity (Insomnia Severity Index) and depression severity (Geriatric Depression Scale). Primary and secondary measures were collected at pre (week 0), post (week 8), and follow-up (week 20). Participants who completed the experiential conditions were invited to provide feedback in the form of semi- xvii structured focus groups following the final session of treatment. Thirty-one participants from six groups reflected on their experiences of participating in CBT-I and CBT-I+. Results Quantitative analyses demonstrated the experiential CBT conditions both generated significantly greater reductions in insomnia and depression severity compared to PCG from pre to post, which were maintained at follow-up. The standard and advanced conditions showed similar reductions on insomnia and depression severity at post and follow up. These results were also consistent for the secondary measures across conditions. Both active treatments demonstrated large effect sizes, high retention, and strong remission rates for older adults with insomnia and depression (published in journal SLEEP). A qualitative analysis was also conducted to explore the participants‟ experiences of treatment. Interview data from the reflective focus groups was transcribed into 424 sentences and 60 codes were extracted. Thirty-four initial themes emerged, which were finally transformed into 3 themes and 10 subthemes. The three themes were (1) positive experiences, (2) negative experiences, and (3) suggested modifications. The positive subthemes were (1a) therapists, (1b) togetherness, (1c) use of strategies reduced symptoms, and (1d) acceptance. The negative subthemes were (2a) persistent symptoms, (2b) program too condensed, and (2c) attendance obstacles. The suggested modifications were (3a) lengthen program, (3b) multi-dimensional learning, and (3c) multi-modal delivery options (manuscript under review in Aging and Mental Health). Conclusion This is the first RCT to demonstrate that specifically treating comorbid insomnia with CBT has an additional positive effect of improving depression for older adults with multiple comorbidities. Both CBT programs were effective at reducing insomnia and depression severity for older adults with comorbidity. Replication of this study is necessary with a larger sample size to conclusively establish whether the two interventions have different or equivalent effects. It was suggested mental health services that deliver treatment for comorbid insomnia with CBT may improve recovery outcomes for older adults with depression. Future CBT-I programs for older adults may be improved by increasing the length of therapy (e.g., 8 sessions to 12 sessions), adding multi-dimensional learning opportunities (e.g., visual/audio/mentorship), and offering various modes of treatment delivery (e.g., group, individual, internet, telephone).
- Description: Doctor of Philosophy
Insomnia, dsyfunctional beliefs about sleep, hopelessness and depression among older adults: The development and testing of a path model
- Authors: Sadler, Paul
- Date: 2011
- Type: Text , Thesis
- Full Text:
- Description: Masters of Applied Science (Psychology)
- Description: Insomnia increases the risk of developing depression among older adults. No study, however, has attempted to explain how insomnia predicts depression from a cognitive perspective. The primary aim of the current study was to test a path model that explored whether dysfunctional beliefs about sleep and hopelessness explain how insomnia influences depression among older adults. It was hypothesised that insomnia would predict depression, both directly and indirectly, via dysfunctional beliefs about sleep and hopelessness. A second exploratory aim tested whether the model differed according to whether or not participants were likely to have a physiological sleep disorder. A community sample of 218 older adults aged from 65 to 96 years, completed the Insomnia Severity Index, Dysfunctional Beliefs and Attitudes About Sleep 10-Item Scale, Beck Hopelessness Scale, Snoring Tiredness Observed Pressure Scale, and Restless Legs Syndrome Questionnaire. Out of the 218 participants, 171 completed the Centre for Epidemiologic Studies Depression Scale three months later. The model was tested using a longitudinal path analysis design. Initial results indicated that the overall model fit was poor. One modification that involved the addition of a direct path from insomnia to hopelessness resulted in an excellent model fit. Results further demonstrated that the revised path model was non-invariant between older adults who were likely to have a physiological sleep disorder and older adults who were unlikely to have a physiological sleep disorder. It was concluded that dysfunctional beliefs about sleep and hopelessness partly explain how insomnia influences depression among older adults, irrespective of the likelihood of having a physiological sleep disorder.
- Authors: Sadler, Paul
- Date: 2011
- Type: Text , Thesis
- Full Text:
- Description: Masters of Applied Science (Psychology)
- Description: Insomnia increases the risk of developing depression among older adults. No study, however, has attempted to explain how insomnia predicts depression from a cognitive perspective. The primary aim of the current study was to test a path model that explored whether dysfunctional beliefs about sleep and hopelessness explain how insomnia influences depression among older adults. It was hypothesised that insomnia would predict depression, both directly and indirectly, via dysfunctional beliefs about sleep and hopelessness. A second exploratory aim tested whether the model differed according to whether or not participants were likely to have a physiological sleep disorder. A community sample of 218 older adults aged from 65 to 96 years, completed the Insomnia Severity Index, Dysfunctional Beliefs and Attitudes About Sleep 10-Item Scale, Beck Hopelessness Scale, Snoring Tiredness Observed Pressure Scale, and Restless Legs Syndrome Questionnaire. Out of the 218 participants, 171 completed the Centre for Epidemiologic Studies Depression Scale three months later. The model was tested using a longitudinal path analysis design. Initial results indicated that the overall model fit was poor. One modification that involved the addition of a direct path from insomnia to hopelessness resulted in an excellent model fit. Results further demonstrated that the revised path model was non-invariant between older adults who were likely to have a physiological sleep disorder and older adults who were unlikely to have a physiological sleep disorder. It was concluded that dysfunctional beliefs about sleep and hopelessness partly explain how insomnia influences depression among older adults, irrespective of the likelihood of having a physiological sleep disorder.
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